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Women who undergo a total hysterectomy, in which both the uterus and the cervix are removed, are no more likely to experience sexual difficulties or urinary or bowel problems after surgery than women who have only their uterus removed, a new review has found.

This finding contradicts perceptions among some women and physicians that retaining the cervix is preferable or even necessary to pelvic function.

Total hysterectomy is a slightly more complex and lengthy operation, but the likelihood of ongoing menstrual bleeding after surgery is increased with subtotal hysterectomy.

“Women considering surgery will have to balance the supposed advantages of a less complicated surgery with a risk of cyclical bleeding after subtotal hysterectomy,” said lead author Anne Lethaby of the University of Auckland in New Zealand. “The review did not find any other differences.”

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

The rationale for the review, according to the authors, was to compare the safety and effectiveness of subtotal and total hysterectomy and to evaluate the perception that total hysterectomy could increase the risk of urinary incontinence, bowel problems and reduced sexual pleasure.

The reviewers identified three randomized controlled trials enrolling a total of 733 women that compared subtotal and total hysterectomy for noncancerous conditions. The most common reasons for hysterectomy in these trials were fibroids and heavy menstrual bleeding.

There was no evidence in these trials that total hysterectomy increased the risk of urinary or bowel problems. In the two years following surgery, women receiving a total hysterectomy were no more likely to suffer from urinary incontinence, increased urinary frequency or constipation than women who underwent subtotal hysterectomy.

They also found no evidence from these trials that removal of the cervix impaired sexual function. Satisfaction with sex, prevalence of painful intercourse and rates of sexual problems in the year or two following surgery did not differ significantly according to the type of hysterectomy.

“Early studies taught that subtotal hysterectomy was better than total hysterectomy in terms of sexual function, urinary function, and GI function, but these studies were not well done,” said Howard Sharp, M.D., of the University of Utah School of Medicine. “Now that we’ve had a few studies that have been done with a much higher degree of scientific rigor, they’re showing us that there’s really no difference in terms of these outcomes.”

The reviewers did find that women having total hysterectomy had a greater risk of fever during surgery. Operating time was about 11 minutes shorter for subtotal hysterectomy in the two trials that measured this, and women who underwent subtotal hysterectomy in these studies also lost less blood, on average, than women having total hysterectomy. However, there was no significant difference in the need for blood transfusions according to type of surgery.

“An 11-minute difference in the operating room is statistically significant, but I think it’s clinically irrelevant,” said Sharp. “And while we would all like to hang on to every drop of blood we can get, what really matters to me is whether I have to transfuse a patient.”

Another potential disadvantage of total hysterectomy, an increased risk of vaginal vault prolapse, was not confirmed in the review. The authors noted that to assess this risk properly, longer follow-up of trials would be needed.

One significant difference of possible relevance to some women was the greater likelihood of ongoing cyclical vaginal bleeding with subtotal hysterectomy. Almost 12 percent of women having subtotal hysterectomy were experiencing ongoing bleeding one year after surgery was completed, compared to fewer than 1 percent of women having total hysterectomy.

“I’ve had patients who have had cyclical bleeding after subtotal hysterectomy, but most patients state that it’s just a nuisance issue,” said Sharp. “However, if definitive treatment is what they want, I make sure that I counsel them about the potential for post-hysterectomy spotting with subtotal hysterectomy.”

According to Lethaby, the review cannot be considered definitive, due to the small number of studies that have compared total and subtotal hysterectomy and the fact that fewer than a thousand women were enrolled.

“While the risks and benefits are clear in the review, more research is required before we can be confident of the findings,” she said.

When mom or dad puffs on a cigarette, their infants may inhale the resulting second-hand smoke. Now, scientists have detected cancer-causing chemicals associated with tobacco smoke in the urine of nearly half the babies of smoking parents.

“The take home message is, ‘Don’t smoke around your kids,’” said Stephen S. Hecht, Ph.D., professor and Wallin Chair of Cancer Prevention at The Cancer Center at the University of Minnesota.

According to a study of 144 infants, published in the May issue of Cancer Epidemiology, Biomarkers & Prevention, Hecht and his colleagues found detectable levels of NNAL* in urine from 47 percent of babies exposed to environmental tobacco carcinogens from cigarette smoking family members. NNAL is a cancer-causing chemical produced in the human body as it processes NNK**, a carcinogenic chemical specific to tobacco.

