Releases Saturday 25 May 2002
No 7348 Volume 324
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(1) LINK BETWEEN STRESS AND HEART DISEASE
MAY BE PREMATURE
(2) VALUE
OF COMMUNITY TREATMENT ORDERS IN
DOUBT
(3) GUIDELINES
DO NOT PREVENT DELIBERATE SELF
HARM
(4) SOME
PATIENTS WITH BREAST CANCER FACE
UNACCEPTABLE
DELAYS
(5) PROPOSALS
TO REGULATE COSMETIC SURGERY
WILL NOT PROTECT
THE PUBLIC
(1) LINK BETWEEN
STRESS AND HEART DISEASE
MAY BE PREMATURE
(Psychological stress and cardiovascular
disease: empirical
demonstration of bias in a prospective
observational study of
Scottish men)
http://bmj.com/cgi/content/full/324/7348/1247
(Commentary: Psychosocial factors
and health ?
strengthening the evidence base)
http://bmj.com/cgi/content/full/324/7348/1247#resp1
It has often been claimed that psychological
stress is an
important cause of heart disease, but
a study in this week's
BMJ shows that previous research may have
been
misleading.
Researchers measured self-assessed stress
amongst
middle-aged Scottish men working in and
around Glasgow in
the early 1970s. These men were then followed
for more
than twenty years to see whether or not
they developed
heart disease. Several different measures
of heart disease
were used.
Men who thought they were most stressed
were also most
likely to report symptoms of ill health,
including symptoms of
angina. In some cases, these symptoms
also led to hospital
admission. A naïve analysis would
therefore apparently show
that stress causes heart disease. However,
hospital
diagnoses of heart disease, electrocardiogram
(ECG) signs
of heart disease and death from heart
disease (and in fact
overall death rates) were actually lower
amongst men
reporting high stress.
"It seems unlikely that genuine coronary
heart disease would
not be associated with an increased risk
of heart disease
death in a middle aged male population
followed up for over
20 years," say the authors.
They suggest a more likely explanation
is that some people
see themselves as experiencing more symptoms
of stress,
and also more symptoms of illness. This
may have led past
researchers to wrongly conclude that stress
causes heart
disease.
Interestingly, the men who saw themselves
as most stressed
in this study, also smoked more, drank
more alcohol and
took less exercise. However, most stressed
men tended to
have better jobs. This greater affluence
probably explained
why, by most objective measures of heart
disease, they were
healthier.
Contact:
John Macleod, Clinical Research Fellow,
Department of
Primary Care and General Practice, University
of
Birmingham, Birmingham, UK
Email: j.a.macleod{at}bham.ac.uk
(2) VALUE OF COMMUNITY
TREATMENT ORDERS IN
DOUBT
(Assessing the outcome of compulsory
psychiatric treatment
in the community: epidemiological
study in Western
Australia)
http://bmj.com/cgi/content/full/324/7348/1244
Compulsory psychiatric treatment in the
community is
thought to reduce the use of health services
by patients with
mental health disorders. However, a study
in this week's
BMJ raises questions about the effectiveness
of such an
invasive procedure.
Researchers matched 228 psychiatric patients
placed on a
community treatment order with an equal
number of control
patients not placed on an order, to predict
subsequent use of
health services.
One year later, hospital admissions and
bed days decreased
for all patients. Outpatient contacts
increased for patients on
a community treatment order compared with
the control
group. Otherwise, orders did not affect
subsequent use of
health services.
This study shows that legislative solutions
such as community
treatment orders may not always offer
a solution to the need
to provide appropriate services for psychiatric
patients within
limited resources, say the authors.
It is important to examine what role such
orders have in
providing effective mental health treatment
and whether
therapeutic gains could be better delivered
by enhancing the
quality and assertiveness of community
treatment for high
risk patients, they conclude.
Contacts:
Neil Preston, Research Psychologist, Mental
Health
Directorate, Fremantle Hospital and Health
Service,
Fremantle, Western Australia
Email: neil.preston{at}health.wa.gov.au
Steve Kisely, Associate Professor, University
Department of
Psychiatry at Fremantle Hospital, University
of Western
Australia, Fremantle, Western Australia
E-mail: stephenk{at}cyllene.uwa.edu.au
(3) GUIDELINES
DO NOT PREVENT DELIBERATE SELF
HARM
(General practice based intervention
to prevent repeat
episodes of deliberate self harm:
cluster randomised
controlled trial)
http://bmj.com/cgi/content/full/324/7348/1254
(Commentary: Clinical guidelines
have limitations)
http://bmj.com/cgi/content/full/324/7348/1254#resp1
Clinical guidelines do not reduce the rate
of repeated self
harm, and more research is needed on how
to manage
patients who deliberately harm themselves,
suggest
researchers from Bristol University in
this week's BMJ.
