Press releases Monday 18 October to Friday 22 October 2010

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) It is unclear if programmes to encourage cycling are effective
• (2) NHS reforms could mean more patients seeking treatment abroad, warn experts
• (3) Increased organ donation rates can be achieved without presumed consent, says expert
• (4) Change in how paramedics use oxygen could reduce deaths
• (5) MRIs may lead to unnecessary breast surgery
• (6) Mental health benefits of living in ethnically diverse neighbourhoods

(1) It is unclear if programmes to encourage cycling are effective

(Research: Interventions to promote cycling: a systematic review)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5293
(Editorial: Promotion of cycling and health)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5405

More research and evaluation are needed to determine the most effective community programmes to encourage cycling, says a study published on bmj.com today.

The authors, led by Dr David Ogilvie from the Institute of Public Health in Cambridge, say that it is unclear whether community approaches to increase cycling amongst children and adults have anything more than a modest effect.

Established research shows that cycling is linked to greater cardio-respiratory fitness in adults and children. And general physical activity reduces the risk of heart disease, type 2 diabetes, some cancers, and premature mortality. However, most UK adults do not do enough physical activity, say the authors, so the desire to increase cycling is understandable, particularly as cycling is a form of physical activity that could be incorporated into many people's daily routines as a mode of transport, potentially resulting in both health and environmental benefits

The question remains, say the authors, are cycling initiatives effective? Ogilvie and colleagues carried out an exhaustive review of twenty-five studies from seven countries (Australia, Denmark, Germany, the Netherlands, Sweden, the UK and the United States) that were linked to cycling promotion.

Several of the programmes specifically promoted cycling, one focused on targeted intervention in obese women and others were linked to improving cycle route networks to work or school.

The authors argue that the evidence is unclear on how effective such programmes are, concluding that most schemes were associated with a modest benefit of the order of a 3.4 per cent increase in household trips made by bike.

They say it essential that future research contain more robust measures to evaluate the impact of cycling schemes delivered through schools and work. "Further controlled evaluative studies incorporating more precise measures are required, particularly in areas without an established cycling culture."

In an accompanying editorial, Professor Nanette Mutrie from the University of Strathclyde and Fiona Crawford from the Glasgow Centre for Population Health, stress that even modest gains from cycling schemes would have an effect on the health of the population.

They concur with Ogilvie and colleagues that more robust evaluation is needed about cycling promotion initiatives. They say: "better measurement of the impacts of interventions on levels of cycling and physical activity is necessary not only to inform future strategy and policy but also to strengthen the case that promoting cycling represents extremely good value for money for both individual and public health."

And in an editorial published by Student BMJ today, two obesity experts ask, will the public health benefits of London's new cycle hire scheme outweigh risks such as exposure to traffic fumes and crashes?

Harry Rutter and Nick Cavill from the National Obesity Observatory say "there appears to be little evidence of the impact of these schemes, especially in terms of health." But they believe that "if Londoners swap their cars for human-powered transport, the benefits will greatly outweigh the risks."

They conclude: "Policies such as congestion charging and the cycle hire scheme that contribute to a shift in the balance of urban traffic away from the car and towards cycling and walking have the potential to create major positive impacts on public health and wellbeing, not only in London, but in any town or city around the world."

Contacts:
Research: David Ogilvie, Clinical Investigator, UK Clinical Research Collaboration Centre for Diet and Activity Research (CEDAR), Institute of Public Health, Cambridge, UK
Email: david.ogilvie@mrc-epid.cam.ac.uk
Editorial: Nanette Mutrie, Professor of exercise and sport psychology, University of Strathclyde, Glasgow, Scotland, UK
Email: nanette.mutrie@strath.ac.uk

(2) NHS reforms could mean more patients seeking treatment abroad, warn experts
(Editorial: Patients seeking treatment abroad)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5769

The planned shake-up of the NHS in England could see a rise in the number of patients seeking treatment elsewhere in the European Union, warn experts on bmj.com today.

