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Press releases Saturday 6 October2007

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(1) No strong evidence linking amateur boxing with long term brain injury
(2) Paramedics can provide an effective alternative to standard ambulance service in the community
(3) Should GPs resume 24 hour responsibility for their patients?
(4) Direct to consumer advertising in Europe will harm public health, warn experts
(5) Experts call for informed public debate on water fluoridation

(1) No strong evidence linking amateur boxing with long term brain injury
(Amateur boxing and risk of chronic traumatic brain injury: a systematic review of observational studies) BMJ Online First
(Boxing and the risk of chronic brain injury)
BMJ Online First

The evidence linking amateur boxing and chronic traumatic brain injury is not strong, concludes a study published on bmj.com today. As such, the researchers say they cannot firmly prove nor reject the theory that amateur boxing leads to chronic brain injury.

Although the evidence for chronic traumatic brain injury in amateur boxing is less clear cut than that in professional boxing, the safety of amateur boxing continues to be questioned.

The British Medical Association wants a complete ban on boxing (amateur and professional), mainly because of the purported risk of cumulative brain injury. However, no recent or systematic review has been performed to assess the evidence for this in the amateur sport.

So a team of sports physicians and clinical academics reviewed the evidence to determine whether amateur boxing leads to chronic traumatic brain injury.

They identified 36 observational studies of amateur boxing and chronic traumatic brain injury. Differences in study design and quality were taken into account to minimise bias. They defined chronic traumatic brain injury as any abnormality in neurological examination, brain imaging, psychometric testing, or electroencephalography (a measurement of the brain's electrical activity).

Overall, 15 (42%) of the 36 studies concluded that relevant abnormalities were present, at least in a proportion of boxers studied. However, the quality of evidence was generally poor.

The best quality studies were those involving psychometric tests and these yielded the most conclusive negative results (no long-term effect of boxing on brain function). Only four of 17 (24%) better quality studies found any indication of chronic traumatic brain injury in a minority of boxers studied.

Similarly, in the six studies that used magnetic resonance imaging (generally accepted as the best method of determining subtle damage and degenerative change), only one concluded that relevant abnormality was present. This was a cyst in a single boxer, which was possibly congenital.

Positive findings were generally limited to studies of poorer quality and design, and few were of sufficient quality to conclude anything other than a weak association.

Amateur boxing is becoming an increasingly popular participation sport, say the authors. This review neither seeks to endorse nor oppose the sport of amateur boxing. Nevertheless, the current evidence, such as it exists, for chronic traumatic brain injury as a consequence of amateur boxing is not strong, they conclude.

In an accompanying editorial, Paul McCrory, neurologist and sports physician at the University of Melbourne, suggests that, because today's boxers have shorter careers and reduced exposure to repetitive head trauma, the likelihood of this condition developing is probably low.

Contacts:
Mike Loosemore, Lead Sports Physician, Olympic Medical Institute, Northwick Park Hospital, Harrow, UK
Email: xob99@tiscali.co.uk 
Charles Knowles, Senior Lecturer and Honorary Consultant Surgeon, Centre for Academic Surgery, Royal London Hospital, London, UK
Email: c.h.knowles@qmul.ac.uk 

(2) Paramedics can provide an effective alternative to standard ambulance service in the community
(Paramedic Practitioner Older People's Support Trial (PPOPS): cluster randomised controlled trial )
BMJ Online First
(Paramedic practitioners and emergency admissions )
BMJ Online First

Paramedics with extended skills can provide a safe and effective alternative to standard ambulance transfer and hospital treatment for older people with a minor injury or illness, finds a study published on bmj.com today.

Older people make up to 21% of visits to hospital emergency departments and previous studies have suggested that paramedics can be trained to manage certain conditions in the community. But current research evidence concerning safety, effectiveness and costs to support these changes in practice is lacking.

So researchers based in South Yorkshire carried out the first randomised trial to evaluate the effectiveness of an alternative approach to managing older people with minor problems.

They selected seven experienced paramedics who had completed the Paramedic Practitioner in Older People's Support (PPOPS) training course. This scheme aims to deliver patient centred care to older people calling the emergency services with conditions judged to be not immediately life threatening.

The trial took place in Sheffield from September 2003 to September 2004 and included 3,018 patients aged 60 years and above calling the emergency services between 0800-2000hrs with a complaint that fell within the scope of practice of the paramedic practitioners. These included falls, lacerations, nosebleeds or minor burns.

During each week, a paramedic practitioner based in the ambulance control room identified eligible calls and notified either a paramedic practitioner in the community (intervention weeks) or in the emergency department for the standard 999 service (control weeks).

Emergency department attendance or hospital admission between 0 and 28 days was recorded, as was interval from time of call to time of discharge. Patient satisfaction with the service they had received was also measured using a postal questionnaire 3 and 28 days after the incident.

Patients in the intervention group were almost 25% less likely to attend the emergency department or require hospital admission within 28 days. These patients also experienced a shorter total episode time by around 42 minutes.

Patients in the intervention group were also more likely to report being highly satisfied with their health care episode than those in the control group.

