Press releases Monday 15 March to Friday 19 March 2010

Please remember to credit the BMJas 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) Staples lead to higher risk of infection after joint surgery than traditional stitches
(2) Integrated care can cut chronic back pain work disability by four months
(3) Hospital ban on sitting on a patient's bed "demeaning"
(4) Can the NHS cut costs while improving care?
(5) Experts call for infection control guidelines for acupuncture
(6) Women with swine flu 13 times more likely to suffer critical illness if they are pregnant
(7) Do financial interests result in positive results in scientific research?

(1) Staples lead to higher risk of infection after joint surgery than traditional stitches
(Research: Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis)
http://www.bmj.com/cgi/content/full/340/mar16_1/c1199
(Editorial: Staples for skin closure in surgery)
http://www.bmj.com/cgi/content/full/340/mar16_1/c403

Using metal staples to close wounds after orthopaedic (joint) surgery can lead to a greater risk of infection than using traditional nylon sutures, concludes a study published on bmj.com today.

Orthopaedic surgeons are therefore advised to reconsider their use of staples to close wounds after hip or knee surgery while further trials are carried out to confirm these findings.

Wound complications are one of the major sources of illness following orthopaedic procedures like knee and hip surgery. They can prolong a patient's stay in hospital or lead to re-admission. There is also a link between superficial wound infection and deep infection.

Orthopaedic surgeons use both metallic staples and nylon sutures to close wounds. Staples are regarded as quicker and easier than sutures, but some have suggested that staples are more likely to cause infection and may also be more expensive.

The optimal method of skin closure still remains unclear, so researchers at Norfolk and Norwich University Hospital analysed the results of six trials that compared the use of staples to sutures following orthopaedic procedures in adults.

The trials involved 683 wounds; 322 patients underwent suture closure and 351 staple closure. Overall, the risk of developing a superficial wound infection was over three times greater after staple closure than suture closure.

For hip surgery only, the risk of developing a wound infection was four times greater after staple closure than suture closure. There was no significant difference between sutures and staples in the development of inflammation, discharge, dehiscence (re-opening of a previously closed wound), necrosis and allergic reaction.

The authors point out that the quality of evidence was generally poor and they call for high quality, well designed trials to confirm their findings. However, based on the current evidence, they suggest that patients and doctors should think more carefully about the use of staples for wound closure after hip and knee surgery.

These results fit with evidence from other specialties, says Consultant Orthopaedic Surgeon, Bijayendra Singh, in an accompanying editorial. He points out that the most consistent benefit of staples is more rapid skin closure, yet the time saved is rarely more than two to three minutes. The saving may also be reduced by the increased costs of removing the staples (compared with absorbable stitches) and reduced even further by the costs of treating the increased number of infections.

Contacts:

Research: Toby Smith, Research Physiotherapist in Orthopaedics, Honorary Lecturer, Norfolk and Norwich University Hospital, Norwich, UK
Email: toby.smith@nnuh.nhs.uk
Editorial: Bijayendra Singh, Consultant Orthopaedic Surgeon, Medway Foundation NHS Trust, Gillingham, UK
Email: bisortho@doctors.org.uk

(2) Integrated care can cut chronic back pain work disability by four months
(Research: Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life)
http://www.bmj.com/cgi/content/full/340/mar16_1/c1035

A programme of integrated care, directed at both the patient and the workplace, can help people with chronic low back pain return to work, on average, four months earlier than those receiving usual care, finds a study published on bmj.com today.

Back pain is a common problem in Western societies. Although the chance of returning to work is generally good, up to a quarter of patients with low back pain remain absent from work in the long term, causing 75% of the costs due to sickness leave and disability.

So researchers based in The Netherlands and Canada set out to evaluate the effectiveness of an integrated care programme in 134 patients with chronic low back pain. All patients were aged between 18 and 65 years and had been absent from work due to low back pain for almost half a year on average.

Patients were randomly assigned to either usual care or integrated care. Integrated care consisted of adjustments to the workplace and a graded exercise programme to teach patients how to move safely while increasing activity levels. The main aim of the programme was to restore occupational functioning and to achieve lasting return to work for patients in their own job or similar work.

