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Colloids no better than crystalloids for fluid replacement in hypovolaemic patients
For decades controversy has existed over the relative benefits of
colloid and crystalloid solutions for fluid resuscitation of
hypovolaemic patients. In their systematic review of randomised controlled trials Schierhout and Roberts (p 961) found that,
compared with crystalloids, use of colloids was associated with an
increase in absolute risk of mortality of 4%. There was no evidence
for differences of effect among different types of injury necessitating fluid resuscitation. The authors conclude that there is no evidence to
support the continued use of the more expensive colloids for acute
volume replacement in critically ill patients.
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Pressure on inpatient services has restricted the option of hospital
admission for uncomplicated active rheumatoid arthritis and alternative
strategies, such as day care, have been implemented without evaluation.
A randomised controlled trial by Lambert et al (p 965) shows the
clinical equivalence of conventional inpatient care and hospital based
day care. Though the overall costs of day care are slightly less than
those of inpatient care, the costs borne by day patients themselves may
be higher. Some patients may value the social convenience of day care.
The antithrombotic effects of heparin have led to its use as a flush
solution for peripheral intravascular infusion devices. On p 969
Randolph et al report a systematic review of the benefit of heparin in
peripheral venous and arterial catheters. Current evidence supports
discontinuing the practice of flushing peripheral venous catheters that
are locked between use with 10 U/ml of heparin solution. However,
heparin significantly prolongs the duration of peripheral arterial
catheter patency and decreases the risk of clots. In peripheral venous
catheters heparin added to the infusion at 1 U/ml decreases phlebitis
and may decrease infusion failure.
Magnesium sulphate is the preferred anticonvulsant for eclampsia, while
little evidence exists on the effectiveness of anticonvulsants in
pre-eclampsia. On p 975 Gülmezoglu and Dooley report a survey of
British and Irish obstetricians which showed that 662 of 860 used
anticonvulsants prophylactically in pre-eclampsia. The use of magnesium
sulphate in pre-eclampsia had risen from 2% in 1991 to 40% in 1996;
in eclampsia 60% would use magnesium. Over half the respondents were
willing to take part in a randomised trial of magnesium versus placebo
in pre-eclampsia.
To explore the experience of diabetes among British Bangladeshis
Greenhalgh et al used a variety of qualitative approaches, including
interviews, story telling, and focus groups, among 40 Bangladeshis and
a control group of white and Afro-Carribean people from east London (p
978). Lay sources of information, belief in external causes of
diabetes, and negative connotations of exercise were prominent among
the Bangladeshis. But the authors point out that material barriers such
as poor housing and unsafe streets were at least as important in
preventing improved health as cultural factors. They suggest that an
understanding of patients' belief systems can help doctors to tailor
their advice most effectively.
Epidemiological studies investigate overall effects within populations,
but clinicians need information about specific risks and benefits for
individual patients. Hannaford and Owen-Smith (p 984) reviewed all
published studies of the risk of cardiovascular disease in current
users of combined oral contraceptives in order to assess the usefulness
of the data in defining the risk for young, healthy women who do not
smoke. Of the 74 papers identified, only five provided information that
directly addressed the clinical question, although 14 others probably
had the potential to answer the question after reanalysis.
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