Medical doctors' perception of the "number needed to treat" (NNT). A survey of doctors' recommendations for two therapies with different NNT

OBJECTIVE: While the number needed to treat (NNT) is in widespread use, empirical evidence that doctors or patients interpret the NNT adequately is sparse. The aim of our study was to explore the influence of the NNT on medical doctors' recommendation for or against a life-long preventive drug therapy. DESIGN: Cross-sectional study with randomisation to different scenarios. SETTING: Postal questionnaire presenting a clinical scenario about a hypothetical drug as a strategy towards preventing premature death among healthy people with a known risk factor. Benefit after 5 years of treatment was presented in terms of NNT, which was set at 50 for half of the respondents and 200 for the other half. SUBJECTS: Representative sample (n = 1616) of Norwegian medical doctors. MAIN OUTCOME MEASURES: Proportion of doctors that would prescribe the drug. Reasons for recommending against the therapy. RESULTS: With NNT set at 50, 71.6% (99% CI 66.8-76.4) of the doctors would prescribe the drug, while the proportion was 52.3% (99% CI 47.5-57.1) with an NNT of 200 (chi = 50.7, p < 0.001). Multivariate logistic regression analysis indicated that the effect of NNT on the likelihood for recommending the therapy was age-dependent; young doctors ( < 36 of age) were more sensitive to the difference in NNTs than older doctors. Thirty-six percent (n = 464) of the doctors would not prescribe the drug, and 77.4% (99% CI 68.5-86.2) of those agreed with an argument stating that only one out of NNT patients would benefit from the treatment. CONCLUSION: Medical doctors appear to be sensitive to the magnitude of the NNT in their clinical recommendations. However, many doctors believe that only one out of NNT patients benefits from therapy. Clinical recommendations based on this assumption may be misleading.     

Treatment of acute rhinosinusitis diagnosed by clinical criteria or ultrasound in primary care

Scand J Prim Health Care 2003;21:00-00. ISSN 0281-34323 Objectives &#114 - &#114 To compare antibiotics and placebo in patients with clinically diagnosed acute maxillary sinusitis (AMS). To study whether sinus ultrasound examination would help to detect those patients who benefit from antibiotic therapy. Design &#114 - &#114 A double-blind, randomised, placebo-controlled multicentre trial. Setting &#114 - &#114 Nine primary care sites in Finland. Subjects &#114 - &#114 150 adult patients (mean age 39.7 years) with a clinical diagnosis of sinusitis. Intervention &#114 - &#114 Antibiotics (amoxicillin 750 mg &#50 2, doxycycline 100 mg &#50 2 or penicillin V 1500 mg &#50 2) or placebo twice daily for 7 days; all patients were examined with sinus ultrasound after randomisation. Main outcome measure &#114 - &#114 Clinical success (patients' report of recovery) in telephone interview at 2 weeks. Results &#114 - &#114 A total of 146 patients completed the 2-week follow-up. Patients receiving antibiotics achieved a slightly higher rate of clinical success than patients receiving placebo (80% vs 66%; p=0.068). Conclusions &#114 - &#114 Antibiotics hasten symptom relief in AMS. Yet many patients recover in 2 weeks without antimicrobial treatment. Only half of patients with a clinical diagnosis of AMS have sinusitis in ultrasound examination.     

Structure and duration of consultations in Estonian family practice

Duration of the consultation is dependent on patient-related factors as well as on factors related to the health care system. Video-recording allows direct evaluation of the consultation and is acceptable to patients. Length of time of consultation is dependent on the patient's age and on the number and nature of the problems, but is not influenced by gender. Objective - &#114 To study the influence of age, gender and the nature of the patient's problems on length of time of consultation in the practices of newly trained family doctors in a recently reconstructed health care system. Design &#114 - &#114 Video-recordings of consultations with consecutive patients in family practice were studied for duration of consultation in relation to age, gender and nature of the problem(s). Setting &#114 - &#114 Primary health care. Subjects &#114 - &#114 405 consecutive consultations were video-taped in the practices of 27 family doctors. Main outcome measures &#114 - &#114 Length of time of consultation and its segments was analysed using the Statistical Package for the Social Sciences. The problems were classified according to the ICPC. Results &#114 - &#114 The average consultation lasted 9.0 min ( &#45 4.9). Physical examination was 2.0 min ( &#45 1.9) and was performed in 79% of all consultations. Respiratory and circulatory problems were the most common. More than one reason for the encounter was given in one-fourth of cases. Consultation time was longer for older age groups and for patients with psychological problems. Conclusion &#114 - &#114 Video-recording allows consultations to be evaluated directly and is acceptable to patients. The high participation rate of patients in our study can be explained by the individual approach and by the family doctor system. The period of consultation was dependent on patient age and on the number and nature of the problems, but was not influenced by gender.     

Prevalence of cardiovascular disorders among the elderly in primary care in Estonia

Scand J Prim Health Care 2003;21:000-000. ISSN 0281-3432 Objectiv e &#114 - &#114 To assess the prevalence of diagnoses of cardiovascular disorders among the elderly in family practice. Design &#114 - &#114 Cross-sectional study. Setting &#114 - &#114 Estonia, population aged 65 years or older (206 &#116 915 persons). Subjects &#114 - &#114 811 elderly persons selected randomly from the lists of family practitioners. Main outcome measures &#114 - &#114 Prevalence of hypertension, hypotension, coronary heart disease (CHD), myocardial infarction (MI), heart failure (HF) and cardiac arrhythmias; differences between the genders and age groups. Results &#114 - &#114 The prevalence of cardiovascular disorders was as follows: hypertension 63.2%, hypotension 11.1%, CHD 56.5%, MI 9.8%, HF 41.4% and arrhythmias 37.5%. Women had a significantly higher prevalence of hypertension and men of MI. The prevalence of CHD and hypotension was significantly higher in the oldest elderly persons. Conclusion &#114 - &#114 Among the older population in Estonia, cardiovascular disorders that have broader diagnostic criteria and need expensive methods for verifying (CHD, HF) have a high prevalence and are most likely over-diagnosed. The need for strict and simple diagnostic methods for these disorders in primary care practice continues to be serious.     

Surfactant protein A gene locus and respiratory distress syndrome in Finnish premature twin pairs

BACKGROUND. Surfactant protein A (SP-A) polymorphisms are associated with susceptibility to respiratory distress syndrome (RDS). According to present hypothesis the association between SP-A polymorphisms and RDS may not be applicable to the entire population of premature infants. AIM. The present study was designed to evaluate the associations between SP-A allelic variants and RDS in a population consisting of 198 premature twin pairs. METHOD. Genotype analysis of the SP-A1 and SP-A2 genes and twin zygosity definition were carried out. RESULTS. The main SP-A1 allele 6A 2 ( P &#114 = &#114 0.030), genotype 6A 2 /6A 2 ( P &#114 = &#114 0.0042) and haplotype 6A 2 -1A 0 ( P &#114 = &#114 0.016) were over-represented in healthy premature twin infants compared to RDS twins. The homozygous genotype 6A 2 /6A 2 was over-represented in twin pairs of whom both were healthy compared to twins concordant for RDS (odds ratio 0.18, confidence intervals 0.06-0.6, P &#114 = &#114 0.0016) and born between 32 and 36 weeks. 6A 2 /6A 2 was also overrepresented in healthy twin pairs with birth weight sum higher than the median (OR 0.15, CI 0.04-0.6, P &#114 = &#114 0.0025). CONCLUSIONS. In twins, the association between SP-A polymorphism and RDS is different from that seen in premature singleton infants. The factor associated with SP-A genotype-specific susceptibility to RDS appears to be related to the size of uterus and the length of gestation at birth.     

