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BMJ No 7129 Volume 316
Papers - Abstracts Saturday 7 February 1998
Risk of connective tissue disease and related disorders among
women with breast implants: a nation-wide retrospective cohort study in
Sweden
Single dose vitamin A treatment in acute shigellosis in
Bangladeshi children: randomised double blind controlled trial
Mortality from overdose among injecting drug users recently
released from prison: database linkage study
Evaluation of adjuvant psychological therapy in patients with
testicular cancer: randomised controlled trial
Evaluation of reagent strips in detecting asymptomatic
bacteriuria in early pregnancy: prospective case series
Qualitative study of educational interaction between general
practitioners and specialists
Risk of connective tissue disease and related disorders among women with breast implants: a nation-wide retrospective cohort study in Sweden
Olof Nyrén, Li Yin, Staffan Josefsson, Joseph K McLaughlin,
William J Blot, Martin Engqvist,
See Editorial by Cooper and
Dennison, p 403 and Letter, p 477
Objective: To examine the relation between connective
tissue disease and related conditions and breast implants.
Setting: Sweden.
Subjects: 7,442 women with implants for cosmetic
reasons or for reconstruction after breast cancer surgery and 3353
women with breast reduction surgery.
Main outcome measures: Subsequent hospitalisation for
definite connective tissue diseases (rheumatoid arthritis, systemic
lupus erythematosus, systemic sclerosis, dermatomyositis, and
Sjögren's syndrome) or related disorders.
Results: 29 women with implants were hospitalised for
definite connective tissue disease compared with 25.5 expected based on
general population rates (standardised hospitalisation ratio 1.1 (95%
confidence interval 0.8 to 1.6)). There were no diagnoses of systemic
sclerosis, and no significant excess in risk for polymyalgia
rheumatica, fibromyalgia, and several related disorders. Among women
who underwent breast reduction surgery, 14 were hospitalised for
definite connective tissue disease compared with 10.5 expected
(standardised hospitalisation ratio 1.3 (0.7 to 2.2)). Compared with
the breast reduction group, women with breast implants showed a slight
reduction for all definite connective tissue disease (relative risk 0.8
(95% confidence interval 0.5 to 1.4)).
Conclusions: This large nationwide cohort study shows
no evidence of association between breast implants and connective
tissue disease.
Department of Medical Epidemiology, International Epidemiology Institute, National Board of Health and
Welfare, Department of Plastic and Hand Surgery, Department of
Epidemiology,
Correspondence to: Dr Nyrén
email: Olof.Nyren@mep.ki.se
Design:
Randomised double blind controlled clinical
trial.
Setting:
Dhaka Hospital, International Centre for
Diarrhoeal Disease Research, Bangladesh.
Subjects:
83 children aged 1-7 years with
bacteriologically proved shigellosis but no clinical signs of vitamin A
deficiency; 42 were randomised to treatment with vitamin A and 41
formed a control group.
Intervention:
Children were given a single oral dose
of 200,000 IU of vitamin A plus 25 IU vitamin E or a control
preparation of 25 IU vitamin E.
Main outcome measures:
Clinical cure on study day 5
and bacteriological cure.
Results:
Baseline characteristics of the subjects in
the two treatment groups were similar. Significantly more children in
the vitamin A group than in the control group achieved clinical cure
(19/42 (45%) versus 8/14 (20%); chi2=5.14, 1
df, P=0.02; risk ratio=0.68 (95% confidence interval: 0.50 to 0.93)).
When cure was determined bacteriologically, the groups had similar
rates (16/42 (38%) versus 16/41 (39%);
chi2=0.02, 1 df, P=0.89; risk ratio=0.98 (0.70 to 1.39)).
Conclusions:
Vitamin A reduces the severity of acute
shigellosis in children living in areas where vitamin A deficiency is a
major public health problem.
Clinical Sciences Division, Centre
for Clinical Epidemiology and Biostatistics,
Correspondence to: Dr Hossain
email: shossain@icddrb.org
Design: Soundex coding of surnames and information on
date of birth were used to link entry and release dates from the local
prison between 1983 and 1994 with clinical data from Edinburgh City
Hospital's cohort of male injecting drug users who are infected with
HIV.
Setting: Edinburgh City Hospital and Edinburgh
Prison.
Subjects: 316/332 male injecting drug users infected
with HIV in the City Hospital HIV cohort; 16 were excluded because they
were enrolled after developing AIDS or because their precise date of
death was not available.
Main outcome measure: Relative risk of dying from
overdose before developing AIDS and relative risk of dying of all
causes before developing AIDS during the 2 weeks after release from
prison; this was compared with relative risks of death during other
time at liberty.
