This week's embargoed articles may not be available until 09:00 (UK time) Thursday.

Press releases Monday 26 January 2009 to Friday 30 January 2009

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's web site (http://www.bmj.com).

Press releases Monday 26 January to Friday 30 January 2009

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) Pain relieving effects of acupuncture are limited
(2) UK breast screening information has serious shortcomings
(3) "Tan jab" linked to rapidly changing moles, warn experts
(4) Concerns over EC plans to allow drug firms to talk directly to patients
(5) And finally ... Scrotumgate: Authors confess to inventing "cello scrotum"

(1) Pain relieving effects of acupuncture are limited
(Research: Acupuncture treatment for pain. Systematic review of randomised clinical trials with acupuncture, placebo acupuncture and no acupuncture groups)
http://www.bmj.com/cgi/doi/10.1136/bmj.a3115
(Editorial: Does acupuncture relieve pain?)
http://www.bmj.com/cgi/doi/10.1136/bmj.a2760

The pain relieving effects of acupuncture compared with placebo are small and seem to lack clinical relevance, according to a study published on bmj.com today.

Researchers at the Nordic Cochrane Centre in Copenhagen analysed evidence from thirteen acupuncture pain trials involving over 3,000 patients. The trials compared three arms of treatment (real acupuncture, placebo or ‘pretend' acupuncture or no acupuncture) for a broad range of common conditions such as knee osteoarthritis, migraine, low back pain and post-operative pain.

Before the analysis, differences in study design and quality were taken into account to minimise bias.

They found a small analgesic effect of real acupuncture compared to placebo acupuncture. This corresponded to a reduction in pain levels of about 4mm on a 100mm pain scoring scale. A 10mm reduction on this scale is classed as ‘minimal' or ‘little change' so the apparent analgesic effect of acupuncture seems to be below a clinically relevant pain improvement, say the authors.

They found a moderate difference between placebo acupuncture and no acupuncture (10mm on a 100mm pain scoring scale), but the effect of placebo acupuncture varied considerably. Some large trials reported effects of placebo that were of clear clinical relevance (24mm), whereas other large trials found effects that seemed clinically irrelevant (5mm).

The authors could not explain this variation, but they did not find an association between the type of placebo acupuncture and its effect.

Our findings correspond with several Cochrane reviews on acupuncture for various types of pain, which all concluded that there was no clear evidence of an analgesic effect of acupuncture, say the authors.

Our findings also question both the traditional foundation of acupuncture and the prevailing theory that acupuncture has important effect on pain in general.

They suggest that future trials focus on reducing bias and trying to separate the physiological effect of using a needle and the psychological impact of the treatment ritual.

In an accompanying editorial, Dr Adrian White and Dr Mike Cummings of the British Medical Acupuncture Society suggest that although the overall effect of acupuncture in relation to usual care is not large, it may be clinically relevant for musculoskeletal conditions, particularly in view of the limited treatment options, and acupuncture's safety record and patient preference.

They believe that future research should focus on comparing acupuncture with best existing treatments for different conditions.

Acupuncture seems, in part at least, to use neurological pathways in common with placebo analgesia and the study of these may offer important insights into improving care, they conclude.

Contact:
Research: Asbjørn Hrobjartsson, Senior Researcher, The Nordic Cochrane Centre, Blegdamsvej 9, Copenhagen, Denmark
Email: ah@cochrane.dk

The information about breast screening sent to women in the United Kingdom has serious shortcomings and should not be used as a basis for informed consent, warn researchers in a paper published on bmj.com today.

Two years ago, Peter Gøtzsche and colleagues at the Nordic Cochrane Centre surveyed breast screening leaflets given to women in six countries, including the UK. They showed that the most important harms of screening (over-diagnosis and over-treatment of healthy women) were not mentioned and that other harms were often either omitted or downplayed.

Now they argue that, although the UK leaflet was later updated, the contents remain essentially the same.

The UK leaflet has the authoritative title "Breast screening: the facts," which suggests that the information can be trusted and is helpful for women when they decide whether to participate in screening, say the authors. However, the leaflet has little information about harms and emphasises the benefits.

For example, the major harm of screening - treatment of healthy people for a cancer disease they do not have - is not mentioned. This, they argue, is in violation of guidelines and laws for informed consent.

Other harms not mentioned or not explained fully in the leaflet include false positive diagnoses (abnormalities detected during screening that often lead to repeat testing to rule out cancer), risks of radiotherapy, and carcinoma in situ (a precursor to cancer).

Meanwhile, there are no reservations in the leaflet about screening older women, say the authors, although it has not been shown that screening these women decreases their risk of dying from breast cancer.

