Releases Saturday 3 February 2001
No 7281 Volume 322

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(1) LIVER DISEASE MAY BE BEING MISSED IN
PRIMARY CARE

(2) MORPHINE SPRAY MORE EFFECTIVE THAN
INJECTION TO RELIEVE PAIN IN YOUNG PEOPLE

(3) NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
ARE ASSOCIATED WITH INCREASED RISK OF
MISCARRIAGE IN PREGNANT WOMEN

(4) LARGE SCALE SUPPLY OF MOSQUITO NETS
REDUCE MALARIA

(5) MEDICAL SCHOOLS MUST NOT ACCEPT
DISHONEST BEHAVIOUR AMONG STUDENTS




(1) LIVER DISEASE MAY BE BEING MISSED IN
PRIMARY CARE

(How are abnormal results for liver function tests dealt with in
primary care? Audit of yield and impact)
http://bmj.com/cgi/content/full/322/7281/276

Treatable chronic liver disease may be being missed in primary
care because abnormal test results for liver function are often
not adequately investigated, according to a study in this week's
BMJ.

Researchers from the Queen's Medical Centre in Nottingham
followed up all adult patients who had an abnormal result for
liver function based on a test requested by their doctor
between January and June 1995. Of 873 patients followed up,
342 were not under hospital review. 157 of these patients
were thought to require further investigation, yet no further
tests had been requested for 91. 66 patients had been partially
investigated by their doctor and, in seven patients, results
suggesting a treatable chronic liver disease had not been
followed up and no referral had been made to a
gastroenterologist.

Our findings show that many important diagnoses - including
communicable, potentially life threatening diseases - are
missed, say the authors. Patients with persistently abnormal
test results should be referred to a hepatologist or
gastroenterologist, they conclude.

Contact:

Stephen Ryder, Consultant Hepatologist, Division of
Gastroenterology, Queen's Medical Centre, Nottingham, UK.
Email: stephen.ryder@mail.qmcuh-tr.trent.nhs.uk

(2) MORPHINE SPRAY MORE EFFECTIVE THAN
INJECTION TO RELIEVE PAIN IN YOUNG PEOPLE

(Multicentre randomised controlled trial of nasal diamorphine
for analgesia in children and teenagers with clinical fractures)
http://bmj.com/cgi/content/full/322/7281/261

Nasal diamorphine spray is a safe and effective method of pain
relief for young people in acute pain with a limb fracture, and
should be used in place of morphine by intramuscular injection,
finds a study in this week's BMJ.

Kendall and colleagues identified 404 patients, aged between
3 and 16 years, attending an emergency department with acute
pain resulting from a limb fracture. 204 patients were given
nasal diamorphine spray and 200 were given intramuscular
morphine. They found that onset of pain relief was faster in the
spray group than in the intramuscular group, with lower pain
scores in the spray group at 5, 10 and 20 minutes after
treatment, but no difference between the groups after 30
minutes. Furthermore, 80% of patients given the spray showed
no obvious discomfort compared with 9% given intramuscular
morphine, and no serious adverse events were seen in patients
given the spray.

There should no longer be any reason to give intramuscular
morphine to such children because the spray is appropriate
wherever intramuscular morphine is being considered,
conclude the authors.

Contact:

Jason Kendall, Consultant, Emergency Department, Frenchay
Hospital, Bristol, UK
Email: frenchayed@cableinet.co.uk

(3) NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
ARE ASSOCIATED WITH INCREASED RISK OF
MISCARRIAGE IN PREGNANT WOMEN

(Risk of adverse birth outcome and miscarriage in pregnant
users of non-steroidal anti-inflammatory drugs: population
based observational study and case-control study)
http://bmj.com/cgi/content/full/322/7281/266

Taking non-steroidal anti-inflammatory drugs during pregnancy
does not seem to increase the risk of adverse birth outcome
(congenital abnormality, low birth weight, or preterm birth) but
is associated with increased risk of miscarriage, according to a
study in this week's BMJ.

Researchers in Denmark investigated 1,462 pregnant women
who had taken up prescriptions for non-steroidal
anti-inflammatory drugs during the period 30 days before
conception to birth. They also compared 4,268 women who
had miscarriages, of whom 63 had taken non-steroidal
anti-inflammatory drugs, with 29,750 women who had live
births.

They found no increased risk of adverse birth outcome in
women who took up prescriptions for non-steroidal
anti-inflammatory drugs, but there was a strong positive
association with miscarriage. However, no firm conclusions as
to whether this association is causal or due to other
confounding factors could be drawn from the data, add the
authors.