Results: 238/316 (75%) injecting drug users served
time in the prison between 1983 and 1994. 33 out of 316 injecting drug
users who were infected with HIV died before developing AIDS during
517 177 days at risk. 20 of these men died of an overdose; 6 of these
deaths occurred within 2 weeks of release during 5903 days at risk.
Death rates from overdose before the development of AIDS were 1.02/1000
days during the 2 weeks after release (recently released) and
0.029/1000 days during other times of liberty. The relative risk of
death from overdose became 7.7 (1.5 to 39.1) after temporal matching
(when the comparison was limited to the first 2 weeks after release
versus the next 10 weeks). The crude relative risk in an
analysis combining stratified prison term and the 2 weeks after release
was 4.5 (1.7 to 11.7) for death from overdose. After temporal matching
these risks became 1.8 (0.4 to 9.2).
Conclusion: Prisons should evaluate interventions to
reduce the risk of death from overdose after release.
Medical
Research Council Biostatistics Unit, Regional
Infectious Diseases Unit,
Correspondence to: Dr Gore
email: sheila.gore@mrc-bsu.cam.ac.uk
Design: Newly diagnosed patients were asked to
participate in a randomised trial of psychological support compared
with standard medical care. Participants and non-participants completed
self assessment questionnaires at baseline and at 2, 4 and 12 months.
Setting: Testicular Tumour Unit of the Royal Marsden
Hospital.
Subjects: 73 of 184 (40%) eligible patients agreed
to enter the randomised trial (participants) and 81 (44%) declined to
participate but agreed to complete further assessments
(non-participants). 30 patients wanted no further contact with the
researchers.
Outcome measures: Hospital anxiety and depression
scale, psychosocial adjustment to illness scale, Rotterdam symptom
checklist, mental adjustment to cancer scale. Only scores on the
hospital anxiety and depression scale are reported for evaluating
treatment efficacy.
Results: 111 of 184 (60%) eligible men declined to
participate in the trial. Patients with stage I disease were most
likely to refuse to participate. A patient was less likely to
participate if he had low volume disease and was receiving no further
treatment. Likelihood of participation was associated with stage of
disease and with type of primary treatment (P<0.001 for
heterogeneity). Patients with early stage disease (P<0.001) and fewer
physical symptoms (P<0.001) were less likely to participate.
Psychosocial factors associated with participation included anxious
preoccupation regarding disease (P=0.01). There were no differences in
outcome between participants and non-participants during follow up.
Patients seemed to gain little benefit from adjuvant psychological
therapy. At 2 months change from baseline favoured the treated group in
the anxiety subscale (mean difference between groups -1.41 (95%
confidence interval -2.86 to 0.03)). This was not sustained when
adjusted for factors related to the disease. By 12 months change from
baseline seemed to favour the control group (mean difference between
groups 1.66 (-0.18 to 3.50)).
Conclusions: Patients with testicular cancer seem to
have considerable coping abilities. Those who declined to participate
in the trial differed from those who participated. Those who agreed to
participate may comprise the clinical group who perceive a need for
psychological support. No evidence was found to indicate a need for
routinely offering adjuvant psychological therapy.
Academic Department of Radiotherapy and
Oncology, Clinical Trials and Statistics Unit,
Correspondence to: Ms
Moynihan
email: clare@icr.ac.uk
Douglas G Tincello, David H Richmond
Design: Prospective case series.
Setting: Antenatal clinic of a large inner city
maternity hospital.
Subjects: All women attending for their first
antenatal clinic. Patients taking antibiotics for any reason and those
with urinary tract symptoms were excluded.
Intervention: A midstream urine specimen was divided;
half was sent for microscopy and formal bacteriological culture and the
other half was tested with a commercial reagent strip test for the
presence of blood, protein, nitrite, and leucocyte esterase.
Main outcome measures: Sensitivity, specificity, and
positive and negative predictive values of the reagent strips in
diagnosing asymptomatic bacteriuria (defined as 105 colony
forming units/ml urine).
Results: Sensitivity was low, with a maximum of 33%
when all four tests were used in combination. Specificity was high,
with typical values of 99% or more. Positive predictive value reached
a maximum of 69% and negative predictive value was typically 95% or
more.
Conclusion: Urine reagent strips are not sufficiently
sensitive to be of use in the screening for asymptomatic bacteriuria
and therefore many patients would be missed. In view of the potentially
serious sequelae of this condition in pregnant women we recommend that
formal bacteriological investigation remain the investigation of choice
in this group of patients.
Department
of Urogynaecology,
Correspondence to: Dr Tincello
Martin N Marshall
Design: Qualitative study using semistructured
interviews and focus groups. A content analysis of the data was
performed.