Encouraging structured personalised diabetes care in general practice

Scand J Prim Health Care 2003;21:000-000. ISSN 0281-3432 Objective &#114 - &#114 To evaluate the quality of diabetes care achieved on the process and outcomes of care in the context of a multifaceted intervention directed at general practitioners (GPs) encouraging regular follow-up and individualised goal-setting. Design &#114 - &#114 A 6-year follow-up study. Setting &#114 - &#114 A total of 243 Danish GPs and a population-based sample of 729 newly diagnosed, predominantly type 2 diabetic patients participated. Main outcome measures &#114 - &#114 Questionnaires and laboratory assessments were used to determine the proportion of patients reviewed regularly, and their pharmacological treatment and risk factors. Results &#114 - &#114 During the study, the proportion of patients who had an annual clinical examination decreased from 100% to 77%. The proportion given oral anti-diabetic agents or insulin increased from 43% to 71%. Median glycated haemoglobin (HbA 1c ) dropped in the 2nd year to 7.7% (normal range 5.4-7.4%), after which it increased gradually, but remained on average at 1.3% above the upper limit of the normal range. Median blood pressure (systolic/diastolic), total cholesterols and fasting triglycerides were maintained at 145-150/81-85 mmHg, 6.0-6.2 mmol/l and 1.66-1.96 mmol/l, respectively. Initial weight loss was partly regained over 6 years. Conclusion &#114 - &#114 Among centrally supported GPs, most patients were regularly reviewed and obtained acceptable levels of risk factors for at least 6 years, although glycaemic control progressively deteriorated after an initial drop to near-normal average level.     

Markers of inflammation in women on different hormone replacement therapies

BACKGROUND AND AIM. To measure inflammatory markers in postmenopausal women on different forms of hormone replacement therapy (HRT). METHOD. C-reactive protein (CRP), fibrinogen, plasma viscosity (PV), albumin and white blood cell (WBC) count were determined in 749 postmenopausal women. RESULTS. CRP concentration was significantly higher in women on estrogen monotherapy (difference of the median (d) 0.96 &#114 mg/l, P &#114 = &#114 0.013), compared to those without HRT, but there was no difference in women on combined HRT. Fibrinogen concentration was significantly lower in women on estrogen monotherapy (d 0.25 &#114 g/l, P &#114 = &#114 0.004) and combined HRT (d 0.4 &#114 g/l, P &#114 < &#114 0.001), compared to women without HRT. Similarly, PV was significantly lower in women on estrogen monotherapy (d 0.017 &#114 mPa·s, P &#114 = &#114 0.007) and women on combined HRT (d 0.039 &#114 mPa·s, P &#114 < &#114 0.001), compared to those without HRT. No differences were found for WBC count and the negative acute phase marker albumin in the various treatment groups. In contrast to oral estrogen administration, levels of CRP, fibrinogen and PV in women on transdermal estrogen therapy did not differ from the no-HRT group. There was no association between these markers of inflammation and plasma estrogen levels. CONCLUSION. Oral estrogen monotherapy was associated with highest concentrations of CRP. In contrast, other markers of inflammation were either similar or lower in the oral HRT group, compared to the group of women without HRT, suggesting that higher CRP concentrations reflect estrogen effects on CRP expression rather than a systemic pro-inflammatory effect.     

General practitioner assessment of structured oncological information accompanying newly referred cancer patients

Scand J Prim Health Care 2003;21:00-00. ISSN 0281-3432 Objective &#114 - &#114 To investigate general practitioner (GP) assessment of a structured oncology information pack sent to GPs when newly referred patients had visited a department of oncology for the first time, and to compare their assessment of this material with their assessment of traditional information provided by the department. Design &#114 - &#114 Randomised, unblinded clinical trial. Setting &#114 - &#114 Patients and GPs in the catchment area of a regional oncology department. Subjects / patients &#114 - &#114 248 cancer patients and their 199 GPs. Main outcome measures &#114 - &#114 GP assessment of the quality of the information material received for each patient. Results &#114 - &#114 88.3% of the 248 questionnaires were returned. The structured information pack improved GP knowledge of oncology; GPs found themselves better equipped to support and counsel patients during the course of their illness, and practitioner satisfaction with the department rose. Conclusion &#114 - &#114 Intervention, though reasonably simple, inexpensive and not particularly time-consuming, improved cooperation between the specialist department and the GP. While this is a small step in the right direction, the need remains for new initiatives and further studies into how to improve cooperation and communication between the primary and secondary healthcare sectors.     

Systemic Antifungal Prophylaxis After Hematopoietic Stem Cell Transplantation: A Meta-Analysis

Background

Hematopoietic stem transplant recipients are subject to increased risk for invasive fungal infections.

Objective

This meta-analysis was undertaken to explore the comparative effectiveness of systemic antifungal prophylaxis in hematopoietic stem cell transplant recipients.

