Releases Saturday 21 June 2003
No 7403 Volume 326
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(1) GUIDELINES ON SARS SHOULD BE REFINED
(2) MANY
PATIENTS ARE NOT SATISFIED WITH
ELECTROCONVULSIVE
THERAPY
(3) NEW
TREATMENT APPROACH MAY HELP
PATIENTS WITH
ECZEMA
(4) CONCERN
OVER UNCONTROLLED USE OF
HIV DRUGS
(1) GUIDELINES ON SARS SHOULD BE REFINED
(Evaluation of WHO criteria for identifying
patients with
severe acute respiratory syndrome
out of hospital:
prospective observational study)
http://bmj.com/cgi/content/full/326/7403/1354
Haematological manifestations in patients
with severe
acute respiratory syndrome: retrospective
analysis BMJ
Volume 326, pp 1358-62
Current World Health Organisation (WHO)
guidelines
for diagnosing suspected SARS may not
be sufficiently
sensitive in assessing patients before
admission to
hospital, suggest researchers from Hong
Kong in this
week's BMJ.
The study took place in a newly opened
SARS
screening clinic at the Prince of Wales
Hospital in Hong
Kong from 12-31 March 2003, and involved
556
hospital staff, patients, and relatives
who had had contact
with someone with SARS. Of the 556 people,
141 were
admitted to hospital, and 97 had confirmed
SARS.
The WHO guidelines currently emphasise
respiratory
tract symptoms such as cough, shortness
of breath, and
breathing difficulty. But the team found
that these
symptoms did not feature strongly in the
early stages of
the illness. Instead, symptoms such as
fever, chills, loss
of appetite, vomiting, and diarrhoea,
were significantly
more common among the 97 patients.
In screening patients for SARS, these symptoms
may be
better indications than the symptoms listed
in the WHO
guidelines, which were based on patients
who were
already in hospital, say the authors.
The WHO guidelines also emphasise temperature
readings of 38C or more, but over half
of cases did not
have such levels of fever during the pre-hospital
screening phase, they add.
"The WHO criteria should be refined to
include routine
daily follow up, documentation of non-respiratory
systemic symptoms, and daily chest radiography
until
patients have passed at least 48 hours
without
symptoms," they conclude.
In a second study at the same hospital,
researchers
found abnormal blood cell counts in patients
with SARS.
For instance, of 157 patients assessed,
98% developed
lymphopenia (a decrease in numbers of
lymphocytes in
the blood), and 55% developed thrombocytopenia
(a
decrease in the number of blood platelets).
Studies of the effect of SARS on various
body systems
are crucial to the understanding of this
disease, say the
authors, and further studies to evaluate
the mechanisms
of these changes are needed.
Contact:
Timothy Rainer, Department of Emergency
Medicine,
Prince of Wales Hospital, Hong Kong, China
Email: rainer1091{at}cuhk.edu.hk
(2) MANY PATIENTS
ARE NOT SATISFIED WITH
ELECTROCONVULSIVE THