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Press releases Saturday 16 September 2006

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(1) EMERGENCY CONTRACEPTION FAILS TO HALT ABORTIONS

(2) WORLD-WIDE WARNING OF HIGHLY DRUG-RESISTANT TUBERCULOSIS

(3) ACUPUNCTURE RELIEVES LOW BACK PAIN AND IS COST-EFFECTIVE

(4) CALCIUM SUPPLEMENTS FAIL TO PREVENT BONE FRACTURES IN CHILDREN

(1) EMERGENCY CONTRACEPTION FAILS TO HALT ABORTIONS

(Emergency Contraception: Is it worth all the fuss?)
http://bmj.com/cgi/content/full/333/7568/560

Easy availability of emergency contraception does not have a notable effect on rates of pregnancy and abortion, according to an editorial in this week’s BMJ.

The usefulness of emergency contraception is questioned by Professor Anna Glasier, director of family planning and well woman services of Lothian Primary Care NHS Trust, Edinburgh, who says it does help some women some of the time, who do not want to get pregnant.

Use of this form of contraception has increased in the UK in recent years and whereas 1% of women requesting an abortion in 1984 said they had used it to try and prevent the pregnancy, 6% of women had done so in 1996 and 12% in 2002.

Emergency contraception has been heralded as the solution to rising abortion rates, says Professor Glasier, but in the UK, abortion rates have increased from 11 per 1,000 women aged 15-44 in 1984 (136,388 abortions) to 17.8 per 1,000 women in 2004 (185,400 abortions) despite the increased use of emergency contraception.

Ten different studies carried out in different countries showed that giving women a supply of emergency contraception to keep at home increased its use by twofold or threefold, but had no measurable effect on rates of pregnancy or abortion.

Most women who did not use their supply, said they did not realise they had put themselves at risk of pregnancy.

Professor Glasier writes: “If you are looking for an intervention that will reduce abortion rates, emergency contraception may not be the solution and perhaps you should concentrate most on encouraging people to use contraception before or during sex, not after it.”

Contact:

Anna Glasier, Director of Family Planning and Well Woman Services, Lothian Primary Care NHS Trust, Edinburgh.
Email: anna.glasier@lpct.scot.nhs.uk

(2) WORLD-WIDE WARNING OF HIGHLY DRUG-RESISTANT TUBERCULOSIS

(Extensively drug-resistant tuberculosis)
http://bmj.com/cgi/content/full/333/7568/559

New forms of highly drug-resistant tuberculosis are emerging and action must be taken soon before they become widespread globally, says an editorial in this week’s BMJ.

The authors say that urgent action is needed to implement effective tuberculosis control strategies, especially in countries where tuberculosis control practices have been inadequate.

Research is also needed to assess the extent of the spread of these highly drug resistant strains of tuberculosis worldwide and improved means of diagnosis of tuberculosis and early detection of drug resistance are urgently required, they add.

Among 536 cases of tuberculosis confirmed at a rural hospital in South Africa earlier this year, 41% were multi-drug resistant and of those, 24% met the exact definition of being extensively drug resistant tuberculosis (also referred to as XDR tuberculosis). Such tuberculosis is almost untreatable.

All patients in this outbreak who were tested were HIV positive and 52 of the 53 died after an average of 25 days.

Strains of extensively drug resistant tuberculosis have also been noted in Europe, Asia and North and South America. It appears that there are several strains of this tuberculosis.

Author Dr Stephen Lawn, senior lecturer in infectious and tropical diseases at the University of Cape Town, South Africa, says that drug resistance to tuberculosis results largely from poorly managed care and control of the disease.

Poor prescribing practices, low drug quality (or erratic supply) and poor adherence to drugs can all contribute to this resistance to drugs. Where HIV rates are high, this allows particularly rapid spread of the disease within hospital settings and the community.

Dr Lawn says several responses to this problem are required including urgent assessment of the scale of the problem and an increase in laboratory capacity.

“Detection rates for cases of tuberculosis need to be improved, highlighting the need for a new diagnostic test,” he writes. “Technologies that can determine the presence of drug-resistance at the point of care are needed as are new drug treatments.”

Contact:

Stephen Lawn, Senior Lecturer in Infectious and Tropical Diseases at the Faculty of Health Sciences, University of Cape Town, South Africa
Email: stevelawn@yahoo.co.uk

(3) ACUPUNCTURE RELIEVES LOW BACK PAIN AND IS COST-EFFECTIVE

Online First
(Randomised controlled trial and cost effectiveness analysis of a short course of traditional acupuncture compared with usual care for persistent low back pain)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38878.907361.7C

(A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38932.806134.7C

Acupuncture has a small but significant benefit for patients with low back pain, and appears to be cost-effective in the longer term, find two studies published on bmj.com today.