Methods

We searched PubMed and The Cochrane Register of Randomized Controlled Trials up to March 2013 for randomized studies on systemic antifungal prophylaxis after hematopoietic stem cell transplantation. We performed a meta-analysis on the relative effectiveness of systemic antifungal prophylaxis on proven or probable invasive fungal infections using direct and indirect effects. Relative effectiveness was reported as odds ratio (OR) for invasive fungal infections, causative agent, empirical antifungal therapy, and withdrawals due to drug adverse events.

Results

Twenty evaluable studies provided data on 4823 patients. The risk for invasive fungal infections while on prophylaxis was 5.1% (95% CI, 3.6−6.8%). In patients receiving fluconazole, risks of proven or probable invasive fungal infections (OR = 0.24; 95% CI, 0.11−0.50; number needed to treat [NNT] = 8), systemic candidiasis (OR = 0.11; 95% CI, 0.05−0.24; NNT = 7), and overall need for empiric antifungal treatment (OR = 0.60; 95% CI, 0.44−0.82; NNT = 8) were reduced compared with patients receiving placebo. Itraconazole was more effective than fluconazole for the prevention of aspergillosis (OR = 0.40; 95% CI, 0.19−0.83; NNT = 23) at the expense of more frequent withdrawals (OR = 3.01; 95% CI, 1.77−5.13; number needed to harm = 6). Micafungin was marginally more effective than fluconazole for the prevention of all mold infections (OR = 0.35; 95% CI, 0.10−1.18; NNT = 79) and invasive aspergillosis (OR = 0.19; 95% CI, 0.03−1.11; NNT = 78) and reducing the need for empiric antifungal treatment (OR = 0.40; 95% CI, 0.13−1.21; NNT = 8). There was a relative lack of comparisons between different antifungal prophylactic strategies, including the newer azoles, voriconazole and posaconazole, in this population. Direct effects derived from single studies showed marginally significant effects for voriconazole compared with fluconazole regarding invasive aspergillosis (OR = 0.50; 95% CI, 0.20−1.20; NNT = 35) and the need for empiric treatment (OR = 0.72; 95% CI, 0.50−1.06; NNT = 15). Voriconazole compared with itraconazole (OR = 0.59; 95% CI, 0.40−0.88; NNT = 8) and posaconazole compared with amphotericin B (OR = 0.28; 95% CI, 0.06−1.24, marginal significance; NNT = 3) were better regarding empirical antifungal treatment.

Conclusions

Even when on antifungal therapy, invasive fungal infection will develop in 1 of 20 patients undergoing hematopoietic stem cell transplantation. There is evidence for the comparable effectiveness of different antifungal drugs used for prophylaxis. Fluconazole is the most widely studied agent, but micafungin might prove to be more effective. There is a relative paucity of studies for the newer azoles, although both voriconazole and posaconazole give proof of their comparative or higher effectiveness to fluconazole in single randomized studies.     

Folate status and homocysteine level in Italian patients aged under 60 on oral anticoagulant therapy

BACKGROUND. Folate deficiency occurs frequently and the related hyper-homocysteinaemia is considered a risk factor for thrombosis. We investigated folate status and homocysteine (Hcy) concentration in patients under 60 years on oral anticoagulant therapy (OAT) for previous venous or arterial thrombosis and in healthy blood donors. PATIENTS AND METHOD. Thirty-nine patients (mean age 35.2 years) on OAT for longer than 6 months and forty 44 healthy blood donors (mean age 36.0 years) were evaluated. Diet, serum folate (SF), red blood cell folate (RCF), homocysteinaemia, vitamin B12 levels and the mutation C677T of methylenetetrahydrofolate-reductase (MTHFR) gene were determined. RESULTS. The mean SF and Hcy concentrations were significantly higher in patients compared with blood donors (SF &#114 = &#114 17.7 versus 10.5 &#114 nmol/L, P &#114 < &#114 0.0001; Hcy &#114 = &#114 11.7 versus 8.9 &#114 &#55 mol/L, P &#114 = &#114 0.009). Twelve out of 39 patients and 7 out of 44 blood donors were homozygous for the mutation C677T of MTHFR gene. Among the remaining subjects, non-homozygous for the mutation, the patients (27) had mean SF and Hcy levels significantly higher than the (37) blood donors (SF &#114 = &#114 18.1 versus 10.8 &#114 nmol/L, P &#114 < &#114 0.0001; Hcy &#114 = &#114 10.3 versus 7.9 &#114 &#55 mol/L, P &#114 < &#114 0.0006). CONCLUSION. Italian patients aged under 60 years on OAT and non-homozygous for the mutation C677T of MTHFR gene, had SF and Hcy concentrations significantly higher than the control group.     

