Smoking kills millions of people every year and yet the medical community seems pathologically opposed to any measure to tackle the issue other than through the promotion of total abstinence. Carl Phillips suggests in his paper in the Harm Reduction Journal this month that smoking for just one month is more dangerous than switching to a smokeless nicotine product for a lifetime.
Take a moment to take a deep drag on a few breathtaking statistics.
Across the world approximately 1.3 billion people use tobacco products and by 2030 it is estimated that 10 million people will die annually from smoking-related diseases and 70% of these deaths will be in developing countries. We’ve known about the harmful effects of smoking for over 50 years and yet over that same period 6 million Britons have died of tobacco-related disease.
It’s no secret that it’s hard to stop smoking. Bandolier published an interesting little analysis of trials which included smokers and heroin addicts. They asked: which is the most addictive? In a rather elegant twist they looked at the cessation rates in the placebo arms of all the relevant trials. Cessation rates for smokers were around 8-9% yet for opiates users were around 43%. No surprises there – smoking is extraordinarily difficult to stop. Even in those that are highly motivated 12 month cessation rates are often no better than 10%. Opposing a harm reduction approach might be doing a grave disservice to those that just find it too tough to stop.
I am intrigued by the concept of tobacco harm reduction – not least because it requires a considerable effort of will to put aside a pathological distrust of Big Tobacco. Some of this post is taken from one I posted over at doc2doc a few months ago. The very first comment on the blogpost at doc2doc sums up the gut reaction of many doctors:
I think we should dismiss this out of hand! This argument is like low tar cigarettes are healthier..so you can smoke more of them. There is no such things as a safe(r) cigarette. The safer cigarette makes no sense given my understanding of how nicotine receptors work, not to say addiction. Do not trust Big Tobacco who have a vested interest in not losing their customers.
End of. Decision made. One suspects that the notion of smokeless nicotine products is simply not endorsable by the scientific orthodoxy in any shape or form. Phillips addresses all the arguments and using a back of a fag packet (though he prefers an envelope) calculation suggests that:
Whatever the explanation for it, the present analysis shows that anti-THR [tobacco harm reduction] activism is deadly. Hiding THR from smokers, waiting for them to decide to quite entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could.
If you are inclined to read the paper then flick to the back first and read the competing interests statement. Not for our Carl a bland ‘nothing to declare’ and instead it reads like a heartfelt plea that we pause, ignore the gut reaction and consider the evidence. It also speaks volumes for the ignominious role of mavericks in the scientific world; they may occasionally be lauded as heroes but more often they will be squeezed out of funding, shunned at the peer-review review stage and ostracised by their own community.
Within the wider medical community tobacco harm reduction remains an exercise in thinking the unthinkable. Doctors recommending it may be vilified and it opens up a researcher to accusations of acting as an industry patsy; labelled as a dull-eyed lackey in the pay of malignant giants. Yet it could save millions of lives and it certainly merits wider debate.
Phillips, C. (2009). Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments Harm Reduction Journal, 6 (1) DOI: 10.1186/1477-7517-6-29
Coffee table
I have to confess that a few years ago I was advising patients to go and get glucosamine for their dodgy knees. There can’t be many GPs that haven’t dropped it into the discussion with a patient with intractable osteoarthritic pain. The therapeutic options for worsening osteoarthritis seem to dwindle rapidly. Unfortunately, the evidence for any effect from glucosamine has been eroded nearly as quickly as the joints involved.
My fondness for glucosamine had been partly motivated by the fact Mrs ND is a vet and she advised me of the potential benefits of glucosamine for arthritis. She was adamant that a glucosamine-chondroitin supplement was good for dogs with arthritis and she gave testimony to having witnessed some near miraculous effects. Apparently this combo could perform wonders for portly labradors, or ‘coffee tables’ as vets occasionally refer to them, with knackered knees.
The GAIT trial was reported a year ago by NCCAM and Dr*T blogged about glucosamine way back last October. I know that NCCAM is not hugely popular amongst anti-quackers in the USA but there are some helpful Q&A here on their $12.5 million GAIT trial.
What were the key results of the study?
Researchers found that:
Participants taking the positive control, celecoxib, experienced statistically significant pain relief versus placebo-about 70 percent of those taking celecoxib had a 20 percent or greater reduction in pain versus about 60 percent for placebo.
Overall, there were no significant differences between the other treatments tested and placebo.
For a subset of participants with moderate-to-severe pain, glucosamine combined with chondroitin sulfate provided statistically significant pain relief compared with placebo-about 79 percent had a 20 percent or greater reduction in pain versus about 54 percent for placebo. According to the researchers, because of the small size of this subgroup these findings should be considered preliminary and need to be confirmed in further studies.
For participants in the mild pain subset, glucosamine and chondroitin sulfate together or alone did not provide statistically significant pain relief.
Essentially this huge and very expensive study involving around 1800 patients showed no benefits of glucosamine other than a small effect in a sub-group. If you go raking through all the subgroups in a large trial it is an inevitability of the way statistics are analysed that eventually you will turn up a significant result. Torture the data and it will tell you anything.
The possibility remains that perhaps glucosamine and chondroitin supplements are an effective treatment to reduce pain in arthritis in dogs. This could be an effect which is confined to canines and can’t be replicated in humans.
Or maybe there is a subtle placebo effect at work manifesting itself through the owners. It’s an intriguing thought. However, the most likely explanation is that the advice that vets give the owners when clients consult about a dog with dodgy knees is having the effect. Vets will give advice on lifestyle changes for the animal and are likely to give non-steroidal analgesia. It is this that makes all the difference – not the glucosamine and chondroitin supplements.
I’ve had a dig around in the vet literature and I found one systematic review of treatments for osteoarthritis in dogs in the Journal of the American Veterinary Medical Association. Incidentally, in the abstract when they talk about ‘comfort’ they are referring to the reliability of the evidence – not how little pain the animals were in. This isn’t clear until one reads the paper. The trial with glucosamine and chondroitin showed no effect above placebo. They commented:
Presently, the strongest evidence available for the medical treatment of clinical signs associated with osteoarthritis in dogs is mostly limited to nonsteroidal anti-inflammatory drugs. Additional controlled studies in all groups of medical treatments are needed.
There is possibly an argument that dogs will present later than their human counterparts. Dogs won’t turn up at the surgery whining at the first twinges in their knees. Perhaps vets are more likely to be treating severe osteoarthritis in dogs and this might fit with the GAIT trial showing an effect in their subset. Perhaps. But I’m grasping at straws.
