Henry McQuay, Dawn Carroll, Alejandro R Jadad, Philip Wiffen, Andrew Moore
Abstract
Objective - To determine effectiveness and adverse effects of anticonvulsant drugs in management of pain.
Design - Systematic review of randomised controlled trials of anticonvulsants for acute, chronic, or cancer pain identified by using Medline, by hand searching, by searching reference lists, and by contacting investigators.
Subjects - Between 1966 and February 1994, 37 reports were found; 20 reports, of four anticonvulsants, were eligible.
Main outcome measures - Numbers needed to treat were calculated for effectiveness, adverse effects, and drug related withdrawal from study.
Results - The only placebo controlled study in acute pain found no analgesic effect of sodium valproate. For treating trigeminal neuralgia, carbamazepine had a combined number needed to treat of 2.6 for effectiveness, 3.4 for adverse effects, and 24 for severe effects (withdrawal from study). For treating diabetic neuropathy, anticonvulsants had a combined number needed to treat of 2.5 for effectiveness, 3.1 for adverse effects, and 20 for severe effects. For migraine prophylaxis, anticonvulsants had a combined number needed to treat of 1.6 for effectiveness, 2.4 for adverse effects, and 39 for severe effects. Phenytoin had no effect on the irritable bowel syndrome, and carbamazepine had little effect on pain after stroke. Clonazepam was effective in one study for temporomandibular joint dysfunction. No study compared one anticonvulsant with another.
Conclusions - Anticonvulsants were effective for trigeminal neuralgia and diabetic neuropathy and for migraine prophylaxis. Minor adverse effects occurred as often as benefit.
Oxford Pain Relief Unit Churchill Hospital Oxford OX3 7LJ Henry McQuay clinical reader in pain relief Dawn Carroll senior research nurse Alejandro R Jadad research fellow Andrew Moore consultant biochemistPharmacy Department Churchill Hospital Philip Wiffen principal pharmacist
Correspondence to: Dr McQuay.
David P Strachan, Iain M Carey
Abstract
Objective - To investigate the effects of the home environment on the risk of severe asthma during adolescence.
Design - A questionnaire based case-control study drawn from a cross sectional survey of allergic diseases among secondary school pupils in Sheffield in 1991.
Subjects - 763 children whose parents had reported that over the previous 12 months they had suffered either 12 or more wheezing attacks or a speech limiting attack of wheeze. A further 763 children were frequency matched for age and school class to act as controls. Analysis was restricted to 486 affected children and 475 others born between 1975 and 1980 who had lived at their present address for more than three years.
Results - Independent associations with severe wheeze were seen for non-feather bedding, especially foam pillows (odds ratio 2.78; 95% confidence interval 1.89 to 4.17), and the ownership of furry pets now (1.51; 1.04 to 2.20) and at birth (1.70; 1.20 to 2.40). These estimates were derived from subjects whose parents denied making changes in the bedroom or avoiding having a pet because of allergy. Parental smoking, use of gas for cooking, age of mattress, and mould growth in the child's bedroom were not significantly associated with wheezing.
Conclusions - Either our study questionnaire failed to detect the avoidance or removal of feather bedding by allergic families or there is some undetermined hazard related to foam pillows. Synthetic bedding and furry pets were both widespread in this population and may represent remediable causes of childhood asthma.
Department of Public Health Sciences St George's Hospital Medical School London SW17 0RE David P Strachan senior lecturer in epidemiology Iain M Carey statistician
Correspondence to: Dr Strachan.
T Fahey, S Griffiths, TJ Peters
Abstract
Objective - To assess whether the way in which the results of a randomised controlled trial and a systematic review are presented influences health policy decisions.
Design - A postal questionnaire to all members of a health authority within one regional health authority.
Setting - Anglia and Oxford regional health authorities.
Subjects - 182 executive and non-executive members of 13 health authorities, family health services authorities, or health commissions.
Main outcome measures - The average score from all health authority members in terms of their willingness to fund a mammography programme or cardiac rehabilitation programme according to four different ways of presenting the same results of research evidence - namely, as a relative risk reduction, absolute risk reduction, proportion of event free patients, or as the number of patients needed to be treated to prevent an adverse event.
