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Preference: Statistics, epidemiology and research design

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Pain, pregnancy or Pilates – there is plenty to peruse

Paracetamol has been under the microscope a lot recently. A new review of oral non-steroidal anti-inflammatory drugs (NSAIDs) versus other oral analgesics for acute soft tissue injury continues this trend. Sixteen trials involving more than 2100 mostly young adults with various strains, sprains and bruises evaluated a range of drugs, including paracetamol and opioids. The review found low-quality but consistent evidence that NSAIDs and paracetamol are similar with respect to pain relief, swelling and return to function but, as you might expect, there is evidence that NSAIDs result in slightly more gastrointestinal side effects (doi:10.1002/14651858.CD007789.pub2).

Meanwhile, the rising tide of allergies in children has spawned an ocean of research. A recent review of eight trials of over 3350 women asks whether giving pregnant women or breastfeeding mothers marine omega-3 supplementation prevents allergies in their young children. The short answer is possibly for some allergies, notably food allergies, but probably not for other conditions such as allergic rhinitis or asthma (doi:10.1002/14651858.CD010085.pub2).

If too much sitting around over this year’s cold winter has brought on extra cases of low back pain, it’s good to know that Pilates can be added to the list of exercise interventions effective for relieving pain and improving function. A review of 10 studies involving over 500 adults with chronic low back pain also compared Pilates with other forms of exercise but found no conclusive evidence that it is superior (doi:10.1002/14651858.CD010265.pub2).

Making sense of the burgeoning evidence included in multiple systematic reviews has become an exercise in itself. Cochrane’s response is to publish overviews. In recent issues, assisted reproductive technology (ART), bronchiectasis and dressings for foot ulcer have all been given the overviews treatment. The ART overview, for example, synthesises the findings of 59 Cochrane reviews categorising 19 interventions as effective, 13 as promising and 14 as ineffective or possibly ineffective (doi:10.1002/14651858.CD010537.pub4). The evidence is less clear-cut when it comes to dressings for treating foot ulcers in people with diabetes. There is no shortage of systematic reviews but a paucity of included studies in these reviews makes drawing robust conclusions an ongoing challenge (doi:10.1002/14651858.CD010471.pub2).

For more on these and other reviews, check out www.cochranelibrary.com.

[Editorial] Coca-Cola’s funding of health research and partnerships

In a bid to increase transparency, Coca-Cola has disclosed spending US$118·6 million in the past 5 years on scientific research and health and wellbeing partnerships. In a list of organisations funded by Coca-Cola, published on Sept 22, they reveal several influential medical organisations that have received funding, including the American Cancer Society, which received roughly $2 million, the American College of Cardiology, which received roughly $3·1 million, and the Academy of Nutrition and Dietetics, as detailed in an article published on Sept 22 in The New York Times.

A comparison of the stages at which cancer is diagnosed in physicians and in the general population in Taiwan [Research]

Background:

Previous investigations have reported that physicians tend to neglect their own health care; however, they may also use their professional knowledge and networks to engage in healthier lifestyles or seek prompt health services. We sought to determine whether the stage at which cancer is diagnosed differs between physicians and nonphysicians.

Methods:

We conducted a nationwide matched cohort study over a period of 14 years in Taiwan. We accessed data from two national databases: the National Health Insurance Research Database and the Taiwan Cancer Registry File. We collected data on all patients with the 6 most common cancers in Taiwan (hepatoma, lung, colorectal, oral, female breast and cervical cancer) from 1999 to 2012. We excluded patients less than 25 years of age, as well as those with a history of organ transplantation, cancer or AIDS. We used propensity score matching for age, sex, residence and income to select members for the control (nonphysicians) and experimental (physicians) groups at a 5:1 ratio. We used 2 tests to analyze the distribution of incident cancer stages among physicians and nonphysicians. We compared these associations using multinomial logistic regression. We performed sensitivity analyses for subgroups of doctors and cancers.

Results:

We identified 274 003 patients with cancer, 542 of whom were physicians. After propensity score matching, we assigned 536 physicians to the experimental group and 2680 nonphysicians to the control group. We found no significant differences in cancer stage distributions between physicians and controls. Multinomial logistic regression and sensitivity analyses showed similar cancer stages in most scenarios; however, physicians had 2.64-fold higher risk of having stage IV cancer at diagnosis in cases of female breast and cervical cancer.

Interpretation:

In this cohort of physicians in Taiwan, cancer was not diagnosed at earlier stages than in nonphysicians, with the exception of stage IV cancer of the cervix and female breast.

[Perspectives] How is comorbidity lived?

I first met Beverly in 2002 after she agreed to be part of a study on the management of illness in low-income households in Baltimore, MD, USA. At the time she was 52 years old—although in fairness she told me she was 52 every year that I knew her. When the study ended, Beverly asked if we could continue our conversations as part of my ongoing research, and we remained in contact for years.

[Comment] Offline: Europe—the land of holy miracles

“There is no future here.” With these words, a leading scientist at one of Italy’s foremost research institutions concluded her assessment of her country’s prospects for scientific success. Her list of concerns was long: a growing scientific brain drain; failure to promote young scientists on the basis of merit; widespread nepotism; the indifference of Italy’s school system to science; and the almost complete inattention of government to the value of science as a part of Italian culture (“there are no votes in science”).

Lyme disease – no evidence it is endemic in Australia

The latest research from Murdoch University has found no evidence that Lyme disease exists in Australia, but the research has revealed that a new Australian tick species warrants further investigation.

The researchers found that no Lyme disease-associated bacteria were found in Australian ticks, but found organisms in one Australian tick, collected from a wild echidna, that caused relapsing fever.

Lead researcher Professor Peter Irwin and his team collected more than 20,000 ticks from across the country to study the bacteria they carry and their potential to cause disease.

Professor Irwin told ABC News, that his research to date had not been able to show conclusively that Australian ticks carry the Lyme disease causing bacteria, but has found organisms in one tick that could trigger a similar illness.

“Borrelia is the name of the bacteria that causes Lyme disease, but there are several different types,” Professor Irwin said.

“One of the types is associated with a disease known as relapsing fever, and we found the DNA bacteria of that type in one tick.

“As the name suggests, relapsing fever causes fevers that come and go, and a wide range of other symptoms in people, some of which have similarities with Lyme disease, such as extreme fatigue and nausea.”

The Department of Health recently welcomed ground-breaking research from Murdoch University.

In 2013, Chief Medical Officer Chris Baggoley set up the Clinical Advisory Committee on Lyme disease to work out how to diagnose and treat “Lyme disease-like syndrome”. The Committee has since ceased. It found that a conclusive finding of a bacterium that could cause Lyme disease- like syndrome in Australia has yet to be made.

The Department of Health will remain engaged with Professor Irwin to consider the implications of this research for human health in Australia. They anticipate that research on ticks taken from humans will be published later in 2015.

Professor Irwin emphasised that it is not yet appropriate to link the bacteria he found in the ticks to them causing disease in humans. He said, however, it is reasonable to consider a possible link between bacteria and disease if the bacteria that are found have a close relationship to known pathogens. Nothing can be assumed without further research.

Kirsty Waterford

 

 

NSW prison smoking ban allows staff to continue with the habit

New Zealand started it, Northern Territory followed and now most of Australia has banned smoking in prisons. New South Wales is the latest to have joined the ranks to ban smoking in correctional facilities. However, NSW’s recently introduced ban isn’t without controversy, as prison officers are exempt.

An Australian Institute of Health and Welfare report ‘The health of Australia’s prisoners 2012’, released mid-2013, found that four out of five prisoners reported that they smoke, with 78 per cent saying they smoked daily.

Smoking bans in prisons are complex, and around the world have been controversial and difficult to implement. New Zealand introduced a blanket ban on smoking in correctional facilities in July 2011, but the New Zealand High Court ruled that the ban was unlawful in December 2012. After a lengthy legal battle, Correctional Services amended legislation which reinstated the blanket ban.

New Zealand Corrections Department Chief Executive Ray Smith said that, since the introduction of smoke-free prisons the work environment had improved for staff and prisoners with better air quality and fewer fires.

“Implementing smoke-free prisons was always going to be a serious challenge, and it has gone incredibly well and without major incident. We are the first national prison service to achieve this,” Mr Smith said.

Prisoners were given 12 months to quit smoking before the blanket ban was introduced in July 2011.

Northern Territory prisons have been smoke-free since July 2013, modelling their approach closely on New Zealand’s successful introduction of smoke-free prisons. The Northern Territory introduced a 12 month plan prior to the ban to encourage staff and inmates to quit smoking. Better access to services to help staff and inmates to quit smoking was provided and a comprehensive rather than a partial, smoking ban was introduced.