However, there was another strand to GAIT which showed that there was no change in structural changes on X-ray. They went on to cast doubt on these findings as the overall changes in joint narrowing were smaller than expected. This week the American College of Rheumatology Annual Scientific Meeting presented an abstract at their conference. This was the Joints on Glucosamine (JOG) Study: A Randomized, Double-Blind Placebo-Controlled Trial to Assess the Structural Benefit of Glucosamine in Knee Osteoarthritis based on 3T MRI study. After 6 months of treatment they found no structural changes using MRI or any evidence of new cartilage formation when measuring a urinary biomarker of cartilage synthesis. It seems likely to be an important trial with negative findings confirming the GAIT findings.
Glucosamine limps on in high street stores but it seems to be running out of steam. One of the GP practices in which I locum has taken the decision to stop prescribing glucosamine. I’ve not been involved in the discussions but I suspect they have taken the view that it is a fundamentally an unremarkable food supplement with a miserable evidence base.
It would have been great to have identified a cheap, well-tolerated remedy to reduce the pain of osteoarthritis. Sadly, wishful thinking isn’t enough and for those with knackered knees it remains a dog’s life.
This post is also published at The Lay Scientist.
Image: Pete Chapman under Creative Commons Attribution ShareAlike 3.0 License
There is almost a sad inevitability about the discussion in the media around the issue of giving heroin to heroin users. When it come to heroin-assisted treatment (HAT) it is inevitable that any reasonable discussion will be drowned out by the clamouring commentariat.
The UK has been using heroin as part of the treatment of users in one form or another since 1926. More recently, there have been studies of HAT in Switzerland, Germany, the Netherlands and Canada which have shown benefits in health, psycho-social adjustment and illicit drug use to socially excluded heroin dependent patients resistant to other treatments.
However, it’s inevitable that ill-informed parallels will be drawn with alcohol, smoking and the funding of almost anything else in the NHS deemed more worthy. It’s even possible to drag in ‘our boys’ fighting the drugs (spot of mission creep here) war in Afghanistan if one wants to work up a proper lather. The RIOTT study (I am assuming the obligatory acronym is an ironic nod to the impact this study will have on Daily Mail readers) isn’t even published yet and already the hysteria begins…
Is it even worth discussing the science amongst this hubbub? It might be better to crawl back under the duvet, let the dust settle and have a more rational discussion when we actually have the results of the UK study.
But there is some science to look at and consider. It is only last month that the New England Journal of Medicine published the results of NAOMI, the North American Opiate Medication Initiative (another tortured acronym) which looked at exactly this issue and it’s probable that RIOTT will have similar results. NAOMI compared oral methadone versus injectable diamorphine. It was open-label and there was no attempt to blind users to their treatment. They had better retention in the diamorphine arm at 88% versus the methadone arm at 54%. The reduction in rates of illicit drugs were 67% in the heroin group and 48% in the methadone group. Overall, the diamorphine arm tended to do better.
There were clear benefits but it wasn’t without issues and there were serious adverse events. There were 18 events in the methadone group (n=111) but none of them were felt to be related to the treatment. In the diamorphine arm (n=115) there were a total of 51 serious adverse events. However, it was reckoned that 27 of these were directly related to the diamorphine and included overdoses and seizures. This has to be put in context: a total of 89,924 doses of diamorphine were self-administered during the course of the study so that’s 0.03% of injections causing an event.
There are some issues around the methodology. Users know what kind of trial they are entering and many will drop-out when they get randomised to methadone rather than injectable. Indeed, this was the case in this study and it raises some issues around bias. The methodology of RIOTT was published in the Harm Reduction Journal in 2006 and is available for free.
The final conclusion of the NEJM paper is a reasonable one:
In this trial, both diacetylmorphine treatment and optimized methadone maintenance treatment resulted in high retention and response rates. Methadone, provided according to best-practice guidelines, should remain the treatment of choice for the majority of patients. However, there will continue to be a subgroup of patients who will not benefit even from optimized methadone maintenance. Prescribed, supervised use of diacetylmor-phine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system.
It will certainly need to be given in a specialised environment so it is likely to remain a very limited intervention. The headlines have tended to highlight that crime rates fall. How can this be surprising? UK studies have shown reductions in criminal activity across all treatment modalities for years. Part of the reason for this emphasis is presumably to make it as palatable to the public as possible. It’s not enough for it to be a useful option to improve health in a limited group of treatment resistant users. There has to be a fringe benefit to society as well.
There is an excellent paper by the authors of NAOMI commenting on some of the controversies around HAT. Again, it is freely available at the Harm Reduction Journal and will give you as good a background knowledge of the issues around HAT as anything. The authors commented on the media:
Treating heroin addiction with heroin tends to evoke a knee-jerk reaction. Lack of understanding, restrictions on time and resources, and the need for a catchy headline often lead to sensationalism by the media. As previously mentioned, opposition both within Canada and the US also contributed to misleading reports from local, national, and international media. The resulting focus has been on a seeming shift in Canadian drug policy in direct contradiction to the US war on drugs, rather than on the scientific or medical merits of the NAOMI study.
Much hand-wringing will be provoked by these studies for the simple reason that some will perceive that the logical development of this whole debate is that the next step will be de-criminalisation of drugs. It is entirely possible that we are waging a phoney ‘war on drugs’ but that’s really not what these studies are all about.
Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, & Schechter MT (2009). Diacetylmorphine versus methadone for the treatment of opioid addiction. The New England journal of medicine, 361 (8), 777-86 PMID: 19692689
If I consider the evidence relevant to my daily practice there is no real requirement for me to appraise this paper. Positive or negative it will have no impact on my daily practice. However, the lack of negative results in the literature is often highlighted and that is one reason this trial deserves attention. I could argue (in a rather lofty and supercilious fashion) that 13 million children worldwide with severe malnutrition is an issue that merits an hour or two of anyone’s time. But mostly I just thought it looked interesting.
Probiotics irritate the hell out of me. Whenever I walk sourly down the yoghurt aisle of the supermarket I can feel the nebulous manafacturer claims wafting past. Of course, there is some evidence for probiotics but for a useful probiotic primer for the more skeptically-minded I would recommend (again) Mark Crislip’s Quackcast on the subject. I understand that the evidence of benefit doesn’t extend a huge amount beyond the confines of antibiotic-associated diarrhoea. I particularly like the Crislip interpretation of the ‘immune modulating’ effects of probiotics. He suggests that they are basically inducing chronic inflammation – not too surprising when one considers the constant stream of bacteria being dumped in the system. He also highlights the link between the known effects of chronic inflammation in the mouth and an associated increase in cardiovascular risk.
The trial’s lead author, Marko Kerac, was on the Lancet’s podcast this week (though it stops working just after 8 minutes). He seems an entirely sensible fellow though he gives an unnervingly positive summary of probiotics that I would be chary of accepting. I should point out that if you are tempted to listen to this podcast the author has an horrendous dose of high rising intonation. In addition, the podcast is abruptly truncated at just over 8 minutes.
