This week in the BMJ

Proactive care with active recall helps children with asthma
Nurse led intervention improves diagnosis of UTIs in children
Stressful events increase exacerbations in relapsing-remitting multiple sclerosis
Better detection and treatment of alcohol use in elderly people is needed
Adding methylxanthines to standard COPD treatment is not beneficial
Mortality among UNITA members remains high after the ceasefire

Proactive care with active recall helps children with asthma

Proactive structured care in general practice may improve the management of childhood asthma. Glasgow and colleagues (p 659) conducted a cluster randomised controlled trial and found that a structured intervention (called the 3+ visit plan) with active recall improved process measures and clinical measures such as reduced speech-limiting wheeze for children with moderate to severe asthma. The authors maintain that delivering optimal health care in chronic illness such as asthma requires health systems to move from a reactive to a proactive orientation.

Nurse led intervention improves diagnosis of UTIs in children

A nurse led model for the management of urinary tract infections (UTIs) in children in primary care improves diagnostic standards and increases referral rates. In a cluster randomised trial Coulthard and colleagues (p 656) assessed the model, which involved ongoing education, the management of children by general practitioners, counselling of families, and direct access to imaging investigations. The intervention improved the rate and quality of diagnoses, halved the number of hospital visits, was valued by parents and doctors, and may have prevented some renal scarring, say the authors.

Credit: DAMIEN LOVEGROVE/SPL

Stressful events increase exacerbations in relapsing-remitting multiple sclerosis

Stressful life events double the risk of an exacerbation in relapsing-remitting multiple sclerosis. Buljevac and colleagues (p 646) conducted a prospective study of 73 patients with the condition to examine the relation between self reported stressful life events and exacerbations. Data from patients' weekly diaries showed that occurrence of at least one stressful event (such as problems with a family member, job stress, or death of a loved one) was associated with a doubling in exacerbations over the following four weeks. The authors state that exacerbations in multiple sclerosis are common but unpredictable, and little previous evidence documents the effect of psychological determinants.

Better detection and treatment of alcohol use in elderly people is needed

Alcohol misuse among elderly people is widely undetected and misdiagnosed, and this has led to the emergence of a "silent epidemic." In a clinical review, O'Connell and colleagues (p 664) highlight the key issues relating to alcohol use disorders within the elderly population. They outline the reasons for underdetection and misdiagnosis, suggest how to improve detection rates, and recommend treatments. Alcohol use disorders as they affect older people must be redefined, say the authors, with increased emphasis on aspects specific to elderly patients.

Credit: DIANE KOSUP/PHOTONICA

Adding methylxanthines to standard COPD treatment is not beneficial

Methylxanthines do not confer any benefit on lung function and symptoms in patients with exacerbations of chronic obstructive pulmonary disease (COPD) at standard levels of significance. In a meta-analysis of four randomised trials comprising 169 patients, Barr and colleagues (p 643) found that changes in lung function, clinical outcomes, and self rated symptom scores were not significantly different between methylxanthine and placebo groups, but significantly more adverse events of nausea and vomiting occurred in patients receiving methylxanthines. These findings contradict current recommendations for using this class of drugs as the second line treatment for exacerbations, say the authors.

Mortality among UNITA members remains high after the ceasefire

The death rates among displaced former members of UNITA and their families remain high in the aftermath of the civil war in Angola. In a retrospective study of mortality in the months before and after the 2002 ceasefire that ended 27 years of civil war, Grein and colleagues (p 650) found that death rates were excessive, particularly among children. Malnutrition, fever or malaria, and war or violence were the main causes of death over the entire period. The main killer in 2001, violence, was replaced by malnutrition in 2002. This reflects years of isolation and armed conflict, as well as an insufficient humanitarian response in the face of a dramatic food crisis.

Credit: J B RUSSELL/PANOS