Researchers at the London School of Hygiene and Tropical Medicine and the Royal College of Nursing say more people could turn elsewhere if they face long waits for treatment or other forms of rationing as new GP commissioning groups seek to control their budgets.

They argue this is "another challenge for general practice commissioning" and look at the implications for healthcare planning across Europe.

British residents have had the right to obtain treatment in another EU country since 1971, although currently the number is small, write Helena Legido-Quigley and colleagues.

Initially, the opportunities were limited but, since 1998, a series of court rulings have increased patients' rights to treatment in other EU member states, particularly for non-hospital care.

However, there is still a lack of clarity about whether patients can go abroad freely, without seeking authorisation, to use specialist medical equipment or expensive facilities usually located in hospitals.

A recent case ruled it was necessary that European law "did not threaten a system of planning that would ensure an appropriate geographical distribution of such costly equipment."

This ruling is important, say the authors, because it begins to clarify the previously uncertain legal interface between hospital and non-hospital care. They write: "It is not whether complex treatments must or must not be provided in a hospital setting. Rather, it is whether their cost and the importance of avoiding waste from the underuse of facilities demands that their distribution be subject to planning."

This also supports the English Department of Health's advice, issued earlier this year, which highlighted the lack of clarity about use of specialised or cost intensive equipment or infrastructure.

If general practice commissioning groups do come about they may not have to deal with many patients who choose to obtain treatment abroad, but they should be aware that some may exercise their rights to do so, say the authors. Where this involves inpatient care or "major medical equipment" they will need to establish appropriate mechanisms for authorisation. Quite how they will do this remains to be seen, they conclude.

Contact:
Helena Legido-Quigley, Research Fellow, London School of Hygiene and Tropical Medicine, London, UK
Email: helena.legido-quigley@lshtm.ac.uk

(3) Increased organ donation rates can be achieved without presumed consent, say experts
(Analysis: Presumed consent: a distraction in the quest for increasing rates of organ donation)
http://www.bmj.com/cgi/doi/10.1136/bmj.c4973

Spain's excellent record on organ donation rates has nothing to do with its presumed consent legislation, say experts in an article published on bmj.com today.

Professor John Fabre, from the Department of Hepatology and Transplantation at King's College London, Paul Murphy from the Department of Neuroanaesthesia and Critical Care at the Leeds General Infirmary, and Rafael Matesanz from the Orgaizacion Nacional de Trasplantes in Madrid say that the Spanish example shows that higher rates can be achieved without presumed consent.

Spain has the world's highest rate of deceased organ donation - two and half times higher than the UK. Presumed legislation was introduced in Spain in 1979.

However, the authors argue that this legislation is largely inactive - they say "crucially, Spain does not have an opt-out register for those who do not wish to become organ donors . . . not a penny is spent on recording objections to organ donation by Spanish citizens, nor on public awareness of the 1979 legislation, the presumed consent law in Spain is dormant."

Numerous individuals and organisations have called for the introduction of presumed consent legislation in the UK on the assumption that this will increase organ donation rates, say the authors. They believe this is a mistake and add that "Spain's outstanding deceased organ donor rate cannot reasonably be attributed to its presumed consent laws."

It would be far better to look at the special characteristics of the Spanish system, they argue.

Each procurement hospital has a transplant coordinator, these individuals are specially trained, most are intensive care doctors and they only work on organ donation on a part-time basis. This means that they can be appointed even at hospitals with a low likelihood of donors and their daily work is carried out where most donors are likely to arise - the intensive care unit.

Spain has approximately three times as many intensive care beds per million of population as the UK. This might influence admission policies to intensive care units, and also end-of-life care policies, both of which can potentially influence organ donation rates.

They highlight the importance of the role of the family and say the family's wishes regarding organ donation must be accepted, as they are in Spain.

They conclude that "advocates of presumed consent often cite the Spanish organ donation system as an example of the success of presumed consent legislation . . . in fact, what Spain has shown is that the highest levels of organ donation can be obtained while respecting the autonomy of the individual and family, and without presumed consent."