He also demonstrates the human qualities of us all. In its perfect manifestation the randomised clinical trial can take out the unreliable subjective element of human behaviour. However, humans still have to interpret the results. In the podcast the author initially expresses disappointment at the lack of positive results and I wouldn’t criticise him for wanting to save the lives of thousands of children.
The abstract finishes with:
Subgroup analyses showed possible trends towards reduced outpatient mortality in the Synbiotic group (p=0.06).
Interpretation
In Malawi, Synbiotic2000 Forte did not improve severe acute malnutrition outcomes. The observation of reduced outpatient mortality might be caused by bias, confounding, or chance, but is biologically plausible, has potential for public health impact, and should be explored in future studies.
After reading the paper I am less convinced about this final conclusion. I get the impression from the paper (though it’s difficult to be certain) that the outpatient phase analysis was entirely post-hoc. The authors have honestly highlighted the potential for any post-hoc findings to be a product of pure chance. I suspect the deep disappointment in the overall negative result has trickled down into the interpretation. The final hook about outpatient mortality adds a tantalising edge to this paper. Getting a paper in the Lancet is tough – would an unrelentingly negative paper with no emphasis on this statistical wrinkle have still been published?
After all, it wasn’t the only significant difference that was found. The Synbiotic group had significantly more severe diarrhoea as an inpatient(at p=0.01 this was the strongest statistical finding in the study), more vomiting as an inpatient (p=0.05) and more cough as an inpatient (p=0.05). These don’t get a mention in the abstract. Given the caution needed when giving probiotics to an immuno-compromised population it would be entirely legitimate to have a quite different emphasis in this report.
At randomisation, groups seem to be well balanced. Minor differences at point of entry to outpatient care (lower HIV and less malnourished according to weight-for-height Z score in the Synbiotic group) raise the possibility of confounding or bias at this point.
In the Synbiotic group 42.6% were HIV positive and in the control group there were 48.5% HIV positive. The p-value for this difference between HIV rates in the two groups is P =0.08. This is not a statistically significant difference but in a total population of 795 children there is only a 4 child swing between significance and non-significance. It is feasible that the outpatient mortality differences could be simply related to this sampling bias and chance. I would not infer any deliberate deception here at all – just the simple desire to do so some good. I’m sure the research will now be repeated in an outpatient population but I’m not convinced the evidence from this trial justified it. On the other hand, maybe their dogged optimism and persistence will triumph and many lives will be saved.
In the podcast the lead author tells the tale of how the senior author, while working for UNICEF in Korea back in ’98, had made the observation that children fed at the local yoghurt factory apparently had better outcomes. He formulated the hypothesis that all those friendly bacteria were having an additive beneficial effect. It would have made a charming modern medical parable – chance favouring the prepared mind and the elegant RCT demonstrating benefit leading to millions of lives saved. No such luck this time.
Kerac, M., Bunn, J., Seal, A., Thindwa, M., Tomkins, A., Sadler, K., Bahwere, P., & Collins, S. (2009). Probiotics and prebiotics for severe acute malnutrition (PRONUT study): a double-blind efficacy randomised controlled trial in Malawi The Lancet, 374 (9684), 136-144 DOI: 10.1016/S0140-6736(09)60884-9
The regular half page advert for the General Chiropractic Council appears in the BJGP as usual this month.
I am sure there is little or no editorial control over the advertising in a journal but I couldn’t help but notice that this month their advert is plastered directly opposite Prof Ernst’s article: ‘Ethics of complementary medicine: practical issues.’¹ I will leave the GCC to muse where on the spectrum between conspiracy and cock-up this sits. Perhaps the BJGP editorial board has similar feelings to Nature and the Daily Mail on the recent Simon Singh vs chiropractic legal battle?
The Prof Ernst article shines a harsh ethical light on some of the claims of the GCC. The banner headline in their advert is:
Why refer patients to Chiropractors? Because Chiropractors manage back pain effectively and use methods recommended in current evidence reviews.
Holding up my paper copy of the BJGP I move my eyes two inches to the right to read Prof Ernst’s comment:
A survey of promotional leaflets distributed by US and Canadian professional chiropractic organisations showed that all of those sampled claim chiropractic services that ‘have not been scientifically validated’. The authors concluded that this ‘reinforces an image of the chiropractic profession as functioning outside the boundaries of scientific behaviour’.
The article goes on to lay out some of the practical ethical issues that are not being addressed across the field of complementary medicine.
Informed consent is taken as a sine qua non of ethical medical practice. We teach students that it is an indispensable ingredient of modern medicine. The ethical issue is at its starkest when considering GPs that practice complementary medicine and in particular homeopathy. The overwhelming weight of evidence suggests that the actual homeopathic remedies are ineffective. I do not doubt that many people who visit a homeopath feel better. This is unsurprising as having an extended consultation with almost any practitioner prepared to sit and listen is clearly a massive intervention in itself. I am struggling to believe that any homeopath tells a patient that the pill itself is an inert blank and they are practising, in Dr Aust’s words, ‘stealth psychotherapy’.
The BJGP provides (presumably for ‘balance’) a commentary² by Brian Buckley, a Cochrane fellow and researcher in primary care in Ireland, with no obvious affiliation to complementary medicine. He offers a limp, half-hearted refutation of Prof Ernst’s article. He makes some effort to set up a straw man argument when he suggests that genuine informed consent is not obtained in the practice of conventional medicine. This bears a striking resemblance to the wholly discredited tack that conventional medicine has but a handful of evidence based options.
The example of prostate specific antigen is cited as an example of the dubious ethical nature of consent. Personally, I am careful to counsel patients on the notoriously limited value of this test. Not for nothing is it commonly considered by GPs that PSA stands for Promotes Stress and Anxiety. He suggests that:
Given pressures of time and other factors, it seems unlikely that all patients give genuinely informed consent… to give genuinely informed consent would require a considerable amount of time and preferable some knowledge of epidemiological principles to discuss it with their doctor.
While I am not suggesting I wouldn’t like more time this is exactly what being a GP is all about. Of course, it all depends where you set the bar for ‘genuinely informed consent’ but practising patient-centred medicine means that GPs spend all day trying to give people enough information to allow them to be genuinely empowered. I’m not suggesting it’s perfect but I am sure most GPs are trying damn hard to achieve it.
There are many areas that could be suggested for a discussion about the ethics of complementary medicine. One argument might highlight patient autonomy and this means that people are free to choose complementary medicine. That’s a powerful argument but it is undone by the premise of informed consent. No one can make an informed choice until they are in full possession of the facts.
