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Press releases Saturday 5 January 2008

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(1) NHS spends £100m a year on unnecessary drugs for indigestion
(2) Wristwatch ban for doctors "potentially dangerous"
(3) Call to stop obesity research and act
(4) Cases of viral meningitis set to rise
(5) Surgery no quick fix for sleep problems

(1) NHS spends £100m a year on unnecessary drugs for indigestion
(Editorial: Overprescribing proton pump inhibitors)
http://www.bmj.com/cgi/content/full/336/7634/2

At least £100m from the National Health Service budget and almost £2bn worldwide is being spent unnecessarily each year on drugs to treat indigestion, according to an editorial in this week's BMJ.

Proton pump inhibitors are one of the most frequently prescribed classes of drug in the world, write two gastroenterology doctors at King's College Hospital in London. They work by inhibiting the backflow of stomach acid that causes indigestion (dyspepsia).

In 2006, expenditure on these drugs was £425m in England and £7bn globally.

Effective and less expensive alternative drugs are available for many patients. Yet prescriptions for proton pump inhibitors have superseded those for all other acid inhibiting agents and now account for over 90% of the NHS drug budget for treating dyspepsia.

Because of their higher cost, prescribing guidelines have been drawn up in several countries and in the UK recommendations for using these drugs – particularly in the long term – are relatively selective.

So what is the evidence that guidelines are not followed?

In a study of hospitalised patients taking proton pump inhibitors in Australia, Ireland, and the UK, 63%, 33% and 67% of patients did not meet their country's criteria for taking the drug, while a US study of hospital in-patients found that most were taking these drugs unnecessarily at time of discharge.

In primary care, a Swedish study of patients who had been taking proton pump inhibitors for four years showed 27% were able to discontinue the drug altogether, while an audit of patients admitted as a medical emergency to a hospital in Wales found that a quarter were taking proton pump inhibitors, but in only half of the patients was the drug deemed appropriate.

After disseminating the NICE guidelines to local doctors, a repeat audit was performed six months later, which found that the same proportion of patients were taking a proton pump inhibitor and again, that only half of these had a recommended indication.

Proton pump inhibitors have been a tremendous therapeutic advance and have transformed the lives of patients with previously intractable symptoms, say the authors. But the drugs are clearly being overused.

There is evidence that taking proton pump inhibitors trebles the risk of Clostridium difficile infection.

They point out that side effects, although quite rare, should not be overlooked, but the adverse effect of overprescription on drug budgets around the world is the real problem. Quite how to motivate doctors to follow guidelines is a matter of considerable importance, they conclude.

Contact:
Ian Forgacs, Consultant Physician, Department of Gastroenterology, Kings College Hospital, London, UK
Email: ian.forgacs{at}kcl.ac.uk

(2) Wristwatch ban for doctors "potentially dangerous"
(Letter: Clinical value of a wristwatch)
http://www.bmj.com/cgi/content/short/336/7634/10

Hospitals are about to implement a "bare below the elbows" dress code policy for doctors, which includes a ban on wristwatches. But researchers in this week's BMJ warn that this could be potentially dangerous in a clinical setting.

There is no evidence that wristwatches are carriers of infection, and little account has been made of the clinical benefits of the wristwatch, write James Henderson and Sarah McCracken.

Most beds and examination couches in hospitals do not currently allow sight of a clock, so they set out to assess the dependence placed on wristwatches.

Twenty appropriately trained staff were asked to evaluate different pulse and respiratory rates on a simulated patient without the use of a second hand. Participants were given as much time as they wanted to make their estimate.

Estimates for a pulse rate of 83 ranged from 60 to 120, and estimates for a respiratory rate of 14 ranged from 10 to 28, showing that it was often not possible for healthcare professionals even to distinguish normal from abnormal without the use of a second hand.

Only one participant gave values for each reading that would not have been potentially dangerous.

This study highlights the necessity for doctors to have sight of a second hand when assessing patients, say the authors, especially in emergency situations where a clock might not be present.

If trusts wish to persist with the banning of wristwatches, they will be obliged to provide each bedspace with its own clock with a second hand, they add. Yet the same guidelines commend the wearing of soft soled shoes to avoid "disturbing patients' rest".

The sound of a thousand clocks ticking might be rather more than a little disturbing, they conclude.

Contact:
James Henderson, Specialist Registrar, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
Email: jh{at}jameshenderson.net

(3) Call to stop obesity research and act
(Letter: Stop all further research – and act)
http://www.bmj.com/cgi/content/short/336/7634/7

All further obesity research, dietary advice, and food labelling should be stopped and the money used to build an integrated, reliable public transport network, according to a letter in this week's BMJ.

Nicole Lavery, a community adviser in Northern Ireland believes we have now reached saturation point as to how many studies and articles it takes to convince us that we are too fat as a nation.

What good does it do to advise people that they need to walk, cycle and swim when the infrastructure is doing its best to prevent exactly this, she asks?

Despite all the suggested health assessments, dieticians' advice, government guidelines, and supermarket labels there is something missing: action to force planners, developers, councils and local authorities to end totally unsustainable, fat-making practices, such as building roads without cycle lanes, she argues.

