bmj.com -- Press Releases

Releases Saturday 12 August 2000
No 7258 Volume 321

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(1) FIRST BORN CHILDREN OF OLDER MOTHERS AT
GREATER RISK OF DIABETES

(2) PLACEBO CONTROLLED TRIALS "A MORAL
ISSUE"

(3) THE ENGLISH PATIENT � FACING COVERT
PRIVATISATION OF THE NHS

(4) HERBAL REMEDIES: DO THEIR BENEFITS
OUTWEIGH THE RISKS?

(1) FIRST BORN CHILDREN OF OLDER MOTHERS AT
GREATER RISK OF DIABETES

(Influence of maternal age at delivery and birth order on risk
of type 1 diabetes in childhood: prospective population based
family study)
http://bmj.com/cgi/content/full/321/7258/420

Children of older mothers have an increased risk of diabetes
according a new study published in this week's BMJ. The
risk is highest among first born children of mothers who start
their families late.

Professor Edwin Gale and colleagues at Southmead Hospital
in Bristol looked at 1375 families in the Oxford area in which
one or more child had diabetes. They found that the mother's
age at delivery was strongly related to risk of type 1 (insulin
dependent) diabetes. The risk increased by 25% for each five
year band of maternal age, so that a 45 year old mother was
more than three times likely to have a child who developed
diabetes than a 20 year old mother. To a lesser extent the
risk of diabetes was also linked to older fathers.

Risk of type 1 diabetes was highest among first born children
of older parents. Second children and their younger brothers
or sisters were progressively less at risk of developing the
condition.

Throughout the country women are in general having their
children at an older age: between 1970 and 1996 the
proportion of children born to mothers aged 30-34 years
increased from 15% to 28%. The authors of the BMJ paper
say: "The increase in maternal age at delivery in the UK over
the past two decades could partly account for the increase in
incidence of childhood diabetes over this period."

Contact:

Dr Polly Bingley Diabetes & Metabolism, Div of Medicine,
University of Bristol Southmead Hospital, UK
Email: polly.bingley{at}bristol.ac.uk

(2) PLACEBO CONTROLLED TRIALS "A MORAL
ISSUE"

(Education and Debate: Declaration of Helsinki should be
strengthened � For and against)
http://bmj.com/cgi/content/full/321/7258/442

The World Medical Association is debating the next revision
of the Declaration of Helsinki which covers issues
surrounding using patients in medical trials. This week's
Education and Debate section in the BMJ carries for and
against arguments over the morality of carrying out placebo
controlled trials when there is an existing accepted treatment
for a condition.

In a placebo controlled trial involving patients, some
individuals receive the treatment under test, and others are
given a placebo � a chemically inert substance given in place
of a drug. Professors Kenneth Rothman and Karin Michels of
Boston USA argue that placebo comparisons are unethical if
there is a demonstrably effective treatment as they would be
denying this treatment to people in need of it. They write:
"The Declaration of Helsinki explicitly forbids the use of a
placebo group if an accepted treatment exists."

Professors Rothman and Michels argue that the World
Medical Association is under pressure from the US Food and
Drugs Administration (FDA) to revise the Declaration. The
FDA, they write, requires many trials to include a placebo
group. "The most glaring defect in the FDA's position is that
scientific arguments, right or wrong, are placed ahead of
ethical concerns" say the two Boston authors. They want to
see the Helsinki Declaration strengthened and become
universally acknowledged as "the inviolable standard for
ethical conduct of human experiments."

Professor Michael Baum of University College London
criticises the Boston authors for taking such an absolutist
stance and suggests the issues are not as simple as they have
suggested.

Contacts:

Professor Kenneth Rothman Dept Epidemiology & Statistics,
Boston University Medical centre, US
Email: kRothman{at}bu.edu

Professor Michael Baum Department of Surgery, University
College London, UK

(3) THE ENGLISH PATIENT � FACING COVERT
PRIVATISATION OF THE NHS

(Editorial: Will intermediate care be the undoing of the
NHS?)
http://bmj.com/cgi/content/full/321/7258/393

Government proposals to allow NHS bodies to levy charges
for the personal elements of care will fundamentally change
the way some English patients receive health care, says an
editorial in this week's BMJ. Proposals in the NHS Plan to
extend NHS provision to the private sector will further erode
the goals of the NHS as a universal comprehensive service
writes Professor Allyson Pollock.

Under the plan, new care trusts will be able to commission
and deliver both primary and community care as well as
social care. They will define what is NHS care and what is
social care, with the social care elements subject to local
authority charging policies. Because they can levy charges for
personal care in the private sector, primary care trusts will
have clear financial incentives to shift intermediate care into
non NHS settings, says the BMJ editorial.

The NHS Plan announced 7000 extra NHS beds by 2004 of
which 5000 will be intermediate care beds, building "a bridge
between hospital and home". Cottage hospitals, private
nursing homes and domiciliary and community settings will
form the heart of the new intermediate sector. Professor
Pollock says some of the 300,000 NHS patients expected to
move annually from hospitals into intermediate care in nursing
and domiciliary settings may have to pay for their personal
care.

From October 2001 the NHS is committed to meet only the
costs of nursing care for nursing home residents; personal
care will be charged for. Professor Pollock says this will
mean some patients in nursing homes may be financially
worse off if the NHS switches some intermediate care to this
sector.

The funding mechanism governing the payment of care
providers will be critical, says Professor Pollock. A
Government committed to a universal comprehensive high
quality NHS would restore the risk-pooling model of
universal provision by bringing the nursing elements of the
workforce in the private sector under NHS control, she
writes.

Contact:

Professor Allyson Pollock School of Public Policy, University
College London, UK
Email: allyson.pollock{at}ucl.ac.uk

(4) HERBAL REMEDIES: DO THEIR BENEFITS
OUTWEIGH THE RISKS?

(Herbal medicines: where is the evidence?)
http://bmj.com/cgi/content/full/321/7258/395

With the market for herbal supplements now approaching
$4bn a year in the United States alone, what evidence is there
to show that these treatments actually work, asks Professor
Ernst of Exeter University's Department of Complimentary
Medicine in a BMJ editorial this week.

An increasing body of evidence is now emerging that suggest
some herbal medicines are effective � and often have fewer
adverse effects than standard treatments, says the author. For
instance, more than 30 clinical trials show St John's Wort to
be as effective as conventional antidepressants and ginkgo
biloba has been shown to be more effective than placebo in
delaying the clinical course of dementia.

Despite these positive results, we should be aware of the
risks, warns the author. We do not fully understand how
many of these medicines work and, as many herbal remedies
are sold as food supplements, they evade the quality and
safety regulations required for conventional treatments. Two
recent cases of severe kidney damage caused by Chinese
herbal tea taken to treat eczema illustrate the need for a
quality standard for all herbal preparations. Potential
herb-drug interactions and the cost-effectiveness of herbal
medicines must also be explored, suggests the author

As more people turn towards herbal medicines, health
professionals need access to reliable information in order to
advise their patients responsibly, concludes the author. The
UK's minister for public health recently called for better
protection and information for the public on herbal medicines
and doctors should take an active part in this process, he
adds.

Contact:

Professor E Ernst, Department of Complimentary Medicine,
School of Postgraduate Medicine and Health Sciences,
University of Exeter, UK
Email: E.Ernst{at}exeter.ac.uk

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