Complementary medicine, when practised by GPs, skirts very close to the edge of ethical acceptability. Full informed consent is needed and surely that should involve informing patients of the absence of effect and the risks of treatment?
1. Ernst, E. (2009). Ethics of complementary medicine: practical issues British Journal of General Practice, 59 (564), 517-519 DOI: 10.3399/bjgp09×453404
2. Buckley, B. (2009). Commentary: Conventional medicine is less than perfect British Journal of General Practice, 59 (564), 519-519 DOI: 10.3399/bjgp09×453558
My contribution to the debate at Pulse on 17 June 2009 is reproduced below. At the Pulse site you can read the counter-piece by Dr Andrew Hamiton who supports acupuncture.
A few years ago I thought there might be something in acupuncture and I was keen to exploit its potential to help my patients. Unfortunately, my personal experience of a medical acupuncture course left me feeling like I had been sold a timeshare or indoctrinated into a cult. The evidence was brushed aside and selectively quoted by GPs in a feverish atmosphere of enthusiastic and misguided holism. I was not impressed and I became sceptical.
Let’s put aside the traditional acupuncture mumbo-jumbo of chi and meridians to consider, as pragmatic GPs, the simple question: does it work?
In the past, it’s been difficult to do trials with realistic placebos and this is undoubtedly part of the reason for the persistence of the belief that acupuncture is a useful medical intervention. The challenge is to separate the real effects of acupuncture from placebo. It’s important to remember that patients inevitably receive more attention, including lifestyle advice and support, when spending time with any therapist. This all tends to get lumped in as the ‘placebo effect’ and helps explain why even sham acupuncture can show benefit over standard care.
A recent large trial compared acupuncture versus toothpicks touched against the skin in patients with chronic low back pain. There was no difference between the acupuncture and toothpick groups. All these groups, even the toothpicks, did better than standard care, and most right-minded folk would confidently call this a placebo effect.
Acupuncturists claim, with no apparent trace of embarrassment, that this represents a trial in acupuncture’s favour and that needling site and even penetration may be less important than thought. In effect they are suggesting that toothpicks are some kind of acupuncture-lite. I would suggest that toothpicks are patently not acupuncture and that this is strong evidence that acupuncture itself is ineffective.
Another recent trial of acupuncture for hot flushes in menopausal women claimed an impressive effect. But there was no attempt at any placebo control and the outrageous bias in the sample practically guaranteed a positive result. Even with these loaded dice the differences found may have been statistically significant but were clinically minimal. The press releases, duly reported by time-pressured news desks, trumpeted the success of acupuncture for alleviating hot flushes.
A casual and selective approach to evidence, allied to vigorous self-promotion, is a hallmark of the acupuncture lobby’s approach to the literature.
Acupuncture relies on the faith-based collusion of expectation between acupuncturist and patient. Its promotion also feeds into a choice culture capable of overriding common sense in many areas of general practice and that rides roughshod over the medical evidence. Some GPs may shrug and suggest there is no harm in it but I feel uncomfortable sitting back as acupuncturists spend an estimated £32 million of precious NHS funds.
Acupuncturists have an emotional investment in this therapy. They are fervent, enthusiastic advocates who almost certainly have nothing but good intentions. But they are performing contortions when describing these trials and to justify the continued use of acupuncture in the face of mounting evidence that it is nothing more that a dramatic placebo.
Acupuncture has been touted as a panacea for 4,000 years and it may have been used by countless millions around the globe but no one, in that whole time, has proved beyond any reasonable doubt that there is a clinically significant effect that can be distinguished from bias. We would have flushed away any drug with such poor results. It’s time that acupuncture was consigned to the sharps bin.
Bonjourrrr, ya antibiotic eating surrender monkeys!
No doctor likes to think that they are the one who is giving out all these antibiotics to viral illnesses. There is always someone else at fault. Partners blame locums. Locums blame nurses. Everyone blames the patients. Me? I blame the French. They have shamelessly flung antibiotics around for years with Gallic abandon. According to a PLOS paper more than 70 prescriptions per 100 inhabitants were issued for antibiotics in 15 regions in France in the winter of 2000. Sacre bleu.
However, it seems that the French have been making a big effort with a nationwide campaign over the period 2002-07. ‘Les Antibiotiques c’est pas automatique’ was a massive push to educate the public and to support doctors to say ‘non’. The researchers report that the use of all major antibiotic classes, except quinolones, decreased in all 22 regions of France by around 27% (95% CI 20 to 34%) over the same period. Of course, as we all know, association is not causation and there could be other reasons that have contributed to the reduction.
The BMJ also reported this week on European variations in prescribing for acute cough. There were some huge variations in antibiotic prescribing with the worst culprits being the Slovakians who prescribed on 90% of occasions. The Spanish were the lowest at 20% but given that antibiotics are available OTC this may not be a wholly reliable indicator. The Welsh and English were high prescribers with rates of 70% and 63% respectively. The crucial news from this prospective study is: there was no difference in outcome between the lowest rates of prescribing and the highest. This screams out to almost everyone that we are over-prescribing antibiotics across Europe. The French were not one of the 13 countries involved but it looks a bit like GPs in glasshouses shouldn’t throw stones.
Public health is a slowburn. There aren’t many that go into medical school with the fiery passion of John Snow for epidemiology burning in their breast. For more of them it is the chest-cracking and heart thumping that fires them up. Preserving antibiotics will almost certainly save lives in the future but you won’t get any credit for it now. There is a significant problem with multi-resistance pneumococcal pneumonia but someone getting pneumonia that responds to penicillin will quietly go home. Where’s the drama in that? We are oblivious to the fine line that separates us from the horrors of the pre-antibiotic age. As has been said: public health isn’t seen when it’s done right.
It’s a slow job. A million tiny incremental steps working toward a global reduction in antibiotic use that could have real significance for all our health. We can all keep chipping away but the results of the French campaign, while encouraging, were not spectacular. Is it enough? Perhaps we should look to a future where public health policy becomes more draconian to curtail our continued profligacy with antibiotics.
Sabuncu, E., David, J., Bernède-Bauduin, C., Pépin, S., Leroy, M., Boëlle, P., Watier, L., & Guillemot, D. (2009). Significant Reduction of Antibiotic Use in the Community after a Nationwide Campaign in France, 2002–2007 PLoS Medicine, 6 (6) DOI: 10.1371/journal.pmed.1000084
Butler, C., Hood, K., Verheij, T., Little, P., Melbye, H., Nuttall, J., Kelly, M., Molstad, S., Godycki-Cwirko, M., Almirall, J., Torres, A., Gillespie, D., Rautakorpi, U., Coenen, S., & Goossens, H. (2009). Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries BMJ, 338 (jun23 2) DOI: 10.1136/bmj.b2242
I’ve been on my hols in beautiful Galloway but Pulse chose this week to print my contribution to the acupuncture debate.
