Releases Saturday 13 May 2000
No 7245 Volume 320
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(1) DOCTORS SHOULD LOOK FOR DRUG MISUSE IN
YOUNG PATIENTS WITH STROKE
(3) WOMEN'S
DEATH RATE INEQUALITIES - THE
ANSWER LIES
IN THE HOME
(4) HEAD
INJURY TRIALS TOO SMALL TO BE OF
BENEFIT
(5) INHALED
STEROIDS IMPROVE THE HEALTH OF
LUNG DISEASE
PATIENTS
(1) DOCTORS SHOULD
LOOK FOR DRUG MISUSE IN
YOUNG PATIENTS WITH STROKE
(Intracerebral haemorrhage in young
adults: the emerging
importance of drug misuse)
http://bmj.com/cgi/content/full/320/7245/1322
The growing pandemic of cocaine use in
Western society is
providing increasing evidence of its association
with
intracerebral haemorrhage. In this week's
BMJ, Andrew
McEvoy and colleagues at the National
Hospital for
Neurology and Neurosurgery in London,
warn doctors to be
alert both for drug misuse and an underlying
vascular cause in
cases of young patients with haemorrhagic
stroke.
The authors report that in 13 recent cases
of young (average
age 31 years) stroke patients who had
misused illegal drugs,
nine out of ten of those investigated
had underlying vascular
problems, including six with intracranial
aneurysm.
Despite the widespread use of ecstasy,
acute neurological
complications from it seem to be rare,
but cocaine and
amphetamine misuse are both well recognised
causes of
intracerebral and subarachnoid haemorrhage.
The mortality
and morbidity of patients who suffer a
stroke after drug
misuse is known to be appreciably greater
than for similar
patients who do not misuse drugs. The
authors recommend
that a through medical history, focusing
on the use of illegal
drugs, plus blood and urine tests, should
be part of the
evaluation of any young patient with stroke.
Contact:
A W McEvoy, University Department of Neurosurgery,
Institute of Neurology National Hospital
for Neurology and
Neurosurgery, London WC1N 3BG
Email: a.mcevoy{at}ion.ucl.ac.uk
(Modernising the NHS, A promising
start, but fundamental
reform is needed)
http://bmj.com/cgi/content/full/320/7245/1329
The NHS has just been promised its largest
sustained
increase in resources since the service
was started in 1948,
with a national plan for health to be
developed over the next
two months by six action teams. The BMJ
has invited six
commentators to set out their priorities
for each of the Prime
Minister's modernisation action teams
over the next few
weeks. To kick off the series, Professor
Alain Enthoven of
Stanford University, who is widely credited
as the driving
force behind the creation of the NHS internal
market, offers
his views on the prime minister's plans
for the NHS.
Professor Enthoven endorses the decision
to pump more
money in to the NHS but warns that the
fundamental
problems of the NHS cannot be fixed in
time to make a
noticeable difference before the next
election. He argues that
consumer choice, competition and strong
incentives to
modernise should all form part of the
national plan.
Enthoven criticises the centralist approach
adopted by
Government, arguing that the centre does
not invariably
knows best and that it will be seen as
coercive and punitive.
He argues that the Government was too
quick to dismantle
the internal market and that a centralised
approach is
incompatible with effective commissioning
by primary care
groups. He warns that the NHS lacks high
quality clinical and
financial databases and makes poor use
of the information it
has. Redressing this deficit must be a
top priority and
resources should be directed to reforms
that will sustain large
improvements over the long run.
Contact:
Alain C Enthoven, Marriner S Eccles professor
of public and
private management, Graduate School of
Business, Stanford
CA 94305-5015, USA
Email: enthoven_alain{at}gsb.stanford.edu
(3) WOMEN'S DEATH
RATE INEQUALITIES - THE
ANSWER LIES IN THE HOME
(Comparing health inequality in men
and women: prospective
study of mortality 1986 - 96)
http://bmj.com/cgi/content/full/320/7245/1303
If health researchers want to find out
about differences in
mortality rates in women they need to
consider not just their
jobs but their home life as well. A paper
in this week's BMJ
suggests that " unlike male mortality
rates " those for women
are best predicted by scales which are
based on the
household situation and so reflect the
modern working
woman's "double day".