Setting: South and West Regional Health Authority.
Subjects: 12 general practitioner principals and 12
hospital consultants were sampled purposefully and underwent a
semistructured interview; a further 16 general practitioners and 16
hospital consultants similarly sampled made up four focus groups
representing the two branches of the medical profession.
Results: There was a mismatch between what the
general practitioners wanted from specialists in educational terms, and
what the specialists were providing. General practitioners wanted to
learn information that was directly applicable to their clinical work
and to use referrals as two way learning opportunities. They were not
sufficiently explicit about their learning needs. Specialists preferred
to concentrate on new developments in their subject and would benefit
from learning different ways of teaching. The participants were willing
to learn from each other. Three models of educational interaction were
identified: traditional didactic lectures given by specialists to
general practitioners, interactive clinically based teaching, and
informal interaction based on referrals.
Conclusions: The two main branches of the medical
profession have to address several significant problems before the full
potential of teaching and learning together can be
realised.
Institute of General
Practice,
Abstract
Design: Retrospective cohort study of all women in
the Swedish national inpatient registry who underwent breast
augmentation surgery with artificial implants during 1964-93, compared
with women who underwent breast reduction surgery during the same
period.
Karolinska Institute,
PO Box 281,
S-171 77 Stockholm,
Sweden
Olof Nyrén, associate
professor
Li Yin, statistician
Staffan Josefsson, programmer
Rockville,
Maryland
Joseph K McLaughlin,
senior scientist
William J Blot,
senior scientist
John D Boice Jr,
senior scientist
Stockholm
Sweden
Martin
Engqvist, register coordinator
University
Hospital,
Uppsala
Sweden
Lars
Hakelius, professor
Harvard School of Public Health,
Boston,
Massachusetts
USA
Hans-Olov Adami,
adjunct professor
Single dose vitamin A treatment in acute shigellosis in
Bangladeshi children: randomised double blind controlled trial
Shahadat Hossain, Rabi Biswas, Iqbal Kabir, Shafique Sarker,
Michael Dibley, George Fuchs, Dilip
MahalanabisAbstract
Objective: To evaluate the efficacy of a single
large oral dose of vitamin A in treating acute shigellosis in children
in Bangladesh.
International
Centre for Diarrhoeal Disease Research,
Bangladesh,
GPO Box 128,
Dhaka
1000,
Bangladesh
Shahadat Hossain, senior medical
officer
Rabi Biswas, research assistant
Iqbal
Kabir, scientist
Shafique Sarker, associate
scientist
George Fuchs, director
Dilip Mahalanabis, former director
University of Newcastle,
Newcastle,
NSW 2300,
Australia
Michael Dibley, senior
lecturer
Mortality from overdose among injecting drug users recently
released from prison: database linkage study
S R Seaman, R P Brettle, S M Gore
Abstract
Objective: To assess whether injecting drug users
have a higher than usual risk of death from overdose in the 2 weeks
after release from prison.
Institute of Public Health,
Cambridge CB2 2SR
S R Seaman, PhD student
S M Gore, senior statistician
City Hospital,
Edinburgh EH11 3XA
R P
Brettle, consultant
Evaluation of adjuvant psychological therapy in patients with
testicular cancer: randomised controlled trial
C Moynihan, J M Bliss, J Davidson, L Burchell, A
Horwich
Abstract
Objective: To determine the efficacy of adjuvant
psychological therapy in patients with testicular cancer and to compare
the characteristics and psychosocial outcomes of men who agreed to
participate with those who declined to participate in a randomised
trial of psychological intervention.
Royal Marsden NHS Trust,
Sutton,
Surrey SM2 5PT
C
Moynihan, medical sociologist
L Burchell,
research assistant
A Horwich, professor of
radiotherapy and oncology
Section of Epidemiology,
Institute of Cancer Research,
Sutton,
Surrey
SM2 5NG
J M Bliss, statistician
J Davidson,
data manager
Evaluation of reagent strips in detecting asymptomatic
bacteriuria in early pregnancy: prospective case series
Abstract
Objective: To evaluate the performance of reagent
test strips in screening pregnant women for asymptomatic bacteriuria at
their first visit to an antenatal clinic.
Liverpool Women's Hospital,
Liverpool L8 7SS
Douglas G Tincello, research registrar
David
H Richmond, consultant gynaecologist
Qualitative study of educational interaction between general
practitioners and specialists
Abstract
Objectives: To identify the main barriers to
effective educational interaction between general practitioners and
specialists and to suggest ways of overcoming these barriers.
Postgraduate Medical School,
University of Exeter,
Exeter EX2 5DW
Martin N Marshall,
lecturer
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