“The level of NNAL detected in the urine of these infants was higher than in most other field studies of environmental tobacco smoke in children and adults,” Hecht said.

“NNAL is an accepted biomarker for uptake of the tobacco-specific carcinogen NNK. You don’t find NNAL in urine except in people who are exposed to tobacco smoke, whether they are adults, children, or infants.”

A previous study by Hecht and his colleagues indicated that the first urine from newborns whose mothers smoked during pregnancy contained as much as one-third more NNAL compared to the babies in the current study. The newborn infants, however, took in the carcinogen directly from their mothers through their placentas rather than by breathing second-hand smoke in the air in their family homes and cars.

In the current study, when babies had detectable levels of NNAL, Hecht said that family members smoked an average of 76 cigarettes per week, in their home or car while the babies were present. In children of smokers whose babies had undetectable levels of NNAL in their urine, the average number of cigarettes smoked by family members was reported at 27 per week.

“With more sensitive analytical equipment, the NNAL from urine of babies in lower frequency cigarette smoking households would most likely be detectable,” Hecht said.

While studies have not determined how the long term risk of exposure to cancer-causing tobacco smoke affects the genetics of babies during their early years when they are growing rapidly, Hecht said that this study demonstrated substantial uptake of NNK and its metabolite NNAL in infants exposed to environmental tobacco smoke.

“These findings support the concept that persistent exposure to environmental tobacco smoke in childhood could be related to cancer later in life,” he said.

UK scientists have cracked one of the key biological processes used by viruses such as HIV and SARS when they replicate, according to a paper published in the journal Nature tomorrow (11 May). Viruses are able to interfere with the host cell processes that our bodies use to replicate cells, and protein synthesis is often one of their targets. For the first time, researchers at the Universities of Cambridge and Oxford have witnessed virus-induced “frameshifting” in action and have been able to identify the crucial role of particular elements.

The research, funded by the Biotechnology and Biological Sciences Research Council (BBSRC), the Medical Research Council (MRC), The Royal Society and The Wellcome Trust, brings us another step closer to understanding the fundamental workings of these devastating viruses.

The scientists have revealed the workings of the process known as ‘ribosomal frameshifting’ that forces a mis-reading of the genetic code during protein synthesis. The correct expression of most genes depends upon accurate translation of the ‘frame’ of the genetic code, which has a three nucleotide periodicity. Viruses such as HIV and SARS bring into the cell a special signal that forces the ribosome to back up by one nucleotide, pushing it into another ‘frame’ and allowing synthesis of different viral proteins. These are exploited by viruses and help them to survive and multiply.

The British researchers successfully imaged frameshifting in action and for the first time observed how a virus encoded element called an RNA pseudoknot interferes with the translation of the genetic code to allow viruses like HIV and SARS to express their own enzymes of replication.

Dr Ian Brierley, the project leader at the University of Cambridge, said: “This collaborative project was set up with Dr Robert Gilbert’s team in Oxford to investigate the structure of a frameshifting ribosome using electron microscopy. The images we obtained give us an insight into how a virus-encoded RNA pseudoknot can induce frameshifting and may be useful in designing new ways to combat virus pathogens that use this process.”

Professor Julia Goodfellow, Chief Executive of the Biotechnology and Biological Sciences Research Council, which was one of the main funders, said: “This is exciting and valuable research and demonstrates clearly why investment in fundamental science is so important. The treatments and therapies that we now take for granted are based on decades of work by scientists furthering our understanding of natural processes. The work to explore fundamental biology today is laying the foundation for potential medical applications over the next twenty years.”

In response to concerns from hospitals to prepare for eventual pandemic flu outbreaks, the French company AirInSpace, with support from ESA’s Technology Transfer Programme, has successfully adapted technology developed to protect astronauts for use in critical care centres to protect immune-deficient patients against airborne pathogens such as the avian flu virus.

Independent tests conducted at the Laboratory of Virology and Viral Pathogenesis in Lyon, France, by Professor Bruno Lina confirmed this week that AirInSpace’s Plasmer™ bioprotection system completely eliminates airborne avian flu virus from highly concentrated aerosols.

