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BMJ No 7128 Volume 316
Papers - Abstracts Saturday 31 January 1998
Quantitive systematic review of topically applied non-steroidal anti-inflammatory drugs
R A Moore, M R Tramèr, D Carroll, P J Wiffen, H J McQuay
Abstract
Objective: To review the effectiveness and safety of topical non-steroidal anti-inflammatory drugs in acute and chronic pain conditions.
Design: Quantitive systematic review of randomised controlled trials.
Data sources: 86 trials involving 10,160 patients.
Main outcome measures: Measures of treatment success approximating at least 50% reduction in pain, local and systemic adverse effects. Analysis at 1 week for acute and 2 weeks for chronic conditions with relative benefit and number needed to treat.
Results: In acute pain conditions (soft tissue trauma, strains, and sprains) placebo controlled trials had a relative benefit of 1.7 (1.5 to 1.9), the number needed to treat was 3.9 (3.4 to 4.4). With analysis by drug (at least three trials), ketoprofen (number needed to treat 2.6), felbinac (3.0), ibuprofen (3.5), and piroxicam (4.2) had significant efficacy. Benzydamine and indomethacin were no different from placebo. In chronic pain conditions (osteoarthritis, tendinitis) placebo controlled trials had a relative benefit of 2.0 (1.5 to 2.7); the number needed to treat was 3.1 (2.7 to 3.8). Small trials (<40 treated patients) exaggerated effectiveness of topical non-steroidals by 33% in acute conditions but not in chronic conditions. There was no relation between trial quality and treatment effect. In both acute and chronic pain local and systemic adverse events and withdrawal from the study related to the drug had a low incidence and were no different from placebo.
Conclusion: Topical non-steroidal anti-inflammatory drugs are effective in relieving pain in acute and chronic conditions.
Pain Research and Nuffield Department of
Anaesthetics,
University of Oxford,
The Churchill,
Oxford Radcliffe
Hospital,
Headington,
Oxford OX3 7LJ
R A
Moore, consultant biochemist
M R
Tramèr, research fellow
D Carroll,
senior research nurse
P J Wiffen,
regional pharmaceutical adviser
H J McQuay,
clinical reader in pain relief
Correspondence to: Dr Moore
email: andrew.moore@pru.ox.ac.uk
Epilepsy in young people: 23 year follow up of the British national child development study
Zarrina Kurtz, Pat Tookey, Euan Ross
Abstract
Objective: To estimate the incidence and prevalence of epilepsy during childhood and early adult life in England, Scotland, and Wales.Design: Prospective study of 17,414 children born in England, Scotland, and Wales between 3 and 9 March 1958, followed up at 7, 11, 16, and 23 years of age, with a review of those with epilepsy at age 28.
Subjects: People with epilepsy developing at or before age 23.
Main outcome measures: The age specific incidence, cumulative incidence, and prevalence of epilepsy.
Results: 124 young people had a confirmed diagnosis of epilepsy during their first 23 years (cumulative incidence 8.4 per 1,000; 95% confidence interval 6.8 to 10.0). 6 had died by age 23. 46 (37%) had neurological impairment or another major health problem in addition to epilepsy. The prevalence of active epilepsy at age 23 was 6.3 per 1,000 (4.9 to 7.7).
Conclusions: A wide variety of seizure disorders is included under the term epilepsy. A third of cases had generalised seizures. In only a quarter was the onset of seizures attributed to a specific cause. Children with additional health problems were more likely to continue to have seizures in early adult life than those with epilepsy alone. 1 in 8 were prescribed drug treatment for 6 years or more after their last seizure. All deaths occurred in young adults over the age of 16.
Department
of Epidemiology and Public Health,
Institute of Child Health,
University College London Medical School,
London WC1N 1EH
Zarrina Kurtz, senior lecturer
Pat Tookey,
research fellow
Department of Community Paediatrics,
King's College School of Medicine and Dentistry,
London SE11 4QW
Euan Ross, professor
Correspondence to: Ms Tookey
email: p.tookey@ich.ucl.ac.uk
Unlicensed and off label drug use in paediatric wards: prospective study
Sean Turner, Alexandra Longworth, Anthony J Nunn, Imti ChoonaraAbstract
Objective: To determine the extent of use in children in hospital of drugs that are not specifically licensed for use in children (unlicensed) and of drugs that are used outside the terms of their product licence that apply to indication, age, dose, or route of administration (off label).Design: Prospective study of drugs administered on paediatric medical and surgical wards for 13 weeks.
Setting: Regional children's hospital.
Subjects: Paediatric inpatients in medical and surgical wards.
Main outcome measures: Comparison of the use of each drug with its product licence to determine whether the drug was used in an unlicensed or off label manner.
