Perineal pain
Episiotomy and perineal trauma from childbirth can cause significant pain and loss of mobility. Elizabeth Peter and colleagues enrolled 237 women with an episiotomy or third- or fourth-degree tear in a randomized controlled trial to compare ibuprofen (n = 127) and acetaminophen with codeine (n = 110). They found that pain relief in the first 24 hours post partum was similar in the 2 groups (mean pain ratings on a visual analogue scale were 3.4 and 3.3 in the ibuprofen and the acetaminophen with codeine groups respectively), as was the proportion of treatment failures (13.8% and 16.0% respectively). Patient satisfaction was also similar in the 2 groups, but significantly fewer women in the ibuprofen group than in the acetaminophen with codeine group reported side effects (52.4% v. 71.7%). The authors report that, although these treatments appear equally effective for managing post-partum pain in women with severe tearing or episiotomy, neither treatment is ideal.
See page 1203
Screening
Screening tests have the potential to reveal latent illness. Olli Miettinen, in the sixth article of his series on “the modern scientific physician,” describes screening as a process of searching for and detecting asymptomatic disease. He describes how screening regimens, applied on the level of a community, aim to initiate the process of “ruling-in” a diagnosis, thus providing a useful “diagnostic shift” and opportunity for early intervention.
See page 1219. For articles on colorectal cancer screening see pages 1181 and 1248
Randomized controlled trials
Authors who report the results of randomized controlled trials (RCTs) often emphasize the statistical significance of their findings rather than the clinical importance. Karen Chan and colleagues examined the reporting of factors related to clinical importance in a random sample of 27 RCTs published in 5 major medical journals. In many studies (22), the primary outcome was clear, and in 20 studies the authors reported sample size calculations. However, authors discussed the clinical importance of their results in only 20 studies, and frequently (15 studies) authors did not justify their interpretation of the clinical importance. Chan and colleagues argue that authors of RCTs need to report more explicitly delta values and minimal clinically important differences to allow independent assessment and honest interpretation of the clinical importance of study results.
In a separate article on RCTs, David Sackett, with continued “coal-face” resolve, examines the use of physiological statistics. He explains strategies for investigators to improve confidence in their trial results by increasing the differences seen between groups (the signal), accommodating potential sources of variation (the noise) and maintaining a strong sample size.
See pages 1197 and 1226
Nurse practitioners
Intersecting mandates of nurse practitioners (NPs) and family physicians (FPs) have created some tension but also opportunities for collaboration. Daniel Way and colleagues reviewed the nature of 566 patient encounters at 2 eastern Ontario primary care practice sites where both family physicians and nurse practitioners practised. In terms of time spent doing health promotion, NPs and FPs were similar (11.3 and 10.0 instances, respectively, per full-time equivalent [FTE] position). In the realm of diagnosing and treating acute illnesses NPs provided fewer services than FPs (18.8 v. 29.3 instances per FTE position). Similarly, NPs spent less time monitoring and treating patients with stable chronic illnesses (15.0 v. 63.7 instances per FTE position). In contrast, NPs provided more services related to disease prevention, including periodic health examinations (78.8 v. 55.7 instances per FTE position). FPs encouraged follow-up with an NP in only 3 (2%) of 173 encounters involving referrals, whereas NPs recommended follow-up with an FP in 13 (16%) of 79 such encounters. The authors suggest that great opportunities for collaboration exist in the form of encouraging FPs to refer more patients to NPs and allowing NPs to become more involved in the treatment of acute and chronic illnesses.
See page 1210