Much of the rest of Australia followed in Northern Territory’s footsteps with Queensland, Tasmania, and Victoria introducing total bans on smoking in correctional facilities. South Australia is trialling bans at the Adelaide Remand Centre later this year while the ACT has committed to phasing out smoking in prisons, but continues to be elusive with a timeline for the ban. Western Australia currently has no intention to ban smoking from correctional facilities, but they have banned smoking indoors.

NSW’s ban on smoking at correctional facilities was introduced mid-August, but a loophole in the legislation allows staff who live in correctional centres to smoke in designated areas, a move likely to be resented by many prisoners who are being forced to quit.

Inmates’ families have been told by NSW Corrective Services that they won’t be permitted to smoke anywhere on the grounds of a correctional centre which includes car parks or inside their cars during visits.

The smoking ban legislation was amended to allow smoking areas to be declared for staff living in NSW’s 84 prison residences by the Minister for Corrections David Elliot a week before the implementation.

A Corrective Services spokesman told the Sydney Morning Herald that staff who live on Corrective Service NSW sites will be able to smoke while off duty in a designated area outside their accommodation and not visible from any correctional centre.

Monarch University researcher Anita Mackay, who has studied smoking bans in prisons around the world, said that she hasn’t come across a situation where there is a complete ban for imprisoned people, while staff are able to smoke. Given that the justification is to protect the health of staff, it doesn’t really align.

Kirsty Waterford

 

Big Tobacco after data on Aussie kids’ attitudes

A global tobacco giant has been accused of using freedom of information laws to obtain taxpayer-funded research showing Australian school children and teenagers’ attitudes to smoking and alcohol.

Public health advocates are concerned that ‘Big Tobacco’ may use the data to hone their marketing of cigarettes to teenagers, as well as to fight plain packaging laws, which are now being implemented across the globe.

British American Tobacco (BAT) is trying to access data from the Victorian Cancer Council Australian Secondary Students’ Alcohol and Drug Survey.

The lawyer seeking the Victorian information for BAT was recently successful in obtaining the Cancer Institute NSW research into adults’ attitudes to smoking, by using the FOI Act.

According to the Sydney Morning Herald, the Institute felt legally compelled to disclose the data, which effectively gave Big Tobacco access to millions of dollars worth of taxpayer funded research for the price of an FOI application.

The information was then used by the tobacco company last year in Britain to contest plain packaging laws.

The Victorian Cancer Council is currently fighting the FOI application in the Victorian Civil and Administive Tribunal.

Victorian Cancer Council CEO Todd Harper said that they are doing everything they can, and are concerned that handing over the data would breach confidentiality and have a chilling effect on future research.

“If this information were to be used for commercial purposes, for instance to hone or localise tobacco or alcohol marketing and pricing strategies to appeal to the young, provision of such information would be highly detrimental to Victoria’s children,” Mr Harper said.

A spokesperson for BAT told the Sydney Morning Herald that the company was seeking information to bolster its case that instead of Australian youth smoking rates going down because of plain packaging, that they’re going up.

“Any evidence to prove the latter needs to be highlighted so that other countries around the world don’t make the same mistake. Any such evidence is also relevant to the Government’s Post Implementation Review into plain packaging, which is still underway,” the spokesperson said.

“In this context, any such request for an FOI to obtain this information is both reasonable and legitimate. Importantly none of the FOI applications sought any personal data or information in respect of children or adolescents,” the spokesperson said.

In a statement provided to Medical Observer the company said that “it is illegal to sell tobacco to children and tobacco advertising has been banned for decades. Children are not, and never will be, our audience and we have always made this clear.”

The survey collects information from students aged 12-17 about their smoking and drinking practices, including what brands they prefer.

The Assistant Minister for Health, Fiona Nash, said the Government would not back away from plain packaging regardless of tactics by tobacco companies to discredit it.

 “If tobacco companies are obtaining research on young people through state FOI legislation to increase their sales to children, then I am appalled,” Ms Nash said.

Professor of Health Policy at Curtin University Mike Daube said the FOI application for the school survey data takes the tobacco industry into new lows.

“The companies claim that they have no interest in children – yet they are going to extraordinary lengths to access research data about children and tobacco, alcohol and drugs,” Professor Daube told the Sydney Morning Herald.

“This use of FOI legislation by the world’s most lethal industry raises another issue of enormous concern. If Big Tobacco can use FOI to harass a Cancer Council, what is to stop them using FOI to obtain information from any researchers employed by universities, or to tie them up in endless legal battles?”

Kirsty Waterford