The technology for the biological decontamination of air onboard manned spacecraft was invented in the early 90s by a group of Russian scientists. In 1997 the Russian space station MIR was equipped with Plasmer reactors to protect cosmonauts and electronic equipment from bacteria, viruses and fungal contamination. In April 2001, reactors were also installed to clean the air from micro-organisms in the Russian segments of the International Space Station.

European space industry has invested in research and development of similar systems to clean air on-board spacecraft, and has achieved excellent results in air monitoring and purification for manned space missions. For example, Italian industry has developed the life support system shared by the Italian Space Agency’s Multi-Purpose Logistics Modules (MPLM) and ESA’s recently completed Columbus laboratory, ready for the International Space Station.

Space tech at work in hospitals

Plasmer is a multistage system using strong electric fields and cold-plasma chambers to eliminate micro-organisms in the air. With support from ESA’s Technology Transfer and Promotion Office, AirInSpace used this space technology in 2001 to develop a transportable and protective unit for use in hospitals and emergency scenarios, providing an easily deployable clean room.

“With the special Plasmer technology we have managed to develop an innovative solution to provide clean air by destroying more than 99.9% of micro-organisms, responding to the special needs of immune-compromised patients in hospitals,” said Laurent Fullana, CEO of AirInSpace.

“Our system ‘ImmunairTM’ uses five Plasmer reactors to provide a clean-air ‘tent’, free of infective germs around a patient’s bed. It is targeted primarily for immuno-haematology, oncology, reanimation and transplant hospital departments.”

A smaller mobile medical device, named PlasmairTM has been successfully launched to help contain infection risks and meet air quality standards in operating theatres, cytotoxic preparation rooms, research labs, intensive care, and sterilization rooms.

Immunair and Plasmair have now been used in more than 70 medical centres in France.

“Mobile equipment using this type of technology could be used to control the risks of cross-contamination in case of patient isolation required during a pandemic outbreak,” said Professor Lina, Head of the French National Reference Centre for the Flu and one of the leading bird-flu experts in France.

“In case of a local avian flu outbreak, our Plasmair and Immunair systems could be put in place within hours to establish emergency temporary hospital facilities, for example in schools, for more people than conventional local hospitals can handle,” Fullana added, confirming that interest has already been expressed from several authorities to establish portable emergency facilities using Plasmer bioprotection systems.

AirInSpace is actively working to expand the use of the Plasmer technology in new air treatment systems for non-hospital applications, such as commercial airliners, private jets, other transportation means, industrial environments and residential usage.

PlasmerTM, ImmunairTM and PlasmairTM are trademarks of AirInSpace.

Antiseptic cleansing and body hair removal do not reduce surgical site infections, investigators report in two new reviews of studies of these common preoperative practices.

“Washing or showering with an antiseptic before going to surgery does not reduce the risk of developing a postoperative wound infection,” said Joan Webster, lead author of the review on preoperative cleansing. “Therefore, patients may be advised to wash with any soap product; this is sufficient to remove transient flora [skin bacteria].”

Webster is associate professor and nursing director for the Research Center for Clinical Nursing at the Royal Brisbane and Women’s Hospital in Herston, Australia.

The reviews appear in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Surgical site infections can occur after invasive surgeries. Antiseptic skin wash is commonly used during preoperative bathing or showering in order to reduce skin bacteria. But it has not been shown that this actually reduces rates of surgical site infections.

Likewise, removal of hair from an intended surgical wound site is routine, but its value for avoiding infections had not been conclusively demonstrated.

“The evidence finds no difference in surgical site infections among patients who have had hair removed prior to surgery and those who have not,” concluded Judith Tanner and colleagues in the second review. “If it is necessary to remove hair then clipping results in fewer surgical site infections than shaving using a razor,” they added.

Tanner is lead for nursing research at Derby City General Hospital in Derbyshire, England.

For both reviews, the investigators gathered and analyzed data from prior clinical trials meeting the rigorous standards of the selection process.

For the bathing and showering review, the reviewers found six eligible studies with 10,007 participants. The antiseptic used in all of the trials was four-percent chlorhexidine gluconate (Hibiscrub).

The authors found no difference in postoperative surgical site infection rate between patients who did and not wash with chlorhexidine, and add that the practice has a downside.

