Releases Saturday 12 May 2001
No 7295 Volume 322
Please remember to credit the BMJ as source when publicising
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(1) CHILDHOOD HEADACHES INFLUENCE ADULT
HEALTH
(2) SOCIAL
DEPRIVATION LINKED TO HEART
ATTACK SURVIVAL
(3) HOW
EFFECTIVE ARE OPIOIDS IN CHRONIC
PAIN RELIEF?
(4) VIOLENT
PATIENTS MOST LIKELY TO BE
REMOVED FROM
GPS' LISTS
(5) ROUTINE
AUDIT IS AN ESSENTIAL PART OF
SCREENING
(1) CHILDHOOD
HEADACHES INFLUENCE ADULT
HEALTH
(Relation between headache in childhood
and physical and
psychiatric symptoms in adulthood:
national birth cohort
study)
http://bmj.com/cgi/content/full/322/7295/1145
Children who experience frequent headaches
are at an
increased risk of recurring headache and
other physical
and psychiatric symptoms in adulthood,
finds a study in
this week's BMJ. These findings may have
implications for
the health of today's children and their
future wellbeing.
Data from over 11,000 people, who were
surveyed at
ages 7, 11, 16, 23 and 33 as part of a
national child
development study, were used to investigate
the relation
between headache in childhood and outcomes
in
adulthood. The research team found that
children with
frequent headache were more likely to
experience
psychosocial adversity and to grow up
with an excess of
both headache and other physical and psychiatric
symptoms. All three outcomes were more
common in
women and those from a manual social class.
These findings confirm that children with
headache do not
simply "grow out" of their physical complaint
and may also
"grow into" others, say the authors. Furthermore,
evidence
shows that the prevalence of headache
in childhood is
increasing steadily in the developed world,
and if this is so
there may well be a corresponding increase
in physical
and psychiatric symptoms as today's children
become
adults.
Contact:
Paul Fearon, Clinical Lecturer, Institute
of Psychiatry and
Guy's, King's and St Thomas's School of
Medicine,
London, UK
Email: p.fearon{at}iop.kcl.ac.uk
(2) SOCIAL DEPRIVATION
LINKED TO HEART
ATTACK SURVIVAL
(Relation between socioeconomic deprivation
and death
from a first myocardial infarction
in Scotland: population
based analysis)
http://bmj.com/cgi/content/full/322/7295/1152
Socioeconomic deprivation has a profound
effect on the
risk of having a first heart attack, the
chance of reaching
hospital alive, and the probability of
surviving the first
month, finds a study in this week's BMJ.
Data obtained from the Scottish Morbidity
Record and
General Register Office revealed that
between 1986 and
1995 in Scotland, 44,465 men and 38,710
women died
before being admitted to hospital after
a first heart attack.
A further 68,626 men and 49,123 women
were admitted
to hospital, of whom 22% died within 30
days.
The effect of socioeconomic deprivation
is greatest in the
young, with a twofold increase in death
before reaching
hospital in those under 65, say the authors.
The most
deprived members of society under 65 have
twice the risk
of a first heart attack and death before
reaching hospital,
they add.
Given these findings, reducing death from
heart disease
requires a focus on primary prevention
that explicitly
addresses socioeconomic inequalities,
conclude the
authors
Contacts:
Dr Kate MacIntyre, Specialist Registrar
in Public Health
Medicine, University of Glasgow, Scotland
Professor John McMurray, Clinical Research
Initiative in
Heart Failure, University of Glasgow,
Scotland
Email: J.McMurray{at}bio.gla.ac.uk
(3) HOW EFFECTIVE
ARE OPIOIDS IN CHRONIC
PAIN RELIEF?
(Randomised crossover trial of transdermal
fentanyl and
sustained release oral morphine
for treating chronic
non-cancer pain)
http://bmj.com/cgi/content/full/322/7295/1154
(Editorial: Opioids in chronic non-malignant
pain)
http://bmj.com/cgi/content/full/322/7295/1134
Fentanyl skin patches achieve better pain
relief and an
enhanced quality of life than sustained
release oral
morphine, say patients with chronic non-cancer
pain in a
study in this week's BMJ.
Patients with chronic non-cancer pain,
requiring
continuous treatment with potent opioids,
were randomly
assigned to two groups to assess their
treatment
preference, pain control, and quality
of life. One group
received four weeks of treatment with
sustained release
oral morphine followed by fentanyl patches
for four
weeks. The second group received the same
treatments
but in reverse order.
Of 212 patients, 138 (65%) preferred fentanyl
patches,
whereas 59 (28%) preferred sustained release
oral
morphine and 15 (7%) expressed no preference.
The
main reason given for preferring fentanyl
was better pain
relief, followed by greater convenience
and fewer adverse
events. Patients receiving fentanyl also
had higher overall
quality of life scores than patients receiving
morphine.