A few years ago I thought there might be something in acupuncture and I was keen to exploit its potential to help my patients. Unfortunately, my personal experience of a medical acupuncture course left me feeling like I had been sold a timeshare or indoctrinated into a cult. The evidence was brushed aside and selectively quoted by GPs in a feverish atmosphere of enthusiastic and misguided holism. I was not impressed and I became sceptical.
You can read the rest of my contribution to the debate at Pulse.
I had to chuckle at the comment by Mike Cummings. It turns out the other GP, Dr Andrew Hamilton, who wrote the pro-acupuncture piece attended the same BMAS course as me in 2003. I think I can safely say that our views have since diverged…
For many months there have been half-page adverts in the British Journal of General Practice (BJGP) by the General Chiropractic Council (GCC).
Why refer patients to Chiropractors?
Because Chiropractors manage back pain effectively and use methods recommended in current evidence reviews
The problem that chiropractic now has is one of credibility. And let’s make no mistake about it the chiropractic profession wants, indeed craves, the credibility.
One article in Chiropractic & Osteopathy in August 2008 asks this very question: How can chiropractic become a mainstream respected profession? The example of podiatry.
Objective: To present a perspective on the current state of the chiropractic profession and to make recommendations as to how the profession can look to the podiatric medical profession as a model for how a non-allopathic healthcare profession can establish mainstream integration and cultural authority.
Well, my first piece of advice would be not to refer to us mainstream practitioners with the pejorative term ‘allopathic’. That aside, I have always felt that there are plenty of chiropractors out there who try to practise evidence-based interventions and who look askance at evidence for chiropractic in a variety of medical conditions. And this is the point the authors make in this paper when considering the original chiropractic concept of ‘innate intelligence’:
These concepts are lacking in a scientific foundation and should not be permitted to be taught at our chiropractic institutions as part of the standard curriculum. Much of what is passed off as “chiropractic philosophy” is simply dogma, or untested (and, in some cases, untestable) theories which have no place in an institution of higher learning, except perhaps in an historical context.
Fundamentally, there exists a gap between this approach and the reality. This is presumably why the GCC are directly targeting general practitioners and advertising in the BJGP. The debacle with Simon Singh is only serving to widen the gap and it is has the potential to set chiropractors’ professional position back years. This paper suggests that chiropractic drops any pretence to treat any other condition and sets out their stall as the market leaders in spine care. Nothing else; pretty much just bad backs. Very sensible and I could envisage the future for chiropractic they set out:
But, most importantly, it means becoming experts in patient management, i.e., helping patients overcome spinal pain, whether that means providing adjustments, exercise, short-term medication use and/or education regarding the issues related to LBP provided in a cognitive-behavioral context. Currently, there is no profession that adequately fills that role, although as we noted earlier, the physical therapy profession is moving quickly in this direction. The opportunity is there for us to correct our mistakes, but we must act now. The only question is whether the chiropractic profession has the integrity, vision and self reflection required to make the necessary changes. Time will tell.
‘Integrity, vision and self-reflection’ eh? The authors must be hanging their head in despair at the current situation. Their claims for efficacy in conditions such as asthma, colic, chronic ear infections etc are being subject to the closest scrutiny and concerns regarding safety are being highlighted.
Prof Edzard Ernst has come to this conclusion.
But I strongly feel that whatever the judge decides, chiropractic (as a profession) can only lose.
Even if he rules in the BCA’s favour, the British public will have learnt a lot of embarrassing things about chiropractic which will severely undermine the reputation of this profession. This damage could well prove to be irreparable.
If I was minded to follow the new NICE guidance on low back pain I can’t see how I can recommend chiropractic to my patients. If anyone is going to do spinal manipulation then I’ll send them to the local physioterrorist who is perfectly capable of all the interventions that chiropractors offer. Many GPs will be even more reticent about referring to chiropractors. The credibility gap is simply too great.
Murphy, D., Schneider, M., Seaman, D., Perle, S., & Nelson, C. (2008). How can chiropractic become a respected mainstream profession? The example of podiatry Chiropractic & Osteopathy, 16 (1) DOI: 10.1186/1746-1340-16-10
Borras, E., Dominguez, A., Fuentes, M., Batalla, J., Cardenosa, N., & Plasencia, A. (2009). Parental knowledge of paediatric vaccination. BMC Public Health, 9 (1) DOI: 10.1186/1471-2458-9-154
This study in Spain was a retrospective cross-sectional survey in Catalonia. They called up the parents of 630 children to ask them about vaccine coverage and to assess their knowledge about vaccines.
It showed that higher vaccination rates were associated with maternal age >30 and better knowledge scores about the vaccination. This seems fairly reasonable but it doesn’t entirely tally with my practical experience. I used to have far more trouble with the educated mothers and have experienced some terrifyingly irrational consultations. At its peak it didn’t matter how much the facts about vaccination were emphasised mothers just couldn’t get past the media screaming the unfounded risks at them.
The highest percentage of unvaccinated children corresponded to the MMR vaccine (1.58%). Non vaccination with the MMR vaccination was observed in 57% of children aged 18 months in the United Kingdom. In Switzerland, 21.34% of children were not vaccinated against rubella in 1998, and 77.52% in Italy in 1997. In Edmonton (Canada), 7% of children had received no dose of the MMR vaccine in 2002. The proliferation of negative publicity about vaccines in the mass media, especially the Internet, questioning the benefits of vaccination and leading to increased belief in natural or alternative therapies may explain these higher proportions of unvaccinated children.
Can you imagine a situation in the UK where the lowest rate of MMR vaccination is 1.58%? Yes, the decimal point is in the right place. It is a quite staggering difference and Spain does not seem to have been gripped by the autism-MMR hoax. DeeTee has posted over at Lay Science on the current situation in Wales and the single vaccine vultures are hovering.
To recap: As of Tuesday, 207 cases of measles had been reported in Wales, with 26 children being admitted to hospital and several ending up in intensive care with life-threatening complications. There have fortunately been no deaths yet, but that is probably a testament to the good care these kids have had in ITU. I just hope none have had measles encephalitis or any other complication that will cause long-term damage.
Has the recent MMR catch up campaign made any difference? We continue to teeter on the brink of an epidemic and the NHS Immunisation Information site reports that:
The data suggests that nationally there has been about 3.5 percentage point increase in the number of children aged 5 – 18 years who have received two doses of MMR from end of September 2008 to the end of April 2009. Over the same period of time, a decrease of about 1.3 percentage points was seen in children aged 5-18 who had received no doses of MMR.