“Antiseptic-impregnated sponges, which are normally used for preoperative showering, are not inexpensive, so there are implications for cost savings to the health care industry,” said Webster. “And because pathogenic organisms quickly become resistant to antiseptic solutions, it is important to limit the use of such solutions to situations where effect has been demonstrated,” she said.

For the hair removal review, the authors found 11 eligible studies with 5775 participants. “Trials which compared hair removal with no hair removal prior to surgery, either using razors or a depilatory cream, demonstrated no statistically significant difference in surgical site infections between comparison groups,” the authors reported.

Notably, three of the trials involving 3,193 subjects showed that patients who were shaved rather than clipped preoperatively had a statistically significantly higher rate of surgical site infections.

“The conclusion is that if hair removal is necessary at a surgical site, clipping is preferable,” said William Schecter, M.D., professor of clinical surgery at the University of California at San Francisco. “There is no information available regarding the necessity to remove hair from a surgical site. I almost always remove hair at the site of a planned operation but there is little research to support or refute this practice,” he said.

As for bathing or showering with an antiseptic, Schecter said, “It’s hard to argue with a good shower prior to surgery in a patient who is either dirty or hasn’t washed in some time. I work at San Francisco General Hospital” - he is chief of surgery - “and unfortunately, many of my patients are homeless so this is not an uncommon problem. However, there is no evidence that washing with skin antiseptics prevents surgical site infections.”

Most non-smoking mothers recognise the need to protect sick children from smoking husbands, but persuading their spouse to quit isn’t always an option, according to research published in the latest Journal of Advanced Nursing.

Researchers at The University of Hong Kong surveyed the mothers of 1,483 children admitted to four major hospitals to see if a health educational initiative would help them to protect their children from passive smoking. None of the mothers smoked, but all of the children’s fathers did.

The study, by the Department of Nursing Studies and the School of Public Health, found that although most of the mothers realised the importance of protecting their child’s health, family tensions and the need to maintain marital harmony often got in the way.

The mothers reported that 86 per cent of their husbands smoked at home, with 54 per cent of the total smoking when their child was around and 32 per cent smoking away from the child. The remaining 14 per cent didn’t smoke while they were at home.

This was despite the fact that half of the children suffered from respiratory problems - putting them at high-risk from passive smoking - and 60 per cent of the total sample had been admitted to hospital more than once.

The majority of the children involved in the research were under 10 and the average age was just under five years-old.

“We divided the mothers into two groups” explains lead author Dr Sophia Chan, Head of the Department of Nursing Studies. “The education group of 752 mothers received health advice from nurses, purpose-designed booklets, a no-smoking sticker and a telephone reminder a week later. The control group of 731 mothers did not.

“Although we found this initiative had some short-term benefits, many of the mothers found it difficult to persuade their husbands to quit smoking and the education group were more likely to take evasive action, such as moving the child out of the room.

“With an increasing number of countries worldwide introducing smoking bans in public areas such as bars and restaurants, there are fears that more parents will smoke at home and that this will have an even greater effect on children.”

Key findings include:

• The average age of the mothers was 34 and two-thirds were housewives. Most of the husbands worked in factories, crafts, services and shops. 
• 95 per cent of the mothers were already aware of the dangers of passive smoking to children’s health. 90 per cent agreed that it could cause lung cancer in smokers, but only 77 per cent felt it posed a lung cancer risk to passive smokers. Awareness of coronary heart disease was 12 per cent lower on both counts. 
• Three-quarters believed that a smoker could quit successfully if they were determined to do so. 
• In the week before the study started, the most common actions taken by mothers when their husband smoked were to open the windows (44 per cent), ask the father not to smoke near the child (42 per cent) and move the child away from the smoke (33 per cent). 
• Only 29 per cent said they had asked their husband to quit smoking in the previous week, 31 per cent had asked him to stop smoking at home and 32 per cent had asked him to smoke fewer cigarettes. 
• Both groups were interviewed at three, six and 12 months. At three months, 78 per cent of the education group said they always took action when their husband smoked, but this fell to 64 per cent at six months and 11 per cent at 12 months. 
• The control group were less likely to intervene, but the difference between the two groups reduced as time went on. 71 per cent of the control group took action at three months (seven per cent lower), 59 per cent at six months (five per cent lower) and 10 per cent at 12 months (one per cent lower). 
• The greatest difference was that more mothers in the education group moved their child away from the smoke at three months. However, this was not sustained and there was no difference between the two groups at 12 months. 
• 12 months after the study started 58 per cent of the education group and 51 of the control group said they always or sometimes intervened when their husband smoked, but less than a fifth said they always took action. 
• 42 per cent of the education group and 50 per cent of the control group seldom or never intervened. The control group (14 per cent) were twice as likely as the education group (seven per cent) to take no action at all.