The one-sided propaganda about breast screening is a global phenomenon that has resulted in misconceptions about its effects, they warn. New evidence that demonstrated less benefit than what was previously thought, and substantially more harm, has largely been ignored.

There is also a potential conflict of interest when those who provide the information are responsible for the success of the screening programme. They suggest that the responsibility for the programmes must be separated from the responsibility for the information material and that information materials should be carefully tested among general practitioners and lay people.

As a result of their analyses, the authors have developed a leaflet that is based on the latest scientific evidence and describes benefits and harms in numbers that are readily understood. They hope that this leaflet gives sufficient information to enable a woman - together with her family and her general practitioner - to decide whether participation in screening is right for her.

Contact:
Peter C Gøtzsche, Nordic Cochrane Centre, Rigshospitalet Department, Copenhagen, Denmark
Email: pcg@cochrane.dk

(3) "Tan jab" linked to rapidly changing moles, warn experts
(Letter: Melanotropic peptides)
http://www.bmj.com/cgi/doi/10.1136/bmj.b277

Melanotan (an unlicensed medicine dubbed the "tan jab") can cause rapid changes in the appearance of moles, warn skin experts in this week's BMJ.

There are two types of Melanotan - Melanotan I and Melanotan II. They work by increasing the levels of melanin (the body's natural pigment that protects us from the sun) resulting in a suntan.

Melanotan has not been tested by the medicines regulator, but both products are being advertised and sold illegally as an injectable tan on the internet and in some tanning salons and body building gyms.

The authors describe two patients attending their dermatology clinic with rapidly changing moles and an intense tan, despite their fair skin type. They were both sunbed users and both had injected Melanotan I and II, bought from the internet, shortly before their moles changed.

The Medicines and Healthcare products Regulatory Agency (MRHA) recently raised concerns about the health risks of these counterfeit drugs, say the authors. These cases highlight a further area of concern - changes in the appearance of existing moles.

They warn that unregulated use of Melanotan may lead to an increase in the number of patients seeking medical advice about changing moles and may even confuse the diagnosis. They suggest healthcare professionals look out for unexpected tanning as a clue to such use.

Contact:
Ewan Langan, Walport Academic Clinical Fellow in Dermatology, University of Manchester, Salford Royal NHS Foundation Trust, Salford, UK
Email: ewan.langan@postgrad.manchester.ac.uk

(4) Concerns over EC plans to allow drug firms to talk directly to patients
(Letters: Drug companies and the public)
EC, don't let drug companies give information to the public
EC proposal can be defeated

Plans by the European Commission to allow drug companies to give information on prescription drugs to the public is troubling for the future objective use and funding of medicines, warn medical students in a letter to this week's BMJ.

The students are representatives of Medsin, a student global health network, and Pharmaware, a UK campaign aiming to maximise ethical interactions between healthcare professionals and pharmaceutical companies.

Patients require high quality, unbiased and objective information, they say, yet these proposals may have some of the negative side effects of direct to consumer advertising. For instance, the profile of profitable branded drugs may be increased, which will increase spending on prescription medicines by patients and the NHS.

They believe that information is best provided by healthcare professionals who are trained to appraise and interpret the evidence on clinical and cost effectiveness, and they call on the European Commission to abandon its proposals and explore options for providing a more impartial and unprejudiced system of high quality peer reviewed information.

But in a second letter, Don Redding, Head of Policy at the Picker Institute Europe argues that the proposal can still be defeated.

Under pressure from campaign groups, including Picker Institute Europe, plans have already been significantly watered down, he says. For example, television and radio were dropped as channels for dissemination, while printed media became more tightly defined as health related publications.

At whatever stage it reappears, the proposal can be defeated if patient and professional groups make their views known to members of the European parliament and to member governments, both of whom will need to approve the measures before they become law, he concludes.

Contacts:
Jonathan Currie, 4th year medical student, Bristol, UK
Email: jonny.currie@gmail.com

Don Redding, Head of Policy, Picker Institute Europe, Oxford, UK
Email: don.redding@pickereurope.ac.uk

(5) And finally ... Scrotumgate: Authors confess to inventing "cello scrotum"
(Letter: Cello scrotum confession)
http://www.bmj.com/cgi/doi/10.1136/bmj.b288

After 34 years, two authors confess to submitting a spoof letter to the BMJ in 1974 describing a condition they dubbed "cello scrotum." It was prompted by a letter on "guitar nipple" published the same year.

The condition was recently quoted in an article on health problems associated with making music in the 2008 Christmas BMJ, prompting the authors to finally come clean.

"Anyone who has ever watched a cello being played would realise the physical impossibility of our claim," they write.

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and from:

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