They recommend caution with the data as it does not represent absolute rates but it seems to represent a trend toward improved uptake.
How else can we help? Well, I would re-iterate Margaret McCartney’s point that I don’t know a single doctor who hasn’t vaccinated their kids. This paper suggests we need older and better educated mothers. I don’t think we can wait for the current crop to age so I guess we will all keep doing our bit to inform whenever and wherever possible.
Bit old and a bit fat?
The Daily Mail today tackled midlife crisis and they have gathered some pearls of wisdom from various ‘leading health experts’. And what a panopoly of colourful opinions it is. Here are some evidence-lite highlights:
The trichologist sticks to unerring logic and tells us the hair is made of protein ergo a high-protein diet will help.
Energy levels in the hair follicles are at their lowest in the morning – another reason why you musn’t miss breakfast.
Eh? As I read this I can feel my hair aching – perhaps my follicle energy levels are dipping. So to summarise: if you have hair then eat.
The plastic surgeon recommends dark berries rich in vitamin E for wrinkles because it is good at “maintaining healthy, smooth skin”. Plastic surgeon?? Thanks, but if I want advice on my diet I’ll go to a nutritionist…
The nutritionist wades in:
Weight gain is often a factor in the midlife crisis. If you have gained weight around the middle, cut back on wheat and refined grain cereals, breads and biscuits as the yeast and sugars in these cause bloating and fat deposits.
To summarise: eat less expensive processed food.
And take a combination of multi-vitamins and minerals in addition to a well-balanced antioxidant formula, such as Vitabiotics Menopace Plus.
To summarise: eat more expensive processed supplements. I will ignore the lack of evidence for supplements and antioxidants to make this point: the article highlighted that men are more likely to be depressed in their midlife crisis. Menopace Plus “is a specially formulated food supplement for women during the menopause.” I don’t expect it makes much difference to the efficacy but, chaps, before you rush out it might be worth bearing that in mind.
The acupuncturist:
Giles Davies, acupuncturist at the Barry Road Clinic, South-East London, says: ‘Try to sleep before 11pm. In acupuncture, chi – the life energy that affects every cell in our body – moves like a tide around the body and it hits the gall bladder at about 11pm.
‘If you are not in a completely relaxed state by this time of night, this can lead to an imbalance in the gall bladder which will disturb your thoughts and make it difficult to sleep. The more you cannot sleep, the more tired you’ll get and the more difficult you will find it to face your midlife challenges.
I’m posting this at about 9pm – that gives me around 2 hours before my chi tide hits my gallbladder. I have to admit I do feel a bit bilious.
The GP
So, after all this drivel at least we can turn to the GP for some sound commonsense advice.
Dr Mike Dixon, GP and medical director of the Prince’s Foundation for Integrated Health, says: ‘People associate taking the herbal treatment St John’s Wort with depression. Though it’s a useful therapy for the condition, it is also a great pick-me-up for anyone who wants to feel more invigorated, so it is a good pre-emptive strike against the classic symptoms of the midlife crisis. You should always check with your GP before taking it as it can interact with other medicines.’
Who knew? If you had checked with me I would have told you that I am completely unaware of the evidence for any benefit for St John’s Wort as a ‘pre-emptive strike against the classic symptoms of midlife crisis’. I was aware of the evidence for its use in depression; but its benefit as a prophylactic in midlife crisis had completely passed me by.
Thank you Dr Dixon. I’m looking forward to delving into the evidence for the prophylactic use of herbal antidepressants in the well documented medical condition of being a bit old and a bit fat.
Or alternatively, I could follow the advice from the urologist who recommends that fat middle-aged pie-munchers (I am paraphrasing) should get some exercise. Give that surgeon an OBE.
Hat tip to Blue Wode and his cool tweets.
The journal Menopause has just published a randomised controlled trial of acupuncture for hot flushes in menopausal women (ACUFLASH).
The authors make some key points in their introduction which are worth highlighting:
The effects of acupuncture treatment are those of a treatment package including the therapeutic relationship and expectation, and acupuncture is available for women seeking an alternative to pharmacological treatment
I’m glad the authors have pointed out that any acupuncture intervention is not simply about the act of sticking a needle in someone. I thought this was revealing:
the treatment is individually tailored and compromises both lifestyle advice and needling in selected acupuncture points
There are major issues with recruitment in this trial. After all, if part of your intervention is based on ‘expectation’ then it is going to matter where you select your patients. Women were recruited by newspaper advertisements and media coverage. They weren’t recruited in a systematic way, say from consecutive patients attending gynaecology appointments or in a GP surgery. Of these 535 volunteers only a further 428 were deemed eligible to get a diary and then only 399 completed and returned it.
A rather large number of women (80) didn’t enter the study because they wanted immediate treatment. In the end, only 267 entered the randomisation phase and 2 of these withdrew immediately when they didn’t get acupuncture. Another 14 in the selfcare arm dropped out at 4 weeks because they ‘wanted active treatment’. The total number of women analysed was 248.
Now apparently Norway is a popular place for acupuncture. The paper quotes two recent surveys that showed 28% reported lifetime use and 10.8% reported use within the previous year. The baseline characteristics make eye-watering reading if one is considering the quality of the ’sample’. Previous use of acupuncture came in at 64% in both acupuncture and self-care group. A whopping 60% of the intervention group expected acupuncture to relieve their hot flushes and 51% of the non-acupuncture self-care group.
Clearly, the women were aware of the treatment they were given. A far more interesting study would have been to give 10 sessions of further ‘lifestyle advice’ to an additional arm (or instead of the self-care group) and assess if there was a significant difference between the groups.
My next major concern is with the length of the study. Why twelve weeks? This seems an incredibly short period of time for a problem which can affect a third of women for up to 5 years. My inner skeptic tell me this is because it is unlikely that the benefit will be sustained. Or it could be because the costs of giving weekly acupuncture for 5 years for minimal or no benefit would make an MP weep. We’ll never know from this trial anyway.
And I would point out that if you gave HRT for 12 weeks the risks of adverse effects would be absolutely minimal. I recognise the women may have been recruited on the basis that they didn’t want drugs but it would be an interesting comparison.
It’s worth a look at some of the ’significant’ results. These women started with an average of 12.6 hot flushes per day. Acupuncture reduced the number of hot flushes by an average of 2.1 per day. This may be statistically significant but is clinically deeply unimpressive. Mean hours of sleep increased by a statistically significant 0.28 hours – that’s just under 17 minutes to you and me.
We can then add these dubious clinical benefits to the massive weaknesses in this study – a flawed recruitment process, an unfair comparison without placebo and a trial period which is clinically irrelevant.
Another comment from the authors:
This study does not allow us to estimate what proportion of the clinical benefit was due to the effects of needling itself and what was due to other factors, such as the patient-provider interaction.