Knowledge on the safety of taking non-steroidal
anti-inflammatory drugs while pregnant is limited, say the
authors. Our observation of an increased risk of miscarriage in
women exposed to non-steroidal anti-inflammatory drugs is
new and needs to be confirmed, conclude the authors.

Contact:

Gunnar Lauge Nielsen, Consultant, Department of Medicine,
Odder Hospital, Odder, Denmark
Email: uxgln@aas.nja.dk

(4) LARGE SCALE SUPPLY OF MOSQUITO NETS
REDUCE MALARIA

(Impact on malaria morbidity of a programme supplying
insecticide treated nets in children aged under 2 years in
Tanzania: community cross sectional study)
http://bmj.com/cgi/content/full/322/7281/270

(Editorial: Insecticide treated bed nets to prevent malaria)
http://bmj.com/cgi/content/full/322/7281/249

Mosquito nets treated with insecticide and distributed as part
of a large scale social marketing programme can substantially
reduce the prevalence of malaria and anaemia in very young
children in Tanzania, finds a study in this week's BMJ. This
strategy has high potential in the control of malaria in
sub-Saharan Africa, say the authors.

Abdulla and colleagues investigated a random sample of 748
children, aged under 2 years, living in 18 villages in southwest
Tanzania. The first survey was done at the time of launching
the social marketing campaign (June 1997), and two other
surveys were carried out at the same period (June to August)
in the subsequent two years. They found that ownership of
treated nets rose rapidly, from 10% to 61%. The prevalence
of severe anaemia decreased from 49% to 26% in the two
years studied, and the mean Haemoglobin level in the children
rose from 80g/l to 89 g/l. Treated nets had a protective
efficacy of 63% against both malaria and anaemia.

Treated mosquito nets might therefore be able to deliver
feasible and effective malaria prevention on a large scale in
areas where malaria is highly endemic, conclude the authors.

Contacts:

Dr Christian Lengeler, Project Leader, Swiss Tropical
Institute, Basle, Switzerland
Email: Christian.Lengeler@unibas.ch

Dr Salim Abdulla, Ifakara Health Research and Development
Center, Ifakara, Tanzania,
Email: ihrdc@twiga.com

(5) MEDICAL SCHOOLS MUST NOT ACCEPT
DISHONEST BEHAVIOUR AMONG STUDENTS

(Are "tomorrow's doctors" honest? Questionnaire study
exploring medical students' attitudes and reported behaviour
on academic misconduct)
http://bmj.com/cgi/content/full/322/7281/274

(Editorial: Cheating at medical school)
http://bmj.com/cgi/content/full/322/7281/250

Academic misconduct does exist amongst medical students
and needs to be taken seriously by medical schools, finds a
study in this week's BMJ.

An anonymous questionnaire was completed by 461 students
in all years at Dundee University medical school. The
questionnaire had 14 scenarios in which a fictitious student,
"John," engaged in dishonest behaviour. For each scenario,
students were asked whether they felt John was wrong and
whether they had done or would consider doing the same.

Most students felt that most of the scenarios were wrong.
However, the proportion of students reporting that they had
engaged in or would consider engaging in the scenarios varied
from 2% for copying answers in a clinical examination to 56%
for copying directly from published text and only listing it as a
reference. About a third of students reported that they had
engaged in or would consider engaging in behaviour described
in four of the scenarios: exchanging information about an
examination, writing "nervous system examination normal"
when this hadn't been performed, lending work to others, and
copying published text without appropriate referencing.

Some of these findings are worrying, as they suggest that, in
some cases, there is no consensus among students on what
constitutes unacceptable behaviour, say the authors. Academic
misconduct needs to be taken seriously by medical schools as
it casts doubt on the validity of qualifications, they conclude.

Medical schools must make their institutional position and their
expectations of students absolutely clear from day one, writes
Shimon Glick in an accompanying editorial. The future of the
medical profession depends on preserving and restoring public
trust in doctors, but this trust must be deserved and earned, he
concludes.

Contacts:

[Paper]: Carol Pope, Press Officer, University of Dundee,
Scotland, UK
Email: c.l.e.pope@dundee.ac.uk

[Editorial]: Shimon Glick, Professor Emeritus, Moshe Prywes
Center for Medical Education, Ben Gurion University of the
Negev, Becr Sheva, Israel
Email: Gshimon@bgumail.bgu.ac.il


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