“When we spoke to the mothers during our 12-month follow-up, some of them expressed concerns about the conflicts that had arisen when they had asked their husbands to quit smoking and they said that they preferred to take evasive action instead” adds Dr Chan, who is currently a Visiting Scientist at Harvard School of Public Health in the USA.

“While it is the responsibility of the mother to protect the health of their child and husband, keeping harmony is sometimes considered more important in Chinese culture.

“Although the mothers openly acknowledged the health risks their husband’s passive smoking posed to their child, they were also very keen to maintain a harmonious relationship with their spouse.

“Recent research suggests that infants are exposed to passive smoking in more than 41 per cent of Hong Kong households and up to 60 per cent of American children under the age of five are regularly exposed to tobacco smoke in their own homes.”

The authors argue that there is a clear need to tackle smoking in the home and that this will be given added momentum by public smoking bans.

“A number of countries have, or are planning to introduce, legislation to ban smoking in public places” says Dr Chan “This includes Hong Kong, which will introduce new legislation covering indoor workplaces, bars and restaurants next year.

“We welcome this move, as evidence shows that public bans can encourage some people to quit smoking and this will reduce the health risks from smoking and passive smoking.

“However, we also need to monitor the effect that public bans have on smoking in the home, especially in densely populated places like Hong Kong, where lots of families live in high-rise buildings with little outside space.”

Stop smoking

If some patients with heart disease don’t take their doctor’s advice to quit smoking, they are probably going to get “shocking” reminders. A study conducted at Washington University School of Medicine in St. Louis found that heart patients who had implanted defibrillators and also smoked were seven times more likely to have the devices jolt their hearts back into normal rhythm than nonsmokers with the devices. When the devices fire, it can feel like a thump or even a strong kick to the chest.

“Eleven percent of cardiovascular deaths are related to smoking, and previous studies have shown that decreasing or quitting smoking is in itself a very effective therapy for patients with heart disease,” says J. Mauricio Sánchez, M.D., lead author of the study, which was published in the April 2006 issue of Heart Rhythm.

“But if having heart disease isn’t enough to make patients want to stop smoking,” continues Sánchez, a cardiology fellow in the cardiovascular division, “the evidence from our study should definitely add a strong argument to quit.”

Implantable cardioverter-defibrillators (ICDs) are self-contained units that are placed within the chest to monitor heart rhythms and deliver electrical charges directly to heart muscle to correct abnormal rhythms. Abnormal rhythms can occur without warning, and some can cause death rapidly if no action is taken. A recent study demonstrated that ICDs decreased the risk of death by 23 percent in patients with congestive heart failure.

“ICDs are implanted in patients at high risk for sudden cardiac death,” Sánchez says. “The devices shock the heart out of dangerous rhythms within seconds after they detect them. It’s like having a little ambulance in your chest.”

The study looked at 105 patients at the School of Medicine with heart disease who had ICDs implanted to prevent sudden cardiac death. The patients were followed for an average of two years.

During this time, more than a third of the patients who smoked received an electrical discharge from their ICDs to correct a potentially life-threatening heart rhythm. Former smokers, those who had stopped smoking at least a month before the study began, still had a fairly high occurrence of ICD discharge - about a quarter of these patients were shocked by the devices. In contrast, among patients who had never smoked, only about 6 percent received an ICD discharge.

Analysis showed that current smoking generated a seven-fold increased risk for ICD discharge, while having formerly smoked was linked to a five-and-a-half-fold increased risk. The risk of ICD discharge associated with smoking was greater than the risk associated with other factors such as age, diabetes, lung disease or use of ACE inhibitors or beta-blockers.