A randomized trial of laypersons' perception of the benefit of osteoporosis therapy: number needed to treat versus postponement of hip fracture

BACKGROUND: Information on the benefits of therapeutic interventions can be ex-pressed in various ways, including relative risk reduction, absolute risk reduction,and number needed to treat (NNT). An alternative to such risk-based measures is postponement of an adverse outcome (eg, hip fracture in the case of osteoporosis). OBJECTIVE: The goal of this study was to examine whether laypersons' perception of the benefit of an osteoporosis therapy differs when it is presented in terms of the NNT to avoid 1 hip fracture compared with the duration of postponement of hip fracture. METHODS: This was a cross-sectional, randomized, controlled trial. Face-to-face interviews of a representative sample of the Danish population were conducted in respondents' homes. Respondents were randomized to receive information about the benefits of a hypothetical osteoporosis intervention either in terms of different magnitudes of NNT (10, 50, 100, or 400) or different durations of postponement of hip fracture (1 month, 6 months, 1 year, or 4 years). Participants were subsequently asked if they would consent to the intervention. RESULTS: A total of 1728 individuals were contacted at home and asked if they would take part in a face-to-face interview; 967 (56%) were successfully interviewed. The age (mean age, 44.5 years; range, 20-74 years) and sex distribution (51% male, 50% female) of the sample was similar to that of the general Danish population. Based on NNTs of 10, 50, 100, and 400, the proportions of respondents who said they would consent to the intervention were a respective 65%,61%, 63%, and 57%. Increasing NNT was not significantly associated with a lower proportion of consent (test for trend chi-square(1)= 0.75; P = NS). Forty-three percent of respondents indicated that the concept of NNT was difficult to understand, and 38% interpreted NNT in a way that was probably incorrect. In terms of postponement of hip fracture by 1 month, 6 months, 1 year, and 4 years, the proportions who said they would consent to the intervention were a respective 25%, 40%, 39%, and 53%. Increasing postponement of hip fracture was significantly associated with higher proportions of consent (test for trend chi-square(1)= 20.09;P < 0.001). Logistic regression analysis found that consenting to therapy was inversely associated with age (NNT: OR, 0.83; 95% CI, 0.72-0.96; postponement of fracture: OR, 0.84; 95% CI, 0.73-0.98) and with the magnitude of benefit presented in terms of postponement of fracture. No other variables were significantly associated with consent to therapy. CONCLUSIONS: When laypersons were presented with brief information about the benefit of a hypothetical osteoporosis intervention and were then offered this therapy, their choices were sensitive to the magnitude of treatment benefit when it was presented in terms of postponement of hip fracture but not in terms of NNT. These findings suggest that it may be easier for laypersons to understand a potential treatment benefit in terms of postponement of fracture rather than NNT.     

Does Static-99 Predict Recidivism Among Older Sexual Offenders?

Static-99 (Hanson & Thornton, 2000) is the most commonly used actuarial risk tool for estimating sexual offender recidivism risk. Recent research has suggested that its methods of accounting for the offenders’ ages may be insufficient to capture declines in recidivism risk associated with advanced age. Using data from 8 samples (combined size of 3,425 sexual offenders), the present study found that older offenders had lower Static-99 scores than younger offenders and that Static-99 was moderately accurate in estimating relative recidivism risk in all age groups. Older offenders, however, had lower sexual recidivism rates than would be expected based on their Static-99 risk categories. Consequently, evaluators using Static-99 should considered advanced age in their overall estimate of risk.     