The usual care group received normal pain treatment with usually little or no workplace involvement.

Patients completed questionnaires at the start of the study and after three, six, nine and 12 months. Sickness absence data were collected every month.

Over the 12-month study period, patients who received integrated care returned to sustainable work after an average of 88 days compared with 208 days for patients receiving usual care, an average reduction of 120 days.

After 12 months patients in the integrated care group also improved significantly more on functional status compared to patients in the usual care group. No statistically significant differences in pain improvement were found between the two groups.

The integrated care programme substantially reduced disability due to chronic low back pain in both working and private life, say the authors. This promising integrated care approach, directed to both the patient and the work environment, could have a great impact on the individual burden of low back pain, they conclude.

Contact:

Johannes Anema, MD PhD, Senior Researcher, EMGO Institute for Health and Care Research, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
Email h.anema@vumc.nl

(3) Hospital ban on sitting on a patient's bed "demeaning"
(Observations: Do not sit on the bed)
http://www.bmj.com/cgi/content/full/340/mar11_1/c1040

First it was flowers, now hospital trusts across the country are banning visitors and clinicians from sitting on a patient's bed in the interests of infection control.

In this week's BMJ, Dr Iona Heath argues that there is "no hard evidence for either of these demeaning prohibitions" and believes that such rules have no place in hospitals.

"Doctors should never be discouraged from sitting, because patients consistently estimate that they have been given more time when the doctor sits down rather than stands," she writes. "Some of the most intimate and effective interactions between doctor and patient that I have either witnessed or experienced have occurred while the doctor has been sitting on the patient's bed," she recalls. "Such interactions are precious and should be made easier rather than more difficult."

This ban also seems to be imposed even for patients who are known to be dying. "Is it all in the interests of being seen to be doing something very noticeable about the worrying levels of hospital-based infections, however ineffective and otherwise disruptive," she asks?

She points out that too many patients report that the technological care in hospital is excellent but that the human dimension of care is often lacking. "So can we not campaign for home within hospital and encourage flowers and sitting on the bed and every other informality unless there is robust evidence to deter us?"

"Rules that mostly diminish the joys of life rather than enhance them, unless absolutely necessary, have no place in hospitals where joy is too often in short supply," she concludes.

Contact:

Iona Heath, General Practitioner, London, UK
Email iona.heath22@yahoo.co.uk

(4) Can the NHS cut costs while improving care?
(Analysis: Shrinking budgets, improving care)
http://www.bmj.com/cgi/content/full/340/mar16_1/c1251
(Feature: Experts' guide to saving money in health)
http://www.bmj.com/cgi/content/full/340/mar16_1/c1281
(Editorial: Disinvestment in health care)
http://www.bmj.com/cgi/content/full/340/mar16_1/c1413

The recent financial crisis and subsequent economic recession have placed healthcare systems in most parts of the world under extreme pressure. In the NHS it's estimated that savings of over £20bn need to be made in the next few years.

But can the NHS save money while maintaining and improving the quality of care? Several articles published on bmj.com today discuss the issue.

Graham Rich, Project Director at University Hospitals Bristol NHS Foundation Trust believes the answer lies in simplifying processes and engaging with patients. He argues that the NHS should invest in networks to help patients cope and live with their conditions and that NICE should focus on stopping treatments that are not cost effective. He also calls for more effort to reduce bureaucracy and better communication between professional and patients to improve the quality of care and to reduce costs.

Meanwhile, Phil Leonard, Senior Manager at Ernst and Young argues that shrinking budgets are an opportunity for managers and doctors to "refocus investment in areas that deliver best value for patients and divert it from underperforming services and unnecessary administration." He believes that "with good planning and execution healthcare organisations can retain the brightest, most committed, staff and spend less overall by concentrating on the resources that give patients the most benefit."

But Yair Zalmanovitch and Dana Vashdi from the University of Haifa in Israel argue that trade-offs are unavoidable and that a government resolved to implement major budget cuts must accept reduced standards for the coverage, and quality of services. "The public deserve to understand the complexity of any change to healthcare policy. Only through knowledge and understanding can they enter into a dialogue whereby policy options can be discussed and agreed," they conclude.

