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Topical non-steroidals are effective and safe
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There is scepticism that topical non-steroidal anti-inflammatory drugs are effective. Moore et al (p 333) performed a systematic review of randomised controlled trials in acute and chronic painful conditions to test the evidence for effectiveness. Placebo controlled trials in acute conditions in 1747 treated patients had an overall number needed to treat of 3.9 and in chronic conditions in 547 treated patients an overall number of 3.1. Small trials (fewer than 40 treated patients) exaggerated treatment efficacy. Adverse effects were rare and no different from those seen with placebo.
Little is known about the long term outlook for children with epilepsy. Kurtz et al used the National Child Development Study cohort (17 414 children born in 1958) to review their experience of epilepsy (p 339). By age 23 the cumulative incidence of epilepsy was 8.4/1000. In only 25% of cases was seizure onset related to a specific cause. Children with uncomplicated epilepsy were less likely to continue to have seizures in adult life than those with neurological impairment or other medical conditions; one third diagnosed by age 16 were off medication and seizure free at 23. Six died between the ages of 17 and 23.
Many drugs used to treat children in hospital are either not licensed for use in children or are prescribed outside the terms of the licence (off label). To find out how often drugs were used in these ways Turner et al studied the drugs used on a medical and a surgical ward of a children's hospital for 13 weeks (p 343). 2013 drugs were given to 609 patients in 707 admissions: 506 (25%) were unlicensed (139) or off label (367), and in 256 admissions (36%) children received an unlicensed or off label drug. Most of the drugs used in this way were well established drugs, but the authors recommend that drugs used in children should be subject to a licensing process.
Two cohorts of medical undergraduates were followed from application to final examination to assess whether learning styles relate to final exam performance or to the extent of clinical experience. On p 345 McManus et al report that the amount of knowledge gained from clinical experience was related to strategic and deep learning styles at both the time of application and the final year. Grades at A level did not correlate with either study habits or clinical experience, and success in the final examination was not related to students' clinical experience. The authors question the validity of final examinations and suggest that medical schools should assess their applicants' learning styles, not just their examination results.
Although many accepted standard forms of treatment for shoulder pain exist, evidence for their efficacy is not well established. In a systematic review on p 354 Green et al assess the efficacy of these common interventions and explore the ways in which shoulder pain is categorised and assessed. They found little evidence to support or refute the efficacy of common interventions for shoulder pain. There is a need for further clinical trials investigating current treatments for shoulder pain, as well as standardisation of the way shoulder disorders are defined, classified, and measured.
In 1995 an audit of general practitioners' administration of aspirin and opiates in suspected myocardial infarction found that only 3% of patients received aspirin, with a low rate of opiate use. Prasad et al repeated the audit among 249 patients referred with chest pain to a coronary care unit by their general practitioners (p 353). 58% of patients with acute myocardial infarction or angina had been given extra aspirin; as before, only a fifth (54) were given intravenous opiates, with 24 inappropriately receiving intramuscular opiates.
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