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Press releases Saturday 24 March 2007
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(1) Warning over heart patients denied most appropriate treatment
(2) Fundamentally flawed mental health bill could put the public at risk
(3) Improving school culture may help cut substance abuse and teenage pregnancies
(4) Legal challenge may be attempt to undermine NICE
(5) Warning over nitric oxide for lung injury patients
(6) Heart surgery for dogs and cats “obscene” says doctor
(1)
Warning over heart patients denied most appropriate treatment
(Meta-analysis and cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery)
http://www.bmj.com/cgi/content/full/334/7594/596
(Cost effectiveness analysis of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study)
http://www.bmj.com/cgi/content/full/334/7594/624
(Editorial: Coronary revascularisation)
http://www.bmj.com/cgi/content/full/334/7594/593
Thousands of patients with heart disease may be denied the best chance of survival because of uncertainty over the most suitable treatment option, warns a cardiac surgeon in this week’s BMJ.
Coronary artery disease occurs when artery walls become thickened by fatty deposits, leading to an inadequate blood supply to the heart. A procedure called ‘revascularisation’ improves blood flow and reduces the risk of death. There are two ways this can be done – by stenting or bypass surgery.
Coronary artery bypass surgery involves grafting healthy arteries and/or veins to the heart, while stenting involves the insertion of a stent (small tube) into blocked arteries.
Many cardiologists favour the less invasive stenting option and stenting procedures now outnumber surgery at least fourfold. But three studies published together in this week’s BMJ question the clinical and cost effectiveness of stenting.
Two show that surgery is at least as effective, and probably more cost effective, than stenting over the medium to long term, while the third concludes that the benefit of stenting over medical or surgical treatment is “too small to justify its additional costs.”
But despite these findings, practice is unlikely to change as many patients may still favour the less invasive approach of stenting, writes David Taggart, Professor of Cardiovascular Surgery at the University of Oxford in an editorial.
Not only does this approach risk higher rates of reintervention but, more importantly, it may also deny many patients with “multivessel” disease (who survive significantly longer after surgery compared with stenting) the prospect of a better long term outcome offered by surgery, he says.
These studies highlight the tension between the adverse economic implications of the phenomenal growth in stent procedures and the absence of an appropriate evidence base to support such a policy, he writes. It also highlights the dangers of individual practitioners rather than multidisciplinary teams making recommendations for stenting in patients with multivessel disease.
He believes that a multidisciplinary approach should be a minimum mandatory “standard of care” to ensure that patients are offered the most clinically appropriate treatment.
Contacts:
Editorial: David Taggart, Professor of Cardiovascular Surgery, University of Oxford, UK
University Hospitals, Geneva, Switzerland
Email:
david.taggart{at}orh.nhs.uk
or
James Roxburgh, Consultant Cardiac Surgeon and Hon. Secretary Society for Cardiothoracic Surgery, London, UK
(2)
Fundamentally flawed mental health bill could put the public at risk
(Editorial: New mental health legislation)
http://www.bmj.com/cgi/content/full/334/7594/596
The new mental health legislation is “fundamentally flawed” and could actually increase the risk to the public, according to an editorial in today’s BMJ.
The Mental Health Bill, which is currently progressing through Parliament, makes a number of amendments to the Mental Health Act 1983.
Writing in the BMJ, Dr John Crichton and Dr Darjee note certain aspects of the proposed legislation which cause them concern. The Bill simplifies the criteria for mental disorder and they highlight in particular the identification of sexual deviance as a category where treatment should be compulsory. There is provision for supervised community treatment but they say it lacks the appropriate safeguards.
The group of people with the responsibility for the detention of patients is widened, despite what they say is a lack of clear guidance detailing how this would work in practice. And the test which determines whether a patient should be detained is being replaced with a broader one as the old test was seen to limit the ability to detain patients.
They argue the government is focussing too much on public safety and that paradoxically that will increase the risk to the public. Dr Crichton and Dr Darjee say the proposed legislation is so broad it would label most violent offenders as having a mental disorder. It would therefore place them within the boundary of needing compulsory psychiatric treatment.
They ask: “What prisoner will engage in an anger management course or a sex offender programme with the prospect of compulsory indefinite detention and transfer to a secure psychiatric hospital? What potential patient with a violent thought will dare seek help from a doctor?”
They go on to argue that the rate of violence in those with mental disorders actually mirrors the rate of violence of those in the same social group. Treating violent and sexual offenders medically is, they say, unlikely to make them change their ways unless the aim is a very long preventative detention.
