Smoking does not influence disability accumulation in primary progressive multiple sclerosis.

BACKGROUND AND PURPOSE: The modifiable risk factor cigarette smoking has been associated with an increased risk of developing multiple sclerosis (MS) and with disease activity in relapsing-remitting MS. However, less is known about the effect of smoking on disease progression in progressive MS. Here the association between cigarette smoking and disability accumulation in primary progressive MS (PPMS) is investigated. METHODS: Kaplan-Meier survival analyses and Cox proportional hazard modelling were used to investigate the influence of cigarette smoking on the risk of reaching Expanded Disability Status Scale (EDSS) 4 and 6 as well as the time from EDSS 4 to 6 in patients with PPMS. RESULTS: In all, 416 patients with PPMS and available smoking history were identified. Median time to EDSS 4 was 4 years in ever-smokers and 5 years in never-smokers (P = 0.27), and it was 9 years to EDSS 6 in both ever-smokers and never-smokers (P = 0.48). Smokers were not at increased risk of faster progression to EDSS 4, 6 and from EDSS 4 to 6. Age at disease onset was the strongest risk factor for progression to EDSS 4, 6 and from EDSS 4 to 6. CONCLUSIONS: Our investigation of a large and well-characterized population based PPMS cohort suggests that cigarette smoking does not influence disability accumulation in PPMS. Our findings support the idea that PPMS is driven by different underlying pathomechanisms than relapsing-remitting MS.

Intractable pain: a neglected area of medical education in the UK.

Unease over the previous management of 67 patients referred for treatment to 3 pain relief clinics led us to investigate the current state of education in pain and pain control in the UK. Twenty-seven medical schools provided data which revealed; (i) in 4 schools no teaching whatsoever is given in these subjects; (ii) in the remainder it is accorded an average of 3.5 hours during the 5 year course, with little evidence of multidisciplinary teaching; (iii) only 10 schools (37%) regularly set questions on pain control in formal examinations. A survey of 219 general practitioners revealed a wide-ranging lack of knowledge about the facilities and approach to treatment at their local pain relief clinic. These findings have wide reaching implications for medical education. At the undergraduate level they demonstrate a need for more multidisciplinary teaching and practical experience in specialist units. Thereafter specialists in pain control must enable practising doctors to keep abreast of new developments. This may require them to devote more time writing for a non-specialist audience and devising short, postgraduate courses.