Contact:
John Fabre, Department of Hepatology and Transplantation, James Black Centre, King's College London School of Medicine, London, UK
Email: john.fabre@kcl.ac.uk

(4) Change in how paramedics use oxygen could reduce deaths
(Research: Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in pre-hospital setting: randomised controlled trial)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5462
(Editorial: Avoidance of high concentration oxygen in chronic obstructive pulmonary disease)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5549

A change to the way paramedics use oxygen when treating patients with chronic lung disease could cut the death rate in these cases by up to 78 per cent, according to a new study published on bmj.com today.

Researchers based in Australia found the risk of death in patients with chronic obstructive pulmonary disease (COPD) was significantly reduced by using titrated (controlled) oxygen therapy instead of the current common approach of high concentration oxygen.

High concentration oxygen is used routinely by many paramedics in emergency situations for patients with acute breathlessness caused by episodes of COPD, a condition that affects over 200 million people across the world.

However, giving high concentration oxygen to patients with severe lung disease can lead to a build up of carbon dioxide in the blood, which can induce respiratory failure.

Hospital audits have also shown an association between using high concentration oxygen and adverse outcomes such as an increase in mortality, length of hospital stay, need for ventilation and admission to high dependency units.

For these reasons, the British Thoracic Society together with 21 other UK Colleges and Societies produced a guideline in 2008 which recommended that oxygen therapy for patients with COPD should be titrated to achieve a blood oxygen saturation of 88-92 per cent compared with a target saturation range of 94-98 per cent for most other medical emergencies. This guidance was implemented by the UK ambulance service in 2009.

Researchers from Tasmania carried out a study involving 405 patients aged 35 and over who were treated by 62 paramedics from the Tasmanian Ambulance Service and transported to a local hospital.

The participants were split into two groups - one group (226) was treated with the standard high concentration oxygen approach and the other (179) with titrated oxygen therapy - and data collected over a 13-month period between 2006 and 2007.

A confirmed COPD subgroup was identified retrospectively as those patients with a definite diagnosis of COPD during the study and this included 214 patients, 117 of whom were treated using high concentration oxygen and 97 with titrated oxygen with a target range of 88-92 per cent.

Results showed significant differences in outcomes, depending on which approach was used.

Overall mortality was 9 per cent (21 deaths) in the high concentration oxygen group and 4 per cent (7 deaths) in the titrated oxygen group. This difference was more pronounced in the confirmed COPD subgroup for which there was a 9 per cent (11 deaths) mortality rate in the high concentration group compared with a 2 per cent mortality rate (2 deaths) in the titrated group.

Overall, titrated oxygen therapy reduced the risk of death from respiratory failure by 58 per cent for all patients and 78 per cent for confirmed COPD patients compared to high concentration oxygen therapy.

Patients who received high concentration oxygen were also significantly more likely to develop respiratory acidosis (a condition in which decreased respiration causes increased blood carbon dioxide and decreased pH) or hypercapnia, when there is too much carbon dioxide in the blood.

The researchers conclude: "Our findings provide the first high quality evidence from a randomised controlled trial for the development of universal guidelines and support the British Thoracic Society's recent guidelines on acute oxygen treatment, which recommend that oxygen should be administered only at concentrations sufficient to maintain adequate oxygen saturations."

In an accompanying editorial, senior doctors Ronan O'Driscoll and Richard Beasley warn that routine use of high concentration oxygen may also be harmful in several other medical emergencies, including heart attack and stroke.

They conclude: "After more than 200 years of haphazard use, it should be recognised that oxygen should be prescribed for defined indications in which its benefits outweigh its risks and that the patient's response must be monitored."

Contact: Research: Richard Wood-Baker, Staff Specialist and Head, CardioRespiratory Medicine, Royal Hobart Hospital, Tasmania, Australia
Email: maaustin@utas.edu.au
Editorial: Ronan O'Driscoll, Consultant Respiratory Physician, Salford Royal University Hospital, Salford, UK
Email: kimberley.southern@srft.nhs.uk

(5) MRIs may lead to unnecessary breast surgery
(Editorial: Magnetic Resonance Mammography)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5513

Women could be undergoing unnecessary breast surgery as a result of having magnetic resonance imaging (MRI), says an expert on bmj.com today.

