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Medical journals are often accused of being remote from the real world. They
present the results of trials conducted on highly selected patients
in ideal circumstances. They view the world from London, Boston, or
Chicago unaware that in Peioria or Harrogate patients don't turn up,
won't comply with treatments, and scoff at "patient centredness" and
that the local hospitals are falling down and run by people who until
yesterday were running sewage plants. Well, this issue has a whiff
even
a stinkfrom the real
world.
The BMJ has published many studies suggesting that serum screening for
Down's syndrome in pregnant women is more effective than screening
based on age, but an audit of over 150 000 deliveries suggests that
may not be true (p
15). The models in support of serum screening assumed that 5% of
mothers were over 35. In fact, 15% are. An editorial considers why
eradication of Helicobacter pylori often fails in ordinary
practice (p
3).
The answer seems to be growing antibiotic resistance. Antibiotics
have traditionally been prescribed for children with acute otitis
media, but systematic reviews suggest that there is little benefit (p
22). But it's hard in the real world to suggest to parents that
antibiotics are not indicated. Now a further review suggests that it
may be worth giving them to children who have high temperatures or
who are vomitingalthough
even then it may be worth waiting for 24 to 48 hours.
Selected patients with stroke can probably be helped with thrombolytic drugs
if seen quickly and if they undergo computed tomography. A
multicentre study from Britain shows how hard this is to achieve in
the real world. Only 37% of patients arrive at hospital within three
hours of their stroke. Computed tomography was requested within three
hours of arrival in hospital in 22% of patients but undertaken in
only 8%. Ideally, all patients with serious illness would be admitted
quickly to hospitals with the full range of services. But many people
live a long way from such hospitals, and, says a report from the
Royal College of Physicians, patients in at least 30 "isolated"
hospitals are at increased risk because of the lack of intensive care
(p
8). The realpolitik of reconfiguring such hospitals is terrifyingat
least to politicians.
Any notion of the real world is philosophically questionable (why, for
example, are my dreams less real than what I do during the day?) and
certainly relative. In the United Statesunlike
in the vast majority of countriesthey
have thought it acceptable to execute mentally retarded prisoners.
Now the Supreme Court has ruled it unacceptable (p
9). But consider the real world of Sierra Leone described in the
obituary of Arthur Osman Farquar Stuart (p
47), the "people's doctor" of Sierra Leone. "What a relief," he
wrote, "to be free of the soldiers who would cut a pregnant woman's
belly open to settle a bet whether she was carrying a baby boy or
baby girl."
Footnotes
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