According to Sánchez, smoking can harm the heart in several ways. One is that nicotine increases the amount of adrenaline, which can lead to blood vessel constriction and decreased blood flow to the heart. Smoking also increases blood clotting factors, which can raise the chance of blood vessel blockage. In addition, the hemoglobin in smokers’ blood has carbon monoxide attached to it and can’t carry as much oxygen. Both smokers and former smokers have more atherosclerosis in the blood vessels of the heart that lower the oxygen level.

Any of these factors can result in an imbalance of oxygen supply compared to oxygen needed by the heart. This oxygen deficiency predisposes the heart to dangerous rhythms.

“Smoking is obviously hard to quit,” Sánchez says. “Heart patients know it’s harmful, yet a good percentage of them continue to smoke. It’s clear that quitting should be advocated for a whole myriad of reasons, and our study reveals another.”

As the United States moves toward a health care system that gives individuals more power and control over their health care decisions, many experts worry consumers will be bewildered by the large number of complex financial and medical issues. Some argue against consumer-directed health care because they don’t believe people can or should be left to make these difficult decisions.

But those difficulties don’t mean we have to turn our back on consumerism and lock in the old paternalistic, top-down system. People do need expert help in navigating the growing complexities of treatment options, and the health sector is beginning to respond by offering health coaches and disease and chronic-care management programs.

And that’s just the beginning: The new information economy will offer even more options, including health care advisors, to help people make better care and health spending decisions.

Growing Industry

Today, when people are seriously ill or have a child with multiple medical needs, they find they must become actively involved in informing themselves about the nature of the illness and treatment options. They rely on their doctors, of course, but they also become experts themselves, gathering information from disease groups, real and virtual discussion groups, medical libraries, and trusted Web sites.

In addition, many people seek the security of having expert advice available through “concierge medicine.” Here, people agree to pay a physician a fixed fee for ready access to appointments, attention to wellness care, help in locating specialists, and expert advice in the event of a medical problem.

Tens of millions of people would like to have that kind of access, but so far only a small number do.

Changing World

This kind of trusted, expert health advisor will be an emerging force in the new world of consumer-directed health care–trusted agents people call on for routine health care advice and for help in making complex medical decisions.

Information technology will make this expertise available to anyone with an Internet connection. New companies will allow millions of people to get clear and understandable information, and will even provide access to one-on-one consultations.

Several new companies are providing such medical-decision support for individuals and companies. One is Health Dialog, a Boston-based company that helps patients understand treatment options and choose what’s best for them through a network of health coaches who are available by phone 24 hours a day.

Enlightened Consumers

According to the Health Dialog Web site, “In an increasingly consumer directed healthcare environment, it is critical that individuals have the information and support they need to become more involved in their healthcare. Health Dialog is built upon the idea that when individuals are more actively engaged in managing their care with their physicians, they are more satisfied with their care, quality goes up, and costs go down.”

Health Dialog uses information from the Foundation for Informed Medical Decision Making, a nonprofit group also based in Boston, which reinforces this point on its Web site:

“When patients get sick, they sometimes face treatment decisions that can be confusing and frightening. … Very often doctors make these decisions for patients, and many patients prefer that model. …

“However, a growing body of research shows that when patients are well informed and play a significant role in deciding how they are going to treat or manage their health conditions… patients feel better about the decision process. Their decisions are more likely to match up with their preferences, values, and concerns. These patients are more likely to stick with the regimens the treatment requires, and they often end up rating their health after treatment as better.”

Empowering People

Don Kemper, chairman and CEO of Healthwise in Boise, Idaho, has worked for 30 years to help people understand the crucial importance of “information therapy” as a vital and integral part of medical care. He says doctors’ actions in writing prescriptions and ordering surgery or chemotherapy must be accompanied by high-quality information for the patient in a clear and understandable format.

“Empirical research suggests that appropriately prescribed, decision-focused, evidence-based health information empowers consumers,” Kemper said, “enabling them to participate as active partners in their own care and improve their health outcomes.”

And this is just the tip of the iceberg. Quality and price data are coming from thousands of sources. New companies will soon begin aggregating and translating this data to become branded sources of reliable quality information. A whole new discipline of medical professionals is likely to emerge - health advisors - to help people seeking one-on-one expertise.