There were no statistically significant differences between the two groups in terms of health outcomes and mortality 28 days after their initial episode.

Despite some study limitations, the authors conclude that this service conveyed significant benefits for patients and the NHS in terms of reduced overall emergency department and hospital attendances, shorter episode times and higher levels of patient satisfaction. The new service also appears to be safe in that they identified no difference in mortality or health outcomes after 28 days.

As pressure increases within the NHS to extend this type of approach, this trial will help to inform practice in this fast developing area, they add.

This trial shows that high quality study designs are feasible in this setting, says an accompanying editorial. Such trials should, therefore, be used to evaluate the more widespread emergency care practitioners scheme and other extended scope paramedic programmes before further costly expansions take place.

Contact:
Suzanne Mason, Reader in Emergency Medicine, School of Health and Related Research, University of Sheffield, Sheffield, UK
Email: s.mason@sheffield.ac.uk 

(3) Should GPs resume 24 hour responsibility for their patients?
(Head to head: Should general practitioners resume 24 hour responsibility for their patients?)
Yes: http://www.bmj.com/cgi/full/335/7622/696
No: http://www.bmj.com/cgi/full/335/7622/697

Complaints about the care provided by out of hours services in the UK are growing, so should general practitioners take back this responsibility? Two experts debate the issue in this week's BMJ.

The new contract for general practitioners introduced in 2004, which allowed practitioners to opt out of 24 hour responsibility, has led to a situation in which the best trained general practitioners concentrate their efforts on daytime care, while patients who become ill at night risk being seen by less experienced doctors, argues Roger Jones, Professor of General Practice at King's College London.

He warns that not only does a parallel out of hours service lead to fragmentation of care and potentially dangerous communication errors, it is likely to be more expensive, in terms of both running costs and unnecessary inpatient costs.

He says: "I am not suggesting that all general practitioners resume out of hours responsibility for their entire professional life. And I am certainly not supporting the view that surgeries should be open at all hours for routine care - this entirely misses the point. However, during vocational training and in the early years of practice, seeing patients in their homes, assessing acute medical problems, and making appropriate decisions about treatment and hospital referral should be regarded as core aspects of training and professional development, just as they are in hospital medicine."

Having covered out-of-hours care himself, Jones does not underestimate the difficulties of re-engaging with personal out-of-hours care but he is convinced that for many doctors and patients a return to a more personal approach to 24 hour responsibility would reap enormous benefits.

The relinquishing of out-of-hours responsibility has led to accusations that general practitioners do not care about their patients. But it is precisely because we want the best care for patients that the change was made, writes Helen Herbert, Chair of the Royal College of General Practitioners in Wales.

She describes her experience of covering out-of-hours care, often in a state of exhaustion, and argues that sleep deprived people should not be making life threatening decisions.

General practitioners are blamed unfairly for the state of out-of-hours services when the responsibility for commissioning and providing these services resides with primary care organisations, she says. She acknowledges that some out of hours services are confusing and fragmented, but believes that general practitioners are the solution to improving urgent care services, not the problem.

And she points out that where out-of-hours care is properly organised and resourced, it works well, and many studies have shown high satisfaction with the care provided.

The profession made the difficult decision to withdraw responsibility for out-of-hours care to ensure the safety of our patients and recruitment of future generations of doctors, she writes, but we must maintain responsibility for these values by providing excellence in preventative care and by influencing the providers, commissioners, and policy makers to ensure provision of the high standards of care that we expect for our patients.

Contacts:
Roger Jones, Professor of General Practice, King's College London, UK
Email: roger.jones@kcl.ac.uk 
Helen Herbert, Chair, Royal College of General Practitioners Wales, Cardiff, Wales
Email: press@rcgp.org.uk 

(4) Direct to consumer advertising in Europe will harm public health, warn experts
(Industry funded patient information and the slippery slope to New Zealand)
http://www.bmj.com/cgi/full/335/7622/694

Allowing the drug industry to supply information on prescription medicines direct to patients in Europe will have serious implications for public health, warn experts in this week's BMJ.

The European parliament is considering allowing the drug industry to have a much greater role in providing information to patients, with no restriction on the type of media, write Les Toop and Dee Mangin from the University of Otago, New Zealand.

In New Zealand and the US, the only two developed countries that allow direct to consumer advertising of prescription medicines, opposition has grown steadily from both the public and doctors.

New Zealand's health system is much closer to those in Europe than the US system. So what can we learn from its experience, they ask?

Last year drug companies spent over $5bn on direct to consumer advertising in the US and tens of millions of dollars in New Zealand. But opposition grew alongside the advertising, and by 2000, New Zealand and US health watchdog groups were becoming more vocal.

The rising concern led the New Zealand Ministry of Health to start a public consultation in the same year. But the advertising was allowed to continue with self regulation and a promised further review of compliance with the rules never took place.

In this context, advertising became more widespread and proved extremely effective. For instance, intensive advertising of celcoxib and refecoxib on prime time television, aimed specifically at long term use in the elderly, resulted in widespread prescribing, despite early warnings of their cardiac risks. Similarly, just a few TV adverts promoting oral terbinafine for toenail infections resulted in a doubling of national prescriptions within weeks.