The BMJ has also asked front line professionals how their specialties could save money whilst maintaining high standards of care. Suggestions include stopping some cardiology procedures, avoiding unnecessary laboratory tests, strengthening community services to keep patients out of hospital, and teaching patients how to monitor their own medications.

In an accompanying editorial, researchers at the Universities of Lancaster and Nottingham believe that “we lack a shared common language” for discussing the subject of disinvestment. They argue that “the concept needs developing to convince stakeholders that it can be an important means of freeing up resources and thereby improve the efficiency and quality of health care." And they call for "a coordinated dialogue … to determine how a systematic, policy based approach to disinvestment is managed."

Alongside these articles, the BMJ is also asking readers to submit their views and suggestions for treatments that could be stopped on bmj.com. And on 27 April the BMJ and King's Fund are holding a debate on the motion, "This House believes that the NHS will not be able to cut costs without substantially damaging the quality of care."

Any journalists wishing to attend this debate should contact Emma Dickinson on 020 7383 6529.

Contact:

Emma Dickinson, BMJ Group Press Officer, London, UK
Email edickinson@bmjgroup.com

(5) Experts call for infection control guidelines for acupuncture
(Editorial: Acupuncture transmitted infections: the tip of the iceberg of a global emerging problem)
http://www.bmj.com/cgi/content/full/340/mar18_1/c1268

Experts on bmj.com today are calling for funding to introduce proper infection control guidelines to tackle the growing number of acupuncture-transmitted diseases.

Professor Patrick Woo and colleagues from the University of Hong Kong describe the number of reported cases as "the tip of the iceberg."

Acupuncture is one of the most widely practised strands of alternative medicine and is based on the theory that inserting and manipulating fine needles at specific points in the body helps to promote the flow of Qi or energy, they explain in an editorial.

Lead author, Professor Woo argues that acupuncture may pose risks to patients as needles are inserted up to several centimetres beneath the skin.

While most patients recover from infections, says Woo, 5-10 per cent of the reported pyogenic bacterial infections end up with serious problems including joint destruction, multi-organ failure, flesh eating disease and paralysis.

Most infections caused are bacterial, maintains Woo, but there have been outbreaks of hepatitis B, and perhaps cases of hepatitis C and HIV that are believed to have been transmitted via acupuncture.

He adds, that in the 21st century a new clinical syndrome has emerged - acupuncture mycobacteriosis. This is an infection caused by mycobacteria that rapidly grow around the acupuncture insertion point as a result of contaminated cotton wool swabs, towels and hot-pack covers. There is a long incubation period but the infection usually leads to large abscesses and ulcers.

The authors conclude that "to prevent infections transmitted by acupuncture, infection control measures should be implemented, such as use of disposable needles, skin disinfection procedures, and aseptic techniques. Stricter regulation and accreditation requirements are also needed."

Contact:

Patrick Woo, Department of Microbiology, University of Hong Kong
Email pcywoo@hkucc.hku.hk

(6) Women with swine flu 13 times more likely to suffer critical illness if they are pregnant
(Research: Critical illness due to 2009 A/H1N1 influenza 2009 in pregnant and postpartum women: population based cohort study)
http://www.bmj.com/cgi/content/full/340/mar18_3/c1279
(Editorial: Critical illness as a result of influenza A/H1N1 infection in pregnancy )
http://www.bmj.com/cgi/content/full/340/mar18_3/c1235

Pregnant women in Australia and New Zealand who had swine flu were 13 times more likely to be admitted to hospital with a critical illness, according to research published on bmj.com today.

The authors conclude that 11% of mothers and 12% of babies died as a result of being admitted to intensive care with swine flu. However they emphasise that given the small numbers included in their research, there are limits to the conclusions that can be drawn from the results.

It has already been established that pregnant women are at a higher risk of developing influenza complications. The recent swine flu pandemic was the first "to occur in an era of modern obstetric and intensive care management", says the study.

The research describes what happened to pregnant women with swine flu who were admitted to intensive care units (ICU) in Australia and New Zealand during the winter of 2009.