Information needs can be solved by an information economy. Technology is increasingly allowing consumers to access information instantly at little or no cost. As this is applied to health care, patients will get smarter, and they will force the health care economy to become more efficient and patient-centered.

This new era is not coming. It’s already here.

People suffering from chronic lung diseases like emphysema and bronchitis are continuing to smoke despite the risks, according to a new study of more than 175,000 U.S. adults.

More than 36 percent of people with chronic obstructive pulmonary disease are current smokers compared with 22 percent of adults without COPD.

“It doesn’t look like a good part of the [COPD] population is getting the information it needs from health care providers,” on the importance of quitting and best ways to do so, said lead researcher Jeannine Schiller, a statistician with the Centers for Disease Control and Prevention.

Although half of the COPD patients tried to quit smoking in the previous year, 14.6 percent succeeded - most of them through sheer willpower.

“I didn’t realize how many people stop cold turkey, and I was surprised at how few use medicines and patches,” Schiller said of the findings from the study in the latest issue of the American Journal of Health Promotion.

The researchers looked at six years of data compiled from federal surveys between 1997 and 2002. Because COPD is rare under age 25, they included only people who were 25 or older - 11,238 adults.

Chronic obstructive pulmonary disease is characterized by airflow blockages that cause shortness of breath, coughing and heavy sputum production. Flare-ups can be frequent and serious. Smoking is the most important risk factor for developing COPD and continued smoking makes the disease worse, according to the authors.

Of all smokers with COPD, nearly 23 percent reported not receiving cessation advice from a health care professional during the past year.

U.S. Public Health guidelines for health-care providers include asking all smokers “about tobacco use at every patient visit” and assisting patients willing to quit “with counseling and pharmacotherapy.”

Judith Ockene, Ph.D., is chief of preventive and behavioral medicine at the University of Massachusetts Medical School. She said the proportion of smokers who aren’t getting medical advice to quit did not surprise her.

Part of the problem may be practitioners giving cessation advice to patients who don’t always choose to hear it, said Ockene, who was not involved with the study. “Some of it may well be that physicians are not telling them to quit because they have decided it’s not working.” She said cessation advice in the study compares favorably with the general population, where “about 60 percent of patients who smoke are advised to stop.”

Although younger smokers in the study (ages 25 to 34) were more likely to try to quit, those who were 65 and older were more likely to succeed.

“Maybe young people feel like they can quit tomorrow or next year. Older people may have comorbidities and other limitations,” Schiller said. “We did see that disabilities that made it hard to get around, for instance climbing steps, were predictive of quitting.”

But Ockene said that asking about the effects of exertion on breathing may not always elicit clear answers: “Sometimes people with bad lung disease aren’t exerting themselves. People may say that climbing stairs doesn’t bother them, when in fact, they are avoiding stairs altogether.”

Stopping cold turkey was the most commonly used method to quit smoking, followed by the nicotine patch.

According to the National Heart, Lung and Blood Institute, COPD affects more than 13.5 million Americans and is the fourth leading cause of death in the United States.

Some ethnic groups may be more susceptible to adverse drug reactions, finds a study published on bmj.com today.

Adverse drug reactions (ADRs) are an important cause of ill health and death. Several factors including genetic make up, age, sex, and even diet, can all alter a patient’s susceptibility to ADRs. But it is not known to what extent susceptibility to ADRs might depend on ethnic group, whether as a result of genetic or cultural factors.

Researchers searched the scientific literature and identified 24 studies that included data for adverse reactions to cardiovascular drugs for at least two ethnic groups. Differences in study quality were assessed to identify and minimise bias.

They found that the risk of angio-oedema (swelling) with blood pressure lowering drugs was three times greater in black patients than non-black patients. The risk of cough was also nearly three times higher in East Asian patients compared with white patients.

For clot-busting therapy, the risk of bleeding increased 1.5-fold in black compared with non-black patients.

Some ethnic groups may be more susceptible to adverse reactions during treatment with cardiovascular drugs, say the authors. These findings may help doctors present more accurate and relevant data to their patients when prescribing cardiovascular therapy. However, differences in study quality and inconsistent reporting of harms mean that these results need to be interpreted cautiously, they add.

Future studies must report both adverse reactions and racial and ethnic classifications more fully, if we are to discover how they are linked, they conclude.