They also say there is too much focus on individual high profile tragedies, for example, the failings in the mental health care of John Barrett, a paranoid schizophrenic who in 2004 stabbed Denis Finnegan to death as he cycled in Richmond Park.
“Results from the National Confidential Inquiry identified only 12 cases, 6% of a sample, where respondents involved in the care of a mentally ill perpetrator believed different legal powers may have made a homicide less likely”.
The writers agree the best way for mental health to protect the public is the provision of comprehensive services, but say the government needs to be realistic about what can be offered. They point to Scotland where the Executive has successfully implemented mental health legislation after keeping the focus on care and treatment. Yet in England and Wales new mental health legislation has faltered because of a confusion of purpose. They say mental health services should be seen as a support for criminal justice agencies and the law when appropriate and conclude:
“Efforts for reform will fail if mental health legislation is wrongly identified as a principal mechanism for enhancing public safety”.
Contact:
John Crichton, Consultant Forensic Psychiatrist, Orchard Clinic, Royal Edinburgh Hospital, Edinburgh, UK
Email: john.crichton{at}lpct.soot.nhs.uk
(3)
Improving school culture may help cut substance abuse and teenage pregnancies
(Improving school ethos may reduce substance misuse and teenage pregnancy)
http://www.bmj.com/cgi/content/full/334/7593/547
Improving the institutional culture (ethos) of schools in the UK may help reduce substance abuse and teenage pregnancies, says an article in this week’s BMJ.
Researchers from the London School of Hygiene and Tropical Medicine’s Centre for Research on Drugs and Health Behaviour say that substance misuse and teenage pregnancy are major public health challenges and argue that existing responses to these issues seem to have brought about only limited benefits.
Previous surveys show that a third of 15 year olds in England have taken illegal drugs in the past year and a quarter of 15 year old girls smoke. Rates of illegal drug use and drinking continue to rise, whilst teenage pregnancy rates in the UK are the highest in western Europe.
So the authors reviewed evidence suggesting that interventions aiming to promote positive school ethos might provide an effective complement to existing approaches.
A study carried out in Scotland found that in some secondary schools ‘risky’ health behaviours (e.g. substance misuse, alcohol and tobacco use) couldn’t be explained by student, family or neighbourhood factors, but did seem to be explained by large school size and independently rated poor school ethos.
And trials in both Australia and the United States showed that projects which aimed to improve school ethos helped improve the health behaviours of their students. Both projects involved a range of activities including improving teacher-student communication, increasing parent and student involvement in school policy-making and better training for teachers.
The US study reported a 34% reduction in a combined measure of alcohol, tobacco and cannabis use among boys, plus significant benefits regarding condom use, frequency of sex, violence and truancy. However, similar benefits were not reported among girls.
The Australian research found that students at schools taking part in the project were slightly less likely to report a range of risky health behaviours (such as regular smoking and drinking and marijuana use). Follow-up research suggested impacts might increase over time as the changes ‘bedded down’ in schools.
This evidence makes sense, say the authors. After the family, and alongside the media and peers, the most important institution in the lives of most children and young people is their school.
The UK government already recognises that the whole school environment has a key role in promoting young people’s health. However, there is little evidence that current government initiatives aiming to make schools healthier are doing much to improve ethos. Improving school ethos to combat disaffection should be viewed as a promising complement to classroom-based interventions, they conclude.
Contact:
Chris Bonell, Senior Lecturer in Social Science and Epidemiology, Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK
Email: chris.bonell{at}lshtm.ac.uk
(4)
Legal challenge may be attempt to undermine NICE
(Editorial: Transparency in health technology assessments)
http://www.bmj.com/cgi/content/full/334/7594/594
A legal challenge against the National Institute for Health and Clinical Excellence (NICE) over its decision to restrict the use of drugs for Alzheimer’s disease may be an attempt to undermine its processes, warns a senior health economist in this week’s BMJ.
NICE, the body that decides what treatments are supplied on the NHS in England and Wales, faces a judicial review over its refusal to make part of its modelling data for the dementia drug donepezil (Aricept) available to the pharmaceutical industry.
NICE argues that this is essential to protect the intellectual property rights of external assessment groups (in this case, Southampton University’s Health Technology Centre). But this lack of transparency has never been challenged before, and although NICE’s rules might be noble, protection of just this part of the assessment process may be unwise, writes Alan Maynard, Professor of Health Economics at York University.