Results - The willingness to fund either programme was significantly influenced by the way in which data were presented. Results of both programmes when expressed as relative risk reductions produced significantly higher scores when compared with other methods (P less than 0.05). The difference was more extreme for mammography, for which the outcome condition is rarer.
Conclusions - The method of reporting trial results has a considerable influence on the health policy decisions made by health authority members.
Department of Public Health Medicine and Health Policy Oxfordshire Health Oxford OX3 9DZ T Fahey senior registrar in public health medicine S Griffiths director of public health medicineDepartment of Social Medicine University of Bristol Bristol BS8 2PR T J Peters senior lecturer in medical statistics
Correspondence to: Dr T Fahey, Department of Social Medicine, University of Bristol, Bristol BS8 2PR.
Hugh M Mather, Robert S Elkeles on behalf of the North West Thames Diabetes and Endocrinology Specialist Group
Abstract
Objective - To determine the views of a large and representative group of consultant physicians on the Calman proposals, in which acute general medical services will change from being primarily consultant led to consultant provided.
Design - Postal questionnaires.
Subjects - All 236 consultant physicians in acute hospitals in North West and South West Thames regions.
Results - Replies were received from 179 (76%). One hundred and thirty seven (77%) indicated that they would not resume emergency residential duties, and 126 (71%) indicated that they would probably withdraw from general medical duties under these circumstances. One hundred and twenty six (70%) and 137 (77%) had not inserted a central venous line or temporary pacemaker, respectively, within the previous five years. Of 157 answering a question on the impact of the Calman proposals on the quality of patient services, 125 considered that it would be detrimental, and only 18 (11%) thought that it would be beneficial.
Conclusion - Most consultant physicians are not prepared to resume emergency duties and could not do so without retraining in practical procedures. There is widespread antagonism to the Calman proposals, and most physicians consider that their impact on the quality of patient services will be detrimental.
Ealing Hospital Southall Middlesex UB1 3HW Hugh M Mather consultant physicianSt Mary's Hospital London W2 1NY Robert S Elkeles consultant physician
Correspondence to: Dr Mather.
Patrick White, Annie Atherton, Graham Hewett, Kate Howells
Abstract
Objective - To test the effects of feedback of information about patients' asthma to primary care teams.
Design - Patients' reports of morbidity, use of health services, and drug use on questionnaire was given to primary care teams. Randomised controlled trial with general practices as the subject of the intervention was used to test effectiveness of supplying information.
Setting - Primary care in district health authority, London.
Subjects - 23 general practices, each of which notified at least 20 asthmatic patients aged 15-60 years for each principal. Practices were randomly allocated to an intervention group (receiving feedback of information on control of asthma) or a control group (no feedback).
Intervention - Information on cards inserted in patients' medical records; booklet copies of information for team members; formal presentation to primary care teams; poster displays of data on patients in each practice.
Main outcome measures - Type and frequency of asthma symptoms, use of health services, use of asthma drugs.
Results - Reported morbidity at entry to the study was substantial: 45% (818) patients reported breathlessness at least once a week. Less than half these patients were using inhaled steroids regularly. Intervention and control groups did not differ in practice or patient characteristics on entry to the study. In spite of the potential for improvement no differences were observed between the two practice groups at the end of the study - for example, breathlessness at least once a week in last six months was experienced by 36% in intervention group v 35% in control group (t equals 0.27, P less than 0.79); surgery attendance in last six months by 48% v 48% (t equals 0.05, P less than 0.96); regular use of inhaled steroids by 60% v 58% (t equals 0.51, P less than 0.62).
Conclusion - Feedback to general practitioners of information about patients' asthma does not on its own lead to change in the outcome of clinical care.
Department of General Practice and Primary Care King's College School of Medicine and Dentistry London SE5 9PJ Patrick White senior lecturer Annie Atherton project manager Graham Hewett research assistant Kate Howells research assistantCorrespondence to: Dr White.