Of course not. If I may re-phrase this slightly – it actually doesn’t allow us to interpret what proportion could be an enhanced placebo effect. The authors claim at the very end that acupuncture treatment is comparable to the effect of SSRIs on hot flushes. I will wait for the trial that puts them head to head before I go for that line.
They claim that acupuncture can contribute to a clinically relevant reduction in hot flushes. I think this is an optimistic interpretation given the absolute reductions in flushes and the absolute improvements in sleep for the limited period of 12 weeks. Given the costs involved I won’t be rushing off to the local commissioners to demand more acupuncture on the NHS.
Many of the aspects of this trial superficially ticks the boxes for a decent quality methodological study. Several don’t; but then that is not unusual in any study. My main gripe is with the suggestion that this is some pragmatic trial and not a method, rather coyly, to enhance the evidence base for acupuncture. Unfortunately, they also fall into the trap of using the term ‘pragmatic’ to excuse methodological flaws. They might as well call it a pragmatic pilot and be done with it. It’s not reasonable to compare acupuncture with ‘normal self care’ (ie no treatment) because it’s been done and the placebo effect is a nightmare. Placebo may be difficult with acupuncture but that doesn’t make research without decent comparisons acceptable. It might be highly convenient to compare acupuncture for just 12 weeks for a condition that continues for months and months but it isn’t that useful. Pragmatism is just a smoke screen for a self-serving slice of CAM dogma.
The main researchers are based at the National Research Centre in Alternative and Complementary Medicine in Norway and this makes one wonder about the flaws in this study. Many would claim that acupuncture is an elaborate and theatrical placebo and this paper really doesn’t move us on past that position. I have no doubt they will be calling for more research…
Einer Kristian Borud, Terje Alraek, Adrian White, Vinjar Fonnebo, Anne Elise Eggen, Mats Hammar, Lotta Lindh Astrand, Elvar Theodorsson, & Sameline Grimsgaard (2009). The Acupuncture on Hot Flushes Among Menopausal Women (ACUFLASH) study, a randomized controlled trial Menopause: The Journal of The North American Menopause Society, 16 (3), 484-493 DOI: 10.1097/gme.0b013e31818c02ad
Well, the Princes’ Foundation for Integrated Health first Annual Conference kicked off today. That bastion of the nation’s health, er, Roger Daltrey, hasn’t been slow to offer his support for HRH and the author of Private Eye’s Medicine Balls, Dr Phil Hammond is chairing the shindig. Very satirical.
The Prince opened up proceedings and I felt his speech needs, frankly, a right royal fisking. However, given that time is precious and I am not sure I have the necessary moral fibre to wade through every point this is more like a mini-fisk. Fisk-lite. You can read the whole speech here.
The Prince initially offered his thanks and heaped much praise on Dr Michael Dixon, the Medical Director of the PFIH. I won’t dwell on Dr Dixon’s arguments in favour of integrative medicine and the interested reader can visit a comprehensive demolition of his fragile arguments at Science- Based Medicine. The Prince continued:
When my Foundation was created some fifteen years ago, a number of doctors and journalists thought that we had taken leave of our senses. (Apparently, I took leave of my senses long before that! However, I rather hope I didn’t lose my common sense – although as you cannot obtain a degree in common sense, but just about in everything else, no-one seems to value it!) Anyway, “How on earth can you mix the complementary and the conventional – witchcraft with proper evidence-based medicine?” they asked.
Good question. HRH then points out that many patients are already integrating it for themselves. Yes, indeed, but many of my patients play golf, eat pies and watch Big Brother. They manage to successfully ‘integrate’ all of those activities into their daily life without the aid of the Foundation. However, just because people are integrating them it does not necessarily follow that there is medical benefit in those activities and the NHS should be supporting them.
But are those who have criticized integration, speaking for patients or for somebody else? Perhaps they are speaking for themselves? For example, if an integrated approach is so dangerous, why is it that I have never heard of any patient groups campaigning against integration? Why have we not heard more opposition from doctors, nurses and other clinicians at the frontline, who deal with the daily suffering of those same patients?
Well, natch, I can only speak for myself but what possible ulterior motive could I have for criticising integration? It is a ludicrous argument to suggest that without a patient group campaigning against integration that this somehow infers safety. I qualify as a doctor at the frontline and I want to be absolutely clear that I oppose the integrated approach when it’s used to promote ineffective alternative therapies.
I am assured by those who are expert, those who are highly qualified and, most importantly, who do know what is going on in G.P. surgeries up and down the country that a mainstream research and evidence-based integrated approach to alleviating unnecessary suffering – quite apart from reducing the demand on consultancy time and the N.H.S.’s bill for drugs – is rapidly becoming more accepted because it is both safe and effective.
Where is the evidence that this integrated approach reduces demands on consultancy time and the drug budget? Please, please don’t tell me you are regarding the Northern Ireland ‘pilot’ as evidence. This statement is pure wishful thinking.
HRH then launches into some of the real canards of quackery. The rebuttal to the question of the safety of complementary medicine is met with the ‘how safe is conventional medicine’ diversion.
And what of the deaths which occur as a result of conventional approaches to treatment, otherwise known as iatrogenic? It is perhaps instructive to study the statistics
I agree it is instructive. Funny how HRH is happy to study the statistics when it relates to the safety of conventional medicine. The statistics also suggest that many complementary medicines are ineffective.
Does the accusation of “quackery” really amount to anything very significant when an increasing number of complementary therapies are coming under statutory and voluntary regulation?
The toothless nature of the Complementary and Natural Healthcare Council has been documented at The Quackometer. There is a feeble uptake amongst therapists and Ofquack is a long way from being an effective regulator of the estimated 150,000 practitioners in the UK.
I was fascinated to read the Independent Evaluation Report of the recent “Northern Ireland Integrated Medicine Pilot Project”, which suggested that integrated care not only helped the presenting problems, but also improved general health and might be cost-effective in the long run.
I wasn’t so much fascinated as embarrassed. Is this the best evidence that HRH can mention in his speech? It has no scientific credibility but again shows how defenders of quackery are happy to quote evidence when it points the right way.
HRH suggests that:
Human relationships, the human effect, personal care and continuity are, I believe, a crucial part of integrated care. The compassion that goes with them is an expression of values and humanity, and also the very act of healing itself.
This is a perfectly sound description of how many doctors practise medicine. I refuse to stand by and let this concept of treating patients as humans be misappropriated by HRH and his cronies. Dr Michael Dixon, a GP, has punted this argument in the past and it is utterly spurious. The implication is that doctors currently do not take these factors into consideration. They are a crucial part of any medical consultation and suggesting otherwise is simply wrong.