Results: 2,013 courses of drugs were administered to 609 paediatric patients in 707 admissions. 506 (25%) of the drug courses (prescriptions) were either unlicensed (139) or off label (367) uses. In 256 (36%) of the 707 admissions patients received one or more courses of an unlicensed or off label treatment in hospital.
Conclusions: Use of drugs in an off label or unlicensed manner to treat children is widespread. Drugs are more likely to be used in an off label manner than in an unlicensed manner.
Department of Pharmacy,
Alder Hey Children's
Hospital,
Liverpool L12 2AP
Sean Turner, clinical
research pharmacist
Anthony J Nunn, director of
pharmacy
Institute of Child Health,
Alder Hey Children's
Hospital
Alexandra Longworth, research assistant
Imti Choonara, senior lecturer in paediatric clinical
pharmacology
Correspondence to: Professor Imti Choonara,
Academic Division of Child Health,
Derbyshire Children's Hospital,
Derby DE22 3NE
email: imti.choonara@nottingham.ac.uk
Clinical experience, performance in final examinations, and learning style in medical students: prospective study
I C McManus, P Richards, B C Winder, K A Sproston
Abstract
Objective: To assess whether the clinical experience of undergraduate medical students relates to their performance in final examinations and whether learning styles relate either to final examination performance or to the extent of clinical experience.Design: Prospective, longitudinal study of two cohorts of medical students assessed by questionnaire at time of application to medical school and by questionnaire and university examination at the end of their final clinical year.
Subjects: Two cohorts of students who had applied to St Mary's Hospital Medical School during 1980 (n=1478) and 1985 (n=2399) for admission in 1981 and 1986 respectively. Students in these cohorts who entered any medical school in the United Kingdom were followed up in their final clinical year in 1986-7 and 1991-2.
Main outcome measures: Students' clinical experience of a range of acute medical conditions, surgical operations, and practical procedures as assessed by questionnaire in the final year, and final examination results for the students taking their examinations at the University of London.
Results: Success in the final examination was not related to a student's clinical experiences. The amount of knowledge gained from clinical experience was, however, related to strategic and deep learning styles both in the final year and also at the time of application, five or six years earlier. Grades in A level examinations did not relate either to study habits or to clinical experience. Success in the final examination was also related to a strategic or deep learning style in the final year (although not at time of entry to medical school).
Conclusions: The lack of correlation between examination performance and clinical experience calls into question the validity of final examinations. How much knowledge is gained from clinical experience as a student is able to be predicted from measures of study habits made at the time of application to medical school, some six years earlier, although not from results of A level examinations. Medical schools wishing to select students who will gain the most knowledge from clinical experience cannot use the results of A level examinations alone but could assess a student's learning style.
Academic Department of Psychiatry, Imperial
College School of Medicine at St Mary's, London W2 1PG
I
C McManus, professor of psychology and medical education
B C Winder, research coordinator
K A
Sproston, research assistant
Northwick Park and St
Mark's Trust, Northwick Park Hospital, Harrow HA1 3UJ
P
Richards, medical director
Correspondence to:
Professor I C McManus,
Centre for Health Informatics and
Multiprofessional Education,
University College London Medical School,
London N19 5NF
email: i.mcmanus@ucl.ac.uk
Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy
Sally Green, Rachelle Buchbinder, Richard Glazier, Andrew Forbes
Abstract
Objective: To review the efficacy of common interventions for shoulder pain.Design: All randomised controlled trials of non-steroidal anti-inflammatory drugs, intra-articular and subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, and surgery for shoulder pain that were identified by computerised and hand searches of the literature and had a blinded assessment of outcome were included.
Main outcome measures: Methodological quality (score out of 40), selection criteria, and outcome measures. Effect sizes were calculated and combined in a pooled analysis if study population, end point, and intervention were comparable.
Results: Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5-22). Selection criteria varied widely, even for the same diagnostic label. There was no uniformity in the outcome measures used, and their measurement properties were rarely reported. Effect sizes for individual trials were small (range -1.4 to 3.0). The results of only three studies investigating "rotator cuff tendinitis" could be pooled. The only positive finding was that subacromial steroid injection is better than placebo in improving the range of abduction (weighted difference between means 35° (95% confidence interval 14 to 55)).
Conclusions: There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable, and responsive in affected people.
Department of Epidemiology and Preventive
Medicine,
Monash University,
Melbourne 3186,
Australia
Sally
Green, PhD scholar
Rachelle Buchbinder,
senior lecturer
Andrew Forbes, senior
lecturer
Family and Community Medicine,
Preventive Medicine
and Biostatistics,
University of Toronto,
Ontario,
Canada
Richard Glazier, assistant professor
Correspondence to: Dr Buchbinder
email: rachelle.buchbinder@med.monash.edu.au
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