A new study comparing health inequality
in men and women
looked at two different ways of predicting
mortality rates. In
men, social class based on employment
relations was the
most important influence on mortality,
showing clear
differences according to the type of job
situation. In women
this employment-based classification was
much less
predictive of inequalities in death rates,
but a different scale
based on social advantage in the household,
revealed large
differences in mortality rates for women.
Dr Amanda Sacker of Royal Free and University
College
London Medical School and co-authors say
the need to use
different scales for men and women may
have several
explanations. It may reflect the amount
of time over a lifetime
women spend in the workplace, or other
differential exposure
to lifestyle outside the workplace. But
it "may also reflect the
nature of women's double-day. Working
women in less
advantaged households return home to a
heavier burden of
domestic labour, most of which falls on
their shoulders, the
disadvantage of their home situation amplifying
any effects of
work stress and hazards."
Contact:
Dr Amanda Sacker Dept Epidemiology and
Public Health,
Royal Free and UCL Medical School, London
Email: amanda{at}public-health.ucl.ac.uk
(4) HEAD INJURY
TRIALS TOO SMALL TO BE OF
BENEFIT
(Size and quality of randomised controlled
trials in head
injury: review of published studies)
http://bmj.com/cgi/content/full/320/7245/1308
Many millions of people are treated world-wide
each year for
severe head injury and there are few treatments
of established
effectiveness. A study in this week's
BMJ reports that
currently available trials of treatment
are too small and too
poorly designed to detect or refute reliably
moderate but
important benefits or hazards of treatment.
Researchers from the Cochrane Injuries
Group looked at
208 separate randomised controlled trials
with an average
number of 82 patients per trial. Doctors
treating severe head
injuries recognise that improvements in
health outcomes of
only a few per cent would be important
because of the large
numbers of patients involved , but most
clinical trials would
miss treatment effects of this size.
The BMJ paper states: "If a widely practicable
treatment
reduced the risk of death or disability
by 5% then treatment
of one million patients would protect
50,000 people from
death or disability." None of the trials
studied was large
enough to detect reliably a 5% absolute
reduction in the risk
of disability or death. The study's authors
say large scale
randomised controlled trials could be
of considerable
importance to public health but that the
limited funding for
head injury research has been a major
obstacle to conducting
these trials.
Contact:
Frances Bunn, Cochrane Injuries Group,
Institute of Child
Health Work
Email: F.bunn{at}ich.ucl.ac.uk
(5) INHALED STEROIDS
IMPROVE THE HEALTH OF
LUNG DISEASE PATIENTS
(Randomised, double blind, placebo
controlled study of
fluticasone propionate in patients
with moderate to severe
chronic obstructive pulmonary disease:
the ISOLDE trial)
http://bmj.com/cgi/content/full/320/7245/1297
Support for the widespread practice of
using high dose
inhaled corticosteroids in patients with
moderate to severe
chronic obstructive pulmonary disease
(COPD ) which
affects lung function comes in this week's
BMJ in a paper by
Burge et al.
COPD occurs predominantly in tobacco smokers
and is a
leading cause of illness and death world-wide.
As lung
function deteriorates (measured by forced
expiratory volume
- FEV ) substantial changes in general
health occur. Dr Peter
Burge and colleagues report on the ISOLDE
trial in which 18
UK hospitals took part involving 751 patients
who were
current or former smokers. The men and
women were aged
between 40 and 75 years.
The ISOLDE trial (Inhaled Steroids in Obstructive
Lung
Disease study) looked not only at FEV
levels measuring lung
function, but at the general health status
of the patients . The
study shows for the first time that, like
FEV, health status
declines at a measurable rate in patients
with severe to
moderate COPD. The use of an inhaled steroid
called
Fluticasone propionate at high doses significantly
reduced the
rate of this decline in health status.
The use of the steroid also
resulted in fewer "exacerbations" - a
worsening of
respiratory symptoms requiring additional
treatment. No
benefit of fluticasone propionate on the
rate of decline in FEV
was found.
"These data provide a rationale for the
current practice of
using inhaled corticosteroids at this
dose in patients with
moderate to severe COPD" states the BMJ
paper.
Contact:
BMA press office for author contact details.
Email: lmillington{at}bma.org.uk
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