In response to mounting concern from the public and the professions, the New Zealand government resolved to ban direct to consumer advertising in late 2003. To date, the government has been unable to pass the necessary legislation, despite a recent round of consultation showing strong opposition from health professional groups and almost complete (90%) opposition from independent consumer and patient organisations.

The lesson from the New Zealand experience for Europe is clear, say the authors.

Allowing industry funded objective information will serve only to manipulate consumer choices. It will not help consumers make better decisions about medicines but will increase the pharmaceuticalisation of health and will expose more of the population to new medicines (many of which offer little benefit over existing medicines) at a time when long term safety is unknown.

It will also rapidly drive up drug costs with major implications for already stretched health budgets - all of which will be of net harm to the overall public health, they warn.

The goal should be a global collaborative commitment to facilitate access to the independent information prescribers and consumers need to be able to make better informed decisions about medicines, they conclude.

Contact:
Professor Les Toop, Department of Public Health and General Practice, University of Otago, Christchurch, New Zealand
Email: les.toop@otago.ac.nz 

(5) Experts call for informed public debate on water fluoridation
(Adding fluoride to water supplies)
http://www.bmj.com/cgi/full/335/7622/699
(Fluoride: a whiter than white reputation?)
http://www.bmj.com/cgi/full/335/7622/732

Adding fluoride to water supplies to prevent dental caries is controversial. In this week's BMJ, researchers express concern over the way evidence is often misinterpreted and uncertainties glossed over, making it hard for people to participate in consultations on an informed basis.

So they highlight problems that should be confronted and emphasise the considerable uncertainties in the evidence in the hope of furthering constructive public consultation and debate.

Worldwide, almost 6% of people receive water containing fluoride to around 1 mg/l, write Sir Iain Chalmers and colleagues. In England and Wales, about 9-10% of water supplies contain 0.5-1 mg/l fluoride, either naturally or as an additive.

Plans to add fluoride to water supplies are often contentious. Problems include difficulties in identifying benefits and harms, whether fluoride is a medicine, and the ethics of a mass intervention.

So, what are the known benefits of adding fluoride to water, they ask? In 1999, the Department of Health commissioned the Centre for Reviews and Disseminations at York to conduct a systematic review on the potential benefits and harms of adding fluoride to water. Despite identifying 3,200 research papers, the reviewers were surprised by the poor quality of the evidence and the uncertainty surrounding the benefits and harms of fluoridation.

There is no such thing as absolute certainty on safety, say the authors. But in the case of fluoridation, people should be aware of the limitations of evidence about its potential harms and that most studies are not sufficiently well designed and large enough to detect small but important risks (especially for chronic conditions) after introducing fluoridation.

They point out that the evidence for alternative ways of preventing dental caries (mainly toothpastes containing fluorides) is strong. However, the use of toothpastes depends on individual behaviour, which has important implications for reducing inequality.

Another important issue is whether fluoride added to water supplies is a medicine, they add. Some people regard it as a form of mass medication, while others point out that it occurs naturally at concentrations comparable to those in fluoridation programmes and is therefore not a medicine.

If fluoride is a medicine, evidence on its effects should be subject to the standards of proof expected of drugs, say the authors. If used as a mass preventive measure in well people, the evidence of net benefit should be greater than that needed for drugs to treat illness. Yet, to date, there have been no randomised trials of water fluoridation.

The ethical implications of water fluoridation must also be considered, they say. Under the principle of informed consent, anyone can refuse treatment with a drug or other intervention. Potential benefit must therefore be balanced against uncertainty about harms, the lower overall prevalence of dental caries now than a few decades ago, the availability of other effective methods of prevention, and people's autonomy.

Finally, they believe that trust in the dissemination of evidence is vital. Those opposing fluoridation often claim that it does not reduce caries and they also overstate the evidence on harm. On the other hand, the Department of Health's objectivity is questionable - it funded the British Fluoridation Society and, along with many supporters of fluoridation, it used the review findings selectively to give an overoptimistic assessment of the evidence in favour of fluoridation.

They conclude: "Against this backdrop of one sided handling of the evidence, public distrust in the information it receives is understandable. We hope this article helps provide professionals and the public with a framework for engaging constructively in public consultations."

In a Personal View article, Rod Griffiths, Regional Director of Public Health for the West Midlands believes that, on balance, fluoridation of water supplies is a good thing.

He points out that Birmingham has had fluoride for 40 years and dental health is among the best in the country, even though other indicators, such as obesity, heart disease, and life expectancy are far from best. And asks, why do some people become so passionate about fluoride, when other regulations about harmful chemicals to which we are all exposed through agriculture and industry attract so much less attention?

Contacts:
Iain Chalmers, Editor, James Lind Library, Oxford, UK
Email: IChalmers@jameslindlibrary.org 
Trevor A Sheldon, Deputy Vice Chancellor, University of York, UK
Email: tas5@york.ac.uk 

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and from:

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