Research highlights – 14 October 2011

Research questions“Research highlights” is a weekly round-up of research papers appearing in the print BMJ. We start off with this week’s research questions, before providing more detail on some individual research papers and accompanying articles.

Controlling MRSA infection in hospital
Infection with meticillin resistant Staphylococcus aureus (MRSA) has become a major cause of morbidity and mortality in patients admitted to hospital, particularly those in intensive care units. Isolation and decolonisation are the two main control measures, with screening of other patients for potential asymptomatic colonisation with MRSA a possible third. Without good evidence on the most effective combination of interventions or the optimal screening method, control strategies tend to vary from hospital to hospital.

This week Julie Robotham and colleagues describe how they used a hypothetical model of MRSA transmission in an attempt to determine the most cost effective MRSA control strategy in intensive care units.  Their analysis indicated that a strategy of universal topical decolonisation, regardless of MRSA status, was the most cost effective in the short term. However, such untargeted use of antibiotics could encourage resistance, making the problem much worse in the long term. If decolonisation of all patients is excluded, the optimal strategy becomes targeted decolonisation based on the results of universal screening using polymerase chain reaction.

In their linked editorial, Jan Kluytmans and Stephan Harbarth consider the practical implications of this study and warn that the effectiveness of the suggested control strategies needs to be confirmed in clinical studies.  For example, the practical difficulty of decolonisation in critically ill patients with endotracheal tubes, catheters, drains, and wounds increases the risk of treatment failure and could tip the balance more towards isolation.

Which is the best online resource? Time for a debate.
The choice of point of care summaries is vast. The million dollar question for clinicians surfing the net for quality, up to date information is which one is choose?  Few studies have compared the quality of point of care summaries, according to Rita Banzi and colleagues. In the absence of evidence, clinicians may rely on their instincts, recommendations, subscriptions, or the appealing marketing lines of such point of care resources, to guide them.

Banzi and colleagues begin to unpick one element of quality; the speed of updating content.  They selected five point of care summaries (Clinical Evidence, Dynamed, EBM Guidelines, eMedicine, and UpToDate), that they judged to be of high quality on the basis of coverage of medical conditions (volume) and editorial quality and evidence based methodology, and measured how quickly they incorporated evidence from certain systematic reviews. At nine months, Dynamed had cited 87% of the 128 eligible systematic reviews that had been published in that time, whereas the other summaries had cited less than 50%.

The authors conclude that Dynamed clearly dominates the other products in terms of speed but acknowledge that updating speed is only one aspect of the overall quality of a point of care product. In his rapid response to the full paper on, Rubin Minhas, editor-in-chief of BMJ Clinical Evidence, widens the debate: “What is the “need for speed?” How quick is too quick and how long is too long? Are priority based approaches better than time based ones? Should users of evidence based point of care tools expect publishers to be transparent about the quality of their products? And is it finally time we had a CONSORT-type framework for clinical decision support tools?”

Impact of late diagnosis and treatment on life expectancy in people with HIV-1
Margaret May and colleagues found that life expectancy in people treated for HIV infection in the UK has increased by over 15 years during 1996-2008 but is still about 13 years less than that of the general population, and a late start to antiretroviral therapy (CD4 cell count <200 cells/mm3) resulted in up to 15 years’ loss of life.

Effect of multidimensional lifestyle intervention on fitness and adiposity in predominantly migrant preschool children (Ballabeina)
In a group of predominantly migrant young children, who tend to have high levels of obesity and low fitness, J J Puder and colleagues found that a multidimensional, culturally tailored, lifestyle intervention programme improved fitness and body fat, though not body mass index.