She suggests the only way we will be able to tie our laces in the future and not need cardiopulmonary resuscitation at the age of 35 is to demand and build a functioning, cyclist and pedestrian centred, integrated public transport network.

But she concludes "having witnessed the government's transport policies in the last decades, I would say: fat chance".

Contact:
Nicole Lavery, Community Adviser, Northern Ireland
Email: nicolelavery{at}hotmail.co.uk

(4) Cases of viral meningitis set to rise
(Clinical Review: Viral meningitis)
http://www.bmj.com/cgi/content/short/336/7634/36

Viral meningitis is common, but many cases go unreported, say researchers in this week's BMJ. And due to the increasing incidence of genital herpes in the UK, cases of meningitis caused by the herpes simplex virus are set to rise, they warn.

In 2005-6, 2898 people were admitted to hospital in England with a diagnosis of viral meningitis, yet this is 10 times the number of cases notified to the Health Protection Agency in both England and Wales over the same period.

Meningitis is an inflammation of the membranes that cover the brain and spinal cord and is most common in young children. Viral meningitis generally has a good prognosis, but bacterial meningitis is life-threatening and requires prompt treatment.

However, the symptoms are similar (fever, severe headache, nausea and vomiting, dislike of light and a stiff neck) and they cannot reliably be differentiated, so all suspected cases should be referred to hospital.

Enteroviruses are the most common cause of viral meningitis at all ages, and infants and young children are most susceptible. No specific antiviral treatment is available.

Herpes simplex virus now ranks second among the causes of viral meningitis in adolescents and adults and is set to increase as the incidence of genital herpes rises.

Other causes include varicella zoster virus (the cause of chickenpox and shingles), HIV and mumps. Before widespread immunisation, mumps was a common cause of meningitis. The recent epidemic among young adults was associated with more than 100 cases of mumps meningitis in England in 2004-6.

Contact:
Eithne MacMahon, Consultant, Infection and Immunology, Guy's and St Thomas' NHS Foundation Trust, London, UK
Tel (via Guy's and St Thomas' NHS Foundation Trust Press Office): +44 (0)20 7188 5577

(5) Surgery no quick fix for sleep problems
(Upper airway surgery should not be first line treatment for obstructive sleep apnoea in adults)
http://www.bmj.com/cgi/content/short/336/7634/44

Surgery for obstructive sleep apnoea has no clear benefit and should not be offered as a first treatment, argue researchers in this week's BMJ.

Obstructive sleep apnoea is a common disorder caused by the collapse of the upper airways during sleep. This leads to loud snoring and sometimes breathing stops temporarily. The condition is associated with multiple morbidities, motor vehicle crashes, and reduced health related quality of life. It mainly affects middle-aged, overweight men.

Guidelines recommend continuous positive airway pressure (CPAP) with weight and alcohol management, if appropriate, as the first line treatment. But upper airway surgery is becoming increasingly popular in Australia and elsewhere.

So Dr Adam Elshaug and researchers at the University of Adelaide conducted their own investigations and analysed existing evidence for upper airway surgery and found the results of surgery were inconsistent.

One review of seven randomised trials concluded that surgery had a general lack of impact on symptoms and, even where improvements in quality of life have been shown immediately after surgery, these were rarely sustained beyond 12-24 months.

Another review of 48 studies found that up to 62% of patients who had surgery reported persistent adverse effects, such as dry throat, difficulty in swallowing, voice changes, and disturbances of smell and taste. Up to 22% regretted having surgery.

Weight loss and other lifestyle modification is recommended as an adjunctive treatment to CPAP, but can be difficult to achieve, write Dr Elshaug and colleagues. CPAP therapy also depends on acceptance and adherence by patients and its benefits in mild to moderate sleep apnoea seem inconclusive, making surgical "cure" seem more attractive.

Furthermore, in Australia, such surgery is mainly done in the private sector, which has different incentive mechanisms from the public system.

However, given the lack of clear benefit from surgery and the potential for harm indicated by currently available evidence, guidelines recommend CPAP as first line treatment for obstructive sleep apnoea generally.

Surgery for obstructive sleep apnoea should be done within controlled clinical trials, they write. Patients should be informed about the trial, as well as of the inconsistent results of surgery, the associated pain, the potential side effects, and the potential for relapse.

Contact:
Adam Elshaug, Hanson Institute Research Fellow and Lecturer, Discipline of Public Health, The University of Adelaide, Australia
Email: adam.elshaug{at}adelaide.edu.au

Also in this week's issue of the BMJ ...

(6) Doctors and the drug industry
http://www.bmj.com/cgi/content/full/336/7634/1
Should we fear the integrity of medical research because clinical trials are overwhelmingly funded by industry?
Paulo Bruzzi of the National Cancer Research Institute in Italy believes we should and says the medical research community must rethink the terms of cooperation with industry.

(7) Reducing hospital admissions
http://www.bmj.com/cgi/content/full/336/7634/4
Concern expressed by researchers at the University of Bristol over the lack of evidence for moving the acute care of some conditions out of hospitals into the community. This is important, given the UK government's agenda for moving care close to home.

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