In the UK, an estimated 16% of the adult population consult their general practitioner for help with back pain in a 12-month period. The annual cost of lower back pain to the NHS has been estimated at £480 million (€703million; $901million) and the burden of lower back pain is estimated at over £10 billion per year in terms of lost productivity and sickness benefits.

Acupuncture is used by an estimated 2% of adults each year for a range of conditions, including back pain. But the evidence is largely inconclusive and the best way to manage low back pain remains unclear.

So, researchers identified 241 adults aged 18 to 65 with persistent non-specific low back pain. The people were provided by members of the British Acupuncture Council. Patients were randomly assigned to either usual NHS care or up to 10 acupuncture treatment sessions. All patients remained under GP care.

Pain levels were measured at intervals during the two-year study period. Satisfaction with treatment and use of pain medication were also recorded.

At 12 months, patients in the acupuncture group showed a small benefit in pain scores compared to patients receiving usual care. Stronger evidence was observed for an increased benefit at 24 months.

At three months, patients in the acupuncture group were significantly more likely to be ‘very satisfied’ with their treatment compared with usual care, and with their overall care, but showed no such difference in satisfaction with information received.

At 24 months, the acupuncture group were more likely to report reduced worry about their back pain, less likely to report current use of pain medication for their back, and more likely to report no pain for the past 12 months.

Although the differences in pain scores between groups were small, they represent a clinically worthwhile benefit and can be viewed as a ‘moderate’ effect, say the authors.

Further research is needed to investigate the optimum timing for such an acupuncture treatment package, and to assess the value of repeated courses of acupuncture for patients experiencing recurrent episodes of low back pain, they conclude.

In a separate paper, the same researchers looked at the cost effectiveness of acupuncture for lower back pain. Costs were measured from both an NHS and a societal perspective, and effectiveness was measured in terms of quality adjusted life years (QALYs) gained.

They found that total NHS costs during the two-year study period were higher on average for the acupuncture group (£460; €673; $859) than for the usual care group (£345; €506; $644).

However, the cost per QALY gained was £4,241 (€6,223; $7,921). This is well below the lower threshold of £20,000 used by the National Institute for Health and Clinical Excellence (NICE) to decide whether the NHS can afford to pay for a health technology.

A short course of traditional acupuncture for the treatment of lower back pain in primary care confers a modest health benefit measured in QALYs for a relatively minor extra NHS cost relative to usual care, say the authors. The use of acupuncture for the treatment of lower back pain therefore appears to be cost-effective in the longer term.

Contact:

Hugh MacPherson, Senior Research Fellow, Department of Health Sciences, University of York, UK
Email: hm18@york.ac.uk

(4) CALCIUM SUPPLEMENTS FAIL TO PREVENT BONE FRACTURES IN CHILDREN

Online First
(Effects of calcium supplementation on bone density in healthy children: meta-analysis of randomised controlled trials)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38950.561400.55

Calcium supplements have very little benefit for preventing fractures in childhood and later adulthood, concludes a study in the BMJ.

Children taking such supplements are have only small improvements in bone density, which are unlikely to reduce fracture risk, says the study carried out by researchers at the Menzies Research Institute in Australia and other approaches could be more beneficial such as increasing vitamin D concentrations and eating more fruit and vegetables.

Osteoporosis is a major public health problem, particularly in women, and low bone mineral density is an important risk factor for osteoporotic fractures. Bone density worsens for women after the menopause, so intervention in childhood to maximise peak bone mass by improving factors such as diet and physical activity can minimise the impact of bone loss related to age.

The researchers analysed the findings of 19 different studies involving 2,859 children collectively aged between three and 18. They included randomised trials of calcium supplementation in healthy children that lasted at least three months and which measured bone outcomes after at least six months of follow-up.

They found there was a small effect on total body bone mineral content and upper limb bone mineral density – children taking the supplements only had 1.7% better bone density in their upper limbs than children not taking the supplements.

However, there was no effect at important sites in the body for fracture in later life – namely the hip and lumbar spine. After children stopped taking calcium supplements, the effect persisted at the upper limb, but disappeared for total body bone mineral content.

The authors conclude: “The small effect of calcium supplementation on bone mineral density in the upper limb is unlikely to reduce the risk of fracture, either in childhood or later life, to a degree of major public health importance. It may be appropriate to explore alternative nutritional interventions, such as increasing vitamin D concentrations and intake of fruit and vegetables.”

Contact:

Tania Winzenberg, Musculoskeletal Epidemiologist, Menzies Research Institute, Tasmania, Australia.
Email: tania.winzenberg@utas.edu.au

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