Survey of pharmacists’ and physicians’ perceptions of therapeutic interchange

Therapeutic interchange has long been an integral part of drug formulary management, but physicians’ and pharmacists’ attitudes toward such programs are relatively unknown. This survey was undertaken to determine pharmacists’ attitudes, physicians’ potential response to a hypothetical interchange, and how well pharmacists predicted physicians’ responses. A survey that described a drug interchange program and several potential responses to the proposed switch was provided to 300 staff physicians at a 512-bed community facility in southwest Florida; the survey was also mailed to pharmacy directors or clinical pharmacy coordinators at 42 southwest Florida hospitals. Responses were obtained from 98 physicians and 95 pharmacists. Most physicians would not cooperate with an interchange if they were not familiar with the proposed drug; 16% would continue to prescribe the original drug, knowing that the new agent would be provided; and 58% would switch to another agent with which they had clinical experience. Only 26% of physicians would follow the interchange program. In contrast, 48% of pharmacists believed that physicians would continue to order the original therapy, 32% believed that physicians would order the new agent, and only 20% believed that physicians would switch to an alternative drug (P < .005 vs physician responses). Clearly, pharmacists’ expectations of physicians’ response to a therapeutic interchange differ significantly from the physicians’ expected behavior. This difference has potentially important implications for actual versus projected cost savings of therapeutic interchange. This paper was presented as a poster at the American Society of Health System Pharmacists Clinical Meeting and Exhibits in New Orleans, Louisiana, December, 1996. (Work completed while employed by Manatee Memorial Hospital in Bradenton, Florida.)     

Evaluation of changes in public interest concerning lipids and other cardiovascular risk factors between 1990 and 1995

Objective - To assess changes between 1990 and 1995 in the knowledge of cardiovascular risk factors, attitudes to lifestyle changes and to the role of primary health care in preventive work in an urban population. Design - Postal questionnaire. Setting - South-western Stockholm. Subjects - 1000 randomly selected men and women aged 40 to 64 years. Main outcome measures - Knowledge of and attitudes toward cardiovascular risk factors and contacts with primary health care. Results - Response rate was 67%. In 1995 69% thought it important to know one's own lipid values (75% in 1990; 95% CI for change -11, -2). Forty-two per cent thought hyperlipidaemia was a definite cause of coronary heart disease (CHD) (50% in 1990; 95% CI for change -13, -2). Sixty-one per cent thought that a reduction in hyperlipidaemia would reduce cardiovascular risk (70% in 1990; CI for change -14, -4), and 53% thought that a reduction in hypertension would do so (65% in 1990; CI for change -17, -7). Fewer people believed in the negative consequences of eating habits. A majority expected doctors to know about patients' smoking (88%) or drinking (87%) habits. Conclusion - Interest in hyperlipidaemia declined between 1990 and 1995, but people expected doctors to take an interest in patients' lifestyles and in prevention. This knowledge is an important working tool for physicians.     

Proton pump inhibitor therapy for peptic ulcer bleeding: Cochrane collaboration meta-analysis of randomized controlled trials

OBJECTIVE: To evaluate the efficacy of proton pump inhibitors (PPIs) in treating peptic ulcer bleeding. MATERIAL AND METHODS: We searched the MEDLINE, EMBASE, CENTRAL, Cochrane Library, and metaRegister of Controlled Trials databases and published proceedings of major meetings through November 2004 for randomized controlled trials that compared oral or intravenous PPIs with placebo or a histamine2-receptor antagonist for peptic ulcer bleeding. Pharmaceutical companies and relevant experts were contacted. Data extraction and assessment of study validity were performed independently in duplicate. Assessed outcomes were 30-day all-cause mortality, rebleeding, surgery, and repeated endoscopic treatment. Influence of study characteristics on outcomes was examined by subgroup analyses and meta-regression. RESULTS: We included 24 trials (4373 participants). Statistical heterogeneity was evident only for rebleeding. Treatment with PPIs had no significant effect on mortality (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.74-1.40; number needed to treat [NNT], incalculable) but significantly reduced rebleeding (OR, 0.49; 95% CI, 0.37-0.65; NNT, 13) and the need for surgery (OR, 0.61; 95% CI, 0.48-0.78; NNT, 34) and repeated endoscopic treatment (OR, 0.32; 95% CI, 0.20-0.51; NNT, 10). Results were similar when analysis was confined to trials with adequate allocation concealment. Treatment with PPIs significantly reduced mortality in Asian trials (OR, 0.35; 95% CI, 0.16-0.74; NNT, 34) and in patients with active bleeding or a nonbleeding visible vessel (OR, 0.53; 95% CI, 0.31-0.91; NNT, 50). CONCLUSIONS: In ulcer bleeding, PPIs reduce rebleeding and the need for surgery and repeated endoscopic treatment. They improve mortality among patients at highest risk.     