An integrated approach represents an advance from “doctor knows best” to empowering the patient by informing, motivating and enabling. It is about establishing a meaning and purpose for patients inside the therapeutic context and also in the world outside. In this way, I believe, we can reduce the burden of long term disease and enable those who have such disease to live longer, happier and more fulfilling lives. This is largely because integration hands more control back to them.
This is as insulting as it is misguided. Perhaps HRH would like to take a tour of the general practices of the UK? Does he think that we do anything other than practice patient-centred care? Medical schools (via the GMC) have recognised for years the importance of training students in patient-centred models of care and we try to give them the communications skills to deliver this aim. Every GP knows their community and integrates the cultural beliefs of their patient and tailors the care they give. Yes, there is room for improvement, and the system often makes it tough. I should think there are few GPs out there who see less than 30-40 patients a day. That doesn’t help when it comes to ‘informing, motivating and enabling’ and there are days when we all fall short.
The disappointing thing with the PFIH is that it is such an opportunity missed. There is nothing wrong with supporting social projects that could impact on health (as they do) but they could be campaigning for more physiotherapists or decent mental health services where there is a snowball’s chance in hell of getting CBT.
Instead, we are being treated to the usual canards that conventional medicine is dangerous with an emphasis on the natural and holistic qualities of complementary medicine. Worse still, they are distorting the true patient-centred focus of normal medical practice. The PFIH could be advocating longer consultation times for GPs or opposing polyclinics to help foster good continuity of care. It is a shocking perversion of the real issues driven by one man; unelected, unqualified and utterly misguided. The vision of integrated care from the Prince’s Foundation is a Trojan horse to ram complementary medicines deep into the heart of the NHS.
One of Australia's best ever batsmen (and, er, colour-blind)
Economic collapse. Mendacious MPs. Revalidation. Litiginous chiropractors. I’m feeling oppressed and I feel I need a tonic. And what better a tonic is there, in early summer in England, than cricket?
I would have liked to have settled down to enjoy some cricket today but sadly the swingeing cuts seem to have also impacted upon Test cricket and we have been reduced to a 3 day game.
So I have been musing on my own personal cricketing failings. I have always suspected that I am handicapped by my colour-blindness. Think about it. How do you fancy spotting a red ball on a green background with an inability to tell red and green apart? It turns out the medical literature has already considered the issue and is there to back up my plaintive pleas.
There is an expected prevalence of around 8% in the male population for colour-vision deficiency. Of course, an incidence of 8-9% means there is likely to be one colour-blind player in every team. Previous studies quoted have suggested rates as low as 4% in first class county cricketers. This study looked at 293 cricketers from seven cricket clubs in Melbourne. They found that 8.9% had colour-vision deficiencies but only 6.7% played at the highest level within those clubs. However, that reduction in those playing at the highest level is statistically significant.
This could lead one to the conclusion that colour-blindness is holding some cricketing men back. This study also looked at some other interesting areas which might prove useful for the village cricket bluffer and will provide ample ammunition to mount a robust defence of any mishaps.
The batting average in those with mild colour-vision deficiencies was 28.3 and those with severe deficiencies was 18.8. (Sadly, the authors report this was not statistically significant but don’t let that stand in the way of your bar-room thesis during the match post-mortem.) It was also noted that those with colour-vision deficiencies rather prefer fielding close to the batter. This might prove a highly useful piece of hard medical evidence for those that find galloping around a boundary rope somewhat wearing. The authors have included some technical explanations which will help beat back any naysayers.
A further hypothesis is that cricketers with abnormal colour vision will have greatest difficulty when fielding in the outfield where the angular size of the ball is small and the ball may often be seen against grass or surrounding foliage. The ball subtends about 12 minutes of arc for a fielder close to the batsman and three to five minutes of arc for a fielder near the boundary. It is known that all observers with abnormal colour vision, even those with a mild deficiency, have difficulty seeing red objects in natural surrounds. For these reasons cricketers with abnormal colour vision should prefer to field close to the batsman.
Rather amazingly 42% of men in this study did not know they had any colour-vision deficiency. So the next time you shell a dolly at long-off perhaps you ought to toddle down to your GP and do an Ishihara test. It could provide some convenient excuses.
Harris, R., & Cole, B. (2007). Abnormal colour vision is a handicap to playing cricket but not an insurmountable one Clinical and Experimental Optometry, 90 (6), 451-456 DOI: 10.1111/j.1444-0938.2006.00180.x
While some of the blogging GPs have been bemoaning the bombardment of flu pandemic related information my inbox has tumbleweed blowing through it.
Predictably, I am not the only one. The NASGP have been running a little survey of their sessional GPs. While I wouldn’t like to speculate on the biases involved in a survey like this I feel it makes a valid point.
Usual story. The RCGP provides some speculative further information in their flu pandemic guidance.
4.10 Locum GPs
4.10.1 It is envisaged that PCOS will act as the employer for all available freelance locum GPs during a flu pandemic. This will preserve their indemnity at a time when they will be working at maximum flexibility, possibly moving frequently between practices.
4.10.2 Like all GPs, locum doctors need to be on a performers’ list relevant to the country in which they plan to work. As part of the preparation for a flu pandemic, PCOs must check their databases ensuring that they are robust and that data on them are correct, including contact details and email addresses.
4.10.3 Locums/freelance GPs must be included in any preparation and training programmes, including information ascades, and be issued with any necessary photo ID cards as provided to other frontline doctors.
4.10.4 It is envisaged that PCOs will contract to employ ALL available locum GPs for the duration of the pandemic so that they have indemnity protection and death-in-service benefits. The rate of pay and details of the employment arrangements are the subject of ongoing discussions at national level.
It is a little disturbing that it might take a pandemic for section 4.10.2 and 4.10.3 to happen. This seems like the kind of good practice that should happen all the time.
So us locum types may end up employed by the PCT. God help us. Personally, I hadn’t given any consideration whatsoever to the personal financial impact of a pandemic. However, it seems that some GPs are bearing it in mind. I heard from a colleague today that some practices have not been slow to contact the PCT to establish the additional payments they will receive in the event of a pandemic. The RCGP have thoughtfully provided some basic information at Appendix 1 (before the WHO pandemic alert levels and children dosages) of their document.
The Department of Health does not intend any general practice to be disadvantaged financially by its participation in responding to an influenza pandemic.
Is it really necessary to bother the PCT at this early stage about financial compensation? I am sure some GPs will be quick to offer the ‘We Are Running A Business” defence and I can understand that a full-blown pandemic could damage a business. It will damage every single business in the UK. The effect on the economy of a full pandemic will be horrendous and it is likely that one of the few businesses that will receive economic protection from the government will be general practices.
It just makes me a little sad inside.