The study involved 1,932 patients, registered
with 98 general
practices, who had attended accident and
emergency
departments at one of four general hospitals
after an episode
of deliberate self harm.
The practices were assigned in equal numbers
to an
intervention or a control group. The intervention
comprised a
letter from the general practitioner inviting
the patient to
consult, and guidelines on assessment
and management of
deliberate self harm for the general practitioner
to use in
consultations. Control patients received
usual general
practitioner care.
After 12 months, the level of repeat episodes
of deliberate
self harm was no different for patients
in the intervention
group compared with the control group.
This lack of benefit
leaves open the question of the most effective
management in
general practice of patients who deliberately
harm
themselves, say the authors.
The high proportion of patients who make
contact with
general practitioners after an episode
of deliberate self harm
suggests that more research is needed
on how best to
manage such patients in primary care to
reduce the incidence
of repeated episodes, they conclude.
Contact:
Deborah Sharp, Professor of Primary Care,
Division of
Primary Health Care, University of Bristol,
Bristol, UK
Email: debbie.sharp{at}bristol.ac.uk
(4) SOME PATIENTS
WITH BREAST CANCER FACE
UNACCEPTABLE DELAYS
(Letter: Grading referrals to specialist
breast unit may be
ineffective)
http://bmj.com/cgi/content/full/324/7348/1279/a
Some patients with breast cancer are waiting
up to 12 weeks
for diagnosis and treatment, despite the
introduction of a two
week wait initiative by the government,
suggest researchers
in this week's BMJ.
Using data from the breast unit at King's
College Hospital,
the team examined all general practitioners'
referrals to the
breast clinic between April 1999 and December
2000.
Altogether 3,597 referrals were made,
665 were marked as
urgent and 2,932 as non-urgent. Sixty-two
urgent patients
and 49 non-urgent patients were subsequently
found to have
breast cancer.
It is evident that the two week wait initiative
is not ensuring
that most patients with symptomatic cancer
are seen within
two weeks of referral, say the authors.
The emphasis on
seeing urgent cases within the time has
been at the expense
of the non-urgent cases. Waiting times
in this group have
increased to 12 weeks in some units.
"By grading patient referrals, we are creating
a two tier
structure, with patients in the non-urgent
group waiting longer
periods for diagnosis and treatment. For
patients with
cancers in this group the delay can be
critical," they argue.
As no grading system is perfect, the only
way of
guaranteeing that all patients with breast
cancer are seen
within two weeks is by seeing all the
referrals in this period.
This has become achievable at our unit
through managing
capacity and demand, they conclude.
Contact:
Jonathan Roberts, Consultant Surgeon, King's
College
Hospital, London, UK
Email: jonathan.roberts{at}kingsch.nhs.uk
(5) PROPOSALS
TO REGULATE COSMETIC SURGERY
WILL NOT PROTECT THE PUBLIC
(Editorial: Regulating cosmetic surgery)
http://bmj.com/cgi/content/full/324/7348/1229
Government proposals for regulating cosmetic
surgery in the
United Kingdom would permit unqualified
surgeons to
remain in practice, according to an editorial
in this week's
BMJ.
The proposals demand only that surgeons
be medically
qualified and have attended some postgraduate
courses,
despite unanimous advice from the profession
on the
importance of training and continuing
medical education in
aesthetic surgery, argues Clive Orton,
President of the British
Association of Aesthetic Plastic Surgeons.
Cosmetic surgery has become a growth industry
and a public
obsession. Many patients do not seek a
referral from their
general practitioner because they fear
an unsympathetic
response or they feel that cosmetic surgery
is not
fundamentally medical. Self referral to
a clinic is an easier
option.
The public would be better protected if
they consulted their
general practitioner first, but it is
likely that the number of self
referrals will increase rather than decrease,
says the author.
"Public education through the professional
bodies is
important, but in the face of increased
public demand, glossy
advertising, and inadequate regulation,
only the most
sanguine optimist can believe that the
situation has been
controlled adequately," he concludes.
Contact:
Clive Orton, President, British Association
of Aesthetic
Plastic Surgeons, Royal College of Surgeons,
London, UK
Email: clive{at}cliveorton.com
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