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Press releases Saturday 18 February 2006

(1) ACUPRESSURE RELIEVES LOW BACK PAIN

Online First
(Treatment of low back pain by acupressure and physical therapy: randomised controlled trial)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38744.672616.AE

Acupressure (applying pressure with the thumbs or fingertips to the same points on the body stimulated in acupuncture) seems to be more effective in reducing low back pain than physical therapy, finds a study published online by the BMJ today.

Low back pain is a common health problem worldwide. In previous studies, acupressure has been shown to be effective in alleviating various types of pain, but little is known about its effect on low back pain.

Researchers in Taiwan recruited 129 patients with chronic low back pain from a specialist orthopaedic clinic. All patients completed a standard disability questionnaire before being randomly allocated to two treatment groups: 64 patients received six sessions of acupressure and 65 patients received physical therapy. Results were analysed immediately after treatment and again after six months.

The mean disability score after treatment was significantly lower in the acupressure group than in the physical therapy group.

In fact acupressure conferred an 89% reduction in disability compared with physical therapy, after adjusting for pre-treatment disability. This improvement lasted for six months.

Benefit was also greater in the acupressure group for variables such as “leg pain,” “pain interferes with normal work,” and “days off from work/school.”

This study shows that acupressure is more effective in alleviating low back pain than physical therapy in terms of pain scores, functional status, and disability, say the authors. The effect was not only seen in the short term, but lasted for six months.

These results support the conclusion of previous studies. Acupressure may thus be useful for reducing pain and improving body function and level of disability in low back pain, they conclude.

Contact:

Professor Tony Hsiu-Hsi Chen, Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
Email: stony@episerv.cph.ntu.edu.tw

(2) HAVE TARGETS IMPROVED PERFORMANCE IN THE ENGLISH NHS?

(Have targets improved performance in the English NHS?)
http://bmj.com/cgi/content/full/332/7538/419

The star rating system for English NHS trusts seems to have improved performance, but systems need to be put in place to minimise gaming and ensure targets are not causing problems elsewhere, warn researchers in this week’s BMJ.

Annual performance ratings have been published for NHS trusts in England since 2001. This process of naming and shaming gave each trust a rating from zero to three stars. Although the government has now abandoned star ratings, targets are likely to remain.

But have targets improved performance and what ought to happen in the future, ask professors Gwyn Bevan and Christopher Hood?

The key target for accident and emergency departments was the percentage of patients to be seen within four hours. In 2002, before any target was set, 23% of patients spent over four hours in accident and emergency, but by 2004 only 5.3% stayed that long.

Similarly, reported performance improved greatly after ambulance trusts were star rated on their response times, and hospitals were rated on the number of patients waiting for elective surgery.

Interestingly, after 2003, reported performance improved in other UK countries, dramatically in Wales and Northern Ireland. This suggests that the naming and shaming policy in England put pressure on the NHS in the other countries, say the authors.

But the use of targets results in gaming, they add. For example, extra staff being drafted into accident and emergency departments, operations being cancelled, and patients having to wait in ambulances until staff were confident of meeting the target.

This means that when reported performance meets the targets, nobody knows how genuine the improvements are.

Nobody would want to return to the NHS performance before the introduction of targets, so how can we maximise the social benefits and minimise the costs of a regime of targets with sanctions?

They suggest introducing more uncertainty in the way that performance is assessed and better auditing of performance data. They also call for an independent body to investigate the genuineness of reported improvements and the costs to other services.

Although these changes would not wholly eliminate the gaming problems associated with any regime of targets and terror, they could reduce them, they say. The current combination of performance measures that are highly predictable to managers and an audit system that is poorly equipped to detect gaming, risks losing credibility, they conclude.

Contact:

Gwyn Bevan, Professor of Management Science, Department of Operational Research, London School of Economics and Political Science, London, UK Email: r.g.bevan@lse.ac.uk

(3) LIVERS FROM NON-HEART BEATING DONORS WOULD BOOST ORGAN SUPPLY

(Editorial: Liver transplantation from non-heart beating donors)
http://bmj.com/cgi/content/full/332/7538/376

Liver transplants from non-heart beating donors have the potential to increase the supply of organs by as much as 20%, according to experts in this week’s BMJ.

They believe that it’s time to take notice of this promising way to boost the supply of human organs for transplantation.

Like most other solid organ transplants, liver transplantation has become a victim of its own success with more patients now on the waiting list as the number of donors declines.

In general liver donation rates are poor in the UK (13 per million population compared with 33 per million in Spain, the best in Europe). In order to use this scarce resource most effectively, clinicians are restricting access to transplantation to patients with a 50% chance of survival at five years.

Even so the supply is not able to meet demand. In the UK about 60 people die on the waiting list each year and up to 80 are removed from the list as their condition deteriorates.

To increase the number of organs available for transplantation, doctors use techniques such as split liver transplantation (one liver given to two recipients) or living donor transplants.

Another potential source of organs is the non-heart beating donor, where organs are retrieved after a “stand off” period of five minutes during which death is certified.

Although the early results were far worse than those with beating heart donors, survival rates are improving as new ways of preserving organs are found, say the authors.

The British Transplant Society has also recently published guidelines on all aspects of non-heart beating donation, including ethical and legal issues.

A reasonable prediction would be that non-heart beating donor livers have the potential to contribute about 10-20% more organs to the donor pool, a challenge which the medical community has to take up, they conclude.

Contact:

Raj Prasad, Consultant Transplant Surgeon, Department of Organ Transplantation, St James’s University Hospital, Leeds, UK
Email: raj.prasad@leedsth.nhs.uk

(4) CONCERN OVER FAST TRACKING OF NEW DRUGS

(Lessons for clinical trials from natalizumab in multiple sclerosis)
http://bmj.com/cgi/content/full/332/7538/416

Concerns over the fast tracking of new drugs for commercial licensing are raised by a senior doctor in this week’s BMJ.

It follows approval of natalizumab, a new drug for multiple sclerosis, and its recall three months later, after three trial patients developed a life threatening condition while being treated.

Natalizumab was licensed by the US Food and Drug Administration in 2004 for use in relapsing multiple sclerosis on the basis of short term results from two unpublished trials. The FDA granted approval before final trial and cumulative safety data were available. Natalizumab was predicted to be the leading drug for multiple sclerosis, with estimated annual sales in excess of $2bn.

Around 3000 patients took part in the trials and nearly 5000 patients have been treated in the United States since it became commercially available. In the United Kingdom, natalizumab was due for appraisal by the National Institute for Health and Clinical Excellence in 2006.

But on 28 February 2005, natalizumab was recalled after three trial patients developed progressive multifocal leucoencephalopathy (PML), a rapidly progressive neurodegenerative disease. Two of the patients died.

The approval of natalizumab and its recall after three months raises questions about the fast tracking of new drugs by the FDA for commercial licensing, says the author, consultant neurologist Abhijit Chaudhuri. It also highlights the potential risks for patients in trials of new drugs where knowledge of long term efficacy, outcome measures, and safety is lacking.

Short term solutions for a chronic disease like multiple sclerosis are not likely to be effective, and experience with natalizumab should be taken as a signal to change the way we treat this disease, he concludes.

Contact:

Abhijit Chaudhuri, Consultant Neurologist, Essex Centre for Neurological Sciences, Oldchurch Hospital, Romford, Essex, UK
Email: chaudhuria@gmail.com

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