He argues that this conflict may be an attempt by the drug industry to enhance its profits from a marginally cost effective drug, and might also be part of a more subtle drive to undermine processes of assessing health technology, which are designed to ensure the delivery of effective treatments to patients and value for money to tax payers.
Australia has a similar system of assessing the cost effectiveness of drugs and devices and attempts have also been made to undermine its processes.
NICE is an essential institution for improving the efficiency of the NHS, writes Maynard. Generally its processes are transparent and sensible. However, the constraints under which it works can be improved. Surely it would have been better to have compensated Southampton for its loss of property rights in its model of treatment for Alzheimer’s disease rather than become entangled in litigation?
He concludes: “With the NHS seeking to control expenditure and target the use of drugs to improve the health of the population in a cost effective manner, and industry wanting to maximise its profits, conflict is inevitable. It is essential that the trade off between health and wealth is managed with transparent and good science by all participants – both public and private.”
Contact:
Alan Maynard, Professor of Health Economics, Department of Health Sciences, University of York, UK
Email: akm3{at}york.ac.uk
(5) Warning over nitric oxide for lung injury patients
(Nitric oxide improves oxygenation but not mortality in acute lung injury: meta-analysis)
http://www.bmj.com/onlinefirst_date.dtl
Use of nitric oxide in patients with acute lung injury does not improve survival and may cause harm, warn researchers in a study published on bmj.com today.
Many doctors treat acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) with inhaled nitric oxide, despite no clear supporting evidence. A review of trials in 2003 concluded that the effects of nitric oxide were uncertain.
So researchers reviewed the effects of nitric oxide, compared to placebo or usual care without nitric oxide, in adults and children with ALI or ARDS.
Twelve trials involving 1,237 patients were included. Overall quality of the trials was good. Their analysis showed no benefit of nitric oxide on mortality. Oxygenation improved after 24 hours of therapy, with limited evidence for a prolonged effect. However, patients receiving nitric oxide had an increased risk of developing renal (kidney) dysfunction.
Nitric oxide is associated with limited oxygenation improvement in patients with ALI or ARDS, but seems to have no benefit on patient survival and may cause harm, say the authors. They do not recommend its routine use in these severely ill patients.
Contacts:
Jan Friedrich, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
or
Neill Adhikari, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
Email: neill.adhikari{at}sunnybrook.ca
(6) Heart surgery for dogs and cats “obscene” says doctor
(Personal View: Not even a dog’s life)
http://www.bmj.com/cgi/content/full/334/7594/638
The disparity between care of domestic animals in the developed world and human beings in sub-Saharan Africa is obscene, says a senior doctor in this week’s BMJ.
Arriving back in Britain after 14 years working in East Africa as a medical missionary, consultant anaesthetist, Raymond Towey says he was shocked to see that open heart surgery is now available for domestic dogs and cats, whereas in sub-Saharan Africa most patients needing such expensive care are sent home to die, assuming they even reach a hospital in the first place.
“I am left with one word that alone sums up my assessment of the amazing advances in the United Kingdom and the appalling comparison with medical care in sub-Saharan Africa: obscene,” he says. Will doctors in years to come wonder at how we could tolerate such an obscene disparity?
He recalls his time as a young hospital doctor in the late 1960s and 1970s when cardiac surgery was taking off. “I am sure that today’s young veterinary surgeons and anaesthetists must be relishing open heart surgery for dogs and cats in a similar way,” he writes.
In 1846 the first successful anaesthetic to be publicly demonstrated was ether and this agent is the mainstay of anaesthetic practice in sub-Saharan Africa. But for open heart surgery in domestic animals, a newer generation of anaesthetic agents is available, which for him accentuates the obscenity.
“Perhaps in time I will emerge from this culture shock and learn to accept with equanimity this appalling disparity between care of domestic animals in the developed world and human beings in sub-Saharan Africa – or perhaps this article is a sign of my underlying inability to adapt,” he adds.
“At the moment, I am hoping that I do not adapt, because either I am suffering from a severe form of “speciesism,” or a global underlying racism exists that allows this obscenity to be tolerated,” he concludes.
Contact:
Raymond Towey, Consultant Anaesthetist, Department of Anaesthesia and Intensive Care, St Mary’s Hospital Lacor, Gulu, Uganda
Email: rmtowey{at}tiscali.co.uk
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(contact: pressoffice{at}bma.org.uk)
and from:
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