The authors, led by Dr Ian Seppelt from the Australian and New Zealand Intensive Care (ANZIC) Influenza Investigators in collaboration with the Australasian Maternity Outcomes Surveillance System, assessed the data relating to all women with swine flu who were pregnant or who had given birth in the last 28 days and were admitted to an ICU in Australia or New Zealand between 1 June and 31 August 2009.

During the study period, 209 women of child-bearing age (15 to 44) were admitted to an ICU with confirmed swine flu. Sixty-four of these (30.6%) were either pregnant or had recently given birth, 57 were admitted to an ICU in Australia and 7 to an ICU in New Zealand.

The results show that women who were more than 20 weeks pregnant were 13 times more likely to be admitted to an ICU than non-pregnant women who had swine flu. Forty-four (68.7%) of the women had to be put on ventilators to assist with breathing and of these, nine women (14.1%) needed further assistance to help oxygen reach their heart and lungs.

Overall seven (11%) of the mothers and seven (12%) of the babies died and Dr Seppelt argues that "although a mortality of 11% seems low when compared to usual outcomes of respiratory failure in intensive care … a maternal morality of 11% is high when compared with any other obstetric condition."

The authors highlight the fact that none of the women in the study had been immunised against seasonal flu despite recommendations that pregnant women should be immunised.

In an accompanying editorial, Dr Stephen Lapinsky from the Mount Sinai Hospital in Toronto, applauds the ANZIC team for their foresight and planning in investigating how swine flu affected pregnant women and those who recently gave birth.

He says the study "provides detailed data to enhance our understanding of maternal risk as well as the maternal and neonatal outcome".

Contacts:

Research: Ian Seppelt, Senior Staff Specialist, Department of Intensive Care Medicine, University of Sydney, Australia
Email seppelt@med.usyd.edu.au
Editorial: Stephen Lapinsky, Site Director, ICU, Mount Sinai Hospital, Toronto, Canadabr/> Email stephen.lapinsky@utoronto.ca

(7) Do financial interests result in positive results in scientific research?
(Research: Association between industry affiliation and position on cardiovascular risk with rosiglitazone: a cross sectional systematic review)
http://www.bmj.com/cgi/content/full/340/mar18_1/c1344

Virtually all (94%) of the scientific authors who provided positive results for the anti-diabetic drug rosiglitazone had financial relationships with pharmaceutical companies, according to research published on bmj.com today.

While the study acknowledges that financial relationships may not necessarily be the reason for positive research results, it concludes that further reform is needed to ensure trust in scientific work.

In 2007, a large scale review of rosiglitazone showed that use of the drug led to a significant increased risk of heart attacks. This in turn led to further studies and commentaries by scientists about the safety of rosiglitazone. Policies were also developed to encourage disclosure of such financial conflicts of interest.

But whether these policies have made any impact on the association between financial conflicts of interest and views expressed in scientific reports is still unknown.

So researchers at the Mayo Clinic in the USA assessed over 200 articles on rosiglitazone to explore a possible link between authors' financial conflicts of interest and their views on the safety of the drug.

They found that almost half of the study authors (45%) had financial conflicts of interest and almost a quarter of these (23%) did not disclose this information. Three studies included in the latter group published a statement declaring no conflicts of interest.

Almost all (94%) authors who had favourable views on the safety of rosiglitazone were more likely to have a financial conflict of interest with a pharmaceutical company than were authors who had unfavourable views.

The researchers conclude by saying: "Disclosure rates for financial conflicts of interest were unexpectedly low, and there was a clear and strong link between the orientation of authors' expressed views on the rosiglitazone controversy and their financial conflicts of interest with pharmaceutical companies."

"These findings, while not necessarily causal, underscore the need for further progress in reporting in order for the scientific record to be trusted," they add.

Contact:

Mohammad Hassan Murad, Assistant Professor of Medicine, Mayo Clinic, Rochester, MN, USA
Email murad.mohammad@mayo.edu

FOR ACCREDITED JOURNALISTS

For more information please contact:

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
British Medical Association
BMA House, Tavistock Square, London WC1H 9JP

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
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