Although the level of adverse events was
similar in both
treatment groups, more patients experienced
constipation
with morphine than with fentanyl. These
findings confirm
that potent opioids can provide satisfactory
pain relief for
the difficult clinical problem of chronic
non-cancer pain,
conclude the authors.
In an accompanying editorial, pain specialist
Henry
McQuay acknowledges that this is a welcome
trial in a
difficult area, but writes: "Unfortunately
the design of the
trial means that we have to question the
results. Rule one
of drug trials that compare different
formulations and use
subjective outcomes such as patient preference
is that the
comparison should be done double blind."
However, the authors argue for simple clinical
trials based
in clinical practice, using outcomes of
greater relevance to
patients. The ethics of perfect design
with placebos and
blinding is questionable, especially when
such complex
trials fail to recruit patients or yield
useful results.
Treatment options for these patients are
limited. As such,
this comparative trial may herald a new
approach for their
care and in ethical clinical trial design.
Contacts:
[Paper]: Laurie Allan, Director, Chronic
Pain Services,
Northwick Park and St Mark's NHS Trust,
Middlesex,
UK
Email: northwick.pain{at}bigfoot.com
[Editorial]: Professor Henry McQuay, Pain
Relief Unit,
Churchill Hospital, Oxford, UK
Email: Henry.McQuay{at}pru.ox.ac.uk
(4) VIOLENT PATIENTS
MOST LIKELY TO BE
REMOVED FROM GPS' LISTS
(General practitioners' reasons for
removing patients from
their lists: postal survey in England
and Wales)
http://bmj.com/cgi/content/full/322/7295/1158
Violent, threatening or abusive behaviour
by patients is the
most common reason for removing a patient
from their
lists, report general practitioners in
this week's BMJ.
In April 2000, researchers at the University
of Sheffield
surveyed 1,000 general practitioners in
England and
Wales about the current scale of, and
reasons for, removal
of patients from their lists (other than
the patient living
outside the practice area). A total of
748 questionnaires
were returned.
They found that 40% of practices had removed
one or
more patients in the previous six months.
Violent,
threatening, or abusive behaviour was
given as a primary
reason in 176 (59%) of these cases and
as a contributory
reason in a further 24 (8%). Other primary
reasons given
were complaint by a patient (5 cases),
non-compliance
with childhood immunisation (4 cases),
and
non-compliance with cervical smear testing
(2 cases). In
83% of most recent removals, the practice
had given the
patient a reason for the removal, either
in writing or in
person.
A substantial proportion of general practitioners
believed
that the target payment systems for childhood
immunisation and cervical smear testing
and financial
arrangements for drug budgets and out-of-hours
care
created financial incentives for removing
patients.
However, non-compliance with childhood
immunisation or
cervical smear testing was rarely reported
as a reason,
and never as the sole reason for removal.
The validity of these findings depends
on doctors being
able and willing to identify and report
the number of
removals and their reasons for them, say
the authors.
Moreover, patients may have different
views of the events
leading to the removal, which future research
should seek
to understand, they conclude.
Contact:
James Munro, Clinical Senior Lecturer,
Medical Care
Research Unit, University of Sheffield,
Sheffield, UK
Email: j.f.munro{at}shef.ac.uk
(5) ROUTINE AUDIT
IS AN ESSENTIAL PART OF
SCREENING
(Routine audit is an ethical requirement
of screening)
http://bmj.com/cgi/content/full/322/7295/1179
Disease prevention and health promotion
activities must be
audited to ensure that they are achieving
their goals and
giving the best protection possible for
the future public
health of the country, according to a
letter to this week's
BMJ.
The value of audit as part of the quality
assurance of such
initiatives is particularly significant
in light of recent
publicity surrounding discrepancies in
the NHS cervical
cancer screening programme.
The authors describe a national audit of
cervical cancer
screening, which has been running since
1992, and
enables rational decisions to be made
about modifications
on issues such as quality, screening interval
and target age
groups. The clinical value of these databases
is enormous,
stress the authors, since before they
existed, follow up of
women with abnormal results was often
inadequate.
They believe that routine audit is an essential
part of any
screening programme, and they urge health
authorities to
continue this activity despite recent
concerns about using
patient information without informed consent.
"The benefit in terms of cancer prevention
is sufficiently
great to warrant the secretary of state
making regulations
in accordance with clause 68 of the Health
and Social
Care Bill, and we urge him to do so,"
they conclude.
Contact:
Peter Sasieni, Coordinator, Cervical Screening
Unit,
London, UK (via Dawn Boyall, Imperial
Cancer Research
Fund Press Office)
Email: d.boyall{at}icrf.icnet.uk
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London WC1H 9JR
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(http://www.eurekalert.org)
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