In the last decade, says Malcolm Kell, Consultant Surgeon and Senior Lecturer at the Eccles Breast Screening Unit at University College Dublin, MRI or magnetic resonance mammography (MRM) has become the most favoured type of investigation for high risk patients when combined with mammography and ultrasound.

Kell says while MRM is extremely useful in monitoring advanced breast cancer and also to assess the response in the breast following chemotherapy, the use of this technology in early stage breast cancer may do more harm than good. He concludes that "there is no compelling evidence that this technique should be routinely used in newly diagnosed breast cancer."

The author refers to one study in women with breast cancer who were being considered for treatment without surgery which shows a 6 per cent increase for mastectomies in women who had an MRM compared to women who did not. He believes the higher rates of surgery could be because MRM is so sophisticated that it picks up harmless recurrence or extension of tumours whose removal will not alter the patient's prognosis.

While supporters of MRM say using it routinely is likely to pick up disease recurrence, the evidence does not back up their view, says Kell.

He argues that the best way to manage early stage breast cancer and reduce the need for unnecessary and invasive surgery is through yearly monitoring and drug treatment and radiotherapy where necessary.

Contact:
Malcolm Kell, Consultant Surgeon and Senior Lecturer, Eccles Breast Screening Unit, University College Dublin, Ireland
Email: malcolm.kell@breastcheck.ie

(6) Mental health benefits of living in ethnically diverse neighbourhoods

(Research: Understanding the effect of ethnic density on mental health: multi-level investigation of survey data from England)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5367
(Editorial: Ethnic density and mental health)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5252

Some ethnic minority groups suffer fewer mental health problems when living in areas with a greater proportion of people from the same ethnic background, independent of levels of affluence, finds a paper published on bmj.com today.

The study, the first of its kind, suggests there may be mental health benefits from living in ethnically diverse neighbourhoods. The "protective effects" were particularly significant for Bangladeshi and Irish people.

The authors, led by Dr Jayati Das-Munshi from the Institute of Psychiatry, King's College London, argue that there is a lack of research to account for the varying rates of common mental disorders amongst ethnic minority groups living in Britain.

The research team set about to investigate whether living in the same area acts as a "buffering effect" for minority groups by providing them with social support and networks or by reducing racism.

Dr Das-Munshi and colleagues used information from the EMPIRIC1 survey of 4281 participants of Irish, Black Caribbean, Indian, Pakistani, Bangladeshi and White British ethnicity. They were aged between 16 and 74 and were chosen at random from 892 areas in England. A combination of structured interviews and questionnaires was used to assess the presence of common mental disorders, the participants' experience of acts of discrimination, and their perceived levels of social support.

The authors argue that the results "provide compelling evidence in support of the notion that ethnically dense areas may be protective of mental health for some ethnic minority groups, despite these areas also tending to be the poorest."

Living in areas with a higher proportion of people from the same background, for most but not all ethnic groups, was associated with better perceived social support and fewer reported experiences of discrimination. However, these effects did not seem to explain the protective effect on mental health.

This view is supported in an accompanying editorial by Professor Helen Lester from the National School for Primary Care Research in Manchester. "A growing body of evidence - which is fairly consistent across time, place, and ethnic group - now shows that ethnic density affects mental health," she says.

She adds: "Das-Munshi and colleagues' study leaves us more convinced of the effect, but further research is needed to clarify the scope and size of the effects, including the "tipping point" or degree of density needed to exert a protective effect on health."

Contacts:
Research: For Jayati Das-Munshi, MRC training fellow in health services and health of public research, contact Louise Pratt, Acting PR and Communications Manager, Institute of Psychiatry, King's College London, UK
Email: louise.a.pratt@kcl.ac.uk
Editorial: Helen Lester, Professor of Primary Care, NIHR National School for Primary Care Research, Manchester, UK
Email: helen.lester@manchester.ac.uk

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