Can the UK guidelines for stroke be effective? Attitudes to the symptoms of a transient ischaemic attack among the general public and doctors

This questionnaire-based study assessed the attitudes of the general public to the symptoms of a transient ischaemic attack (TIA) and determined the current level of knowledge about the management of TIA among doctors. The public chose to wait for symptom recurrence before seeking medical advice for amaurosis (41%) and upper limb (UL) monoparesis (51%), sensory loss (68%), or paraesthesia (95%). However, medical advice would be sought most often for slurred speech alone (89%) or combined with UL monoparesis (99%). Most physicians confirmed that these symptoms could represent a 'carotid TIA' but many considered diverse symptoms as relevant. While most general practitioners would prescribe anti-platelet therapy, 22-40% would not refer first-time TIA patients, depending upon the presenting symptom. In conclusion, the general public does not recognise the importance of TIA symptoms and the need for rapid assessment. This is compounded by deficiencies in the medical management of TIA. Stroke guidelines will remain ineffective without public awareness campaigns and physician education.     

Antiepileptic drugs in treatment of pain caused by diabetic neuropathy

Pain is frequent in diabetic neuropathy and is very hard to manage. Antiepileptic drugs have been used in treating pain for several decades. Their effectiveness has been described in different types of neuropathic pain, but when used as analgesics in painful diabetic neuropathy it still remains controversial. To clarify this effectiveness, a meta-analysis was performed to determine which antiepileptic drug had the best analgesic potential for managing pain in patients suffering from painful diabetic neuropathy. The search covered the Cochrane, MEDLINE, EMBASE, and LILACS databases, between January 1966 and September 2005. The following information was obtained from each article: criteria for diagnosing diabetic neuropathy, patients' age average, antiepileptic drug received and dose, sample size, duration of the disease and treatment follow-up, outcome measurement, evaluation of pain, and rescue medication. A combined 2.33 relative risk (95% confidence interval [CI] 1.88-2.88) was obtained; this result indicated that the antiepileptic drugs studied were effective for controlling pain in diabetic neuropathy. The corresponding necessary number to treat (NNT) values were established for evaluating which antiepileptic drug was most effective as an analgesic, according to our interests; pregabalin was shown to be the antiepileptic drug having the lowest NNT (NNT=3.24 and 95% CI 2.12-6.81) for achieving greater than 50% analgesia in patients suffering from painful diabetic neuropathy. Antiepileptic drugs are frequently used in the specific case of diabetic neuropathy; the combined result of this meta-analysis has demonstrated their analgesic benefit.     

Evaluation of changes in public interest concerning lipids and other cardiovascular risk factors between 1990 and 1995

OBJECTIVE: To assess changes between 1990 and 1995 in the knowledge of cardiovascular risk factors, attitudes to lifestyle changes and to the role of primary health care in preventive work in an urban population. DESIGN: Postal questionnaire. SETTING: South-western Stockholm. SUBJECTS: 1000 randomly selected men and women aged 40 to 64 years. MAIN OUTCOME MEASURES: Knowledge of and attitudes toward cardiovascular risk factors and contacts with primary health care. RESULTS: Response rate was 67%. In 1995 69% thought it important to know one's own lipid values (75% in 1990; 95% CI for change -11, -2). Forty-two per cent thought hyperlipidaemia was a definite cause of coronary heart disease (CHD) (50% in 1990; 95% CI for change -13, -2). Sixty-one per cent thought that a reduction in hyperlipidaemia would reduce cardiovascular risk (70% in 1990; CI for change -14, -4), and 53% thought that a reduction in hypertension would do so (65% in 1990, CI for change -17, -7). Fewer people believed in the negative consequences of eating habits. A majority expected doctors to know about patients' smoking (88%) or drinking (87%) habits. CONCLUSION: Interest in hyperlipidaemia declined between 1990 and 1995, but people expected doctors to take an interest in patients' lifestyles and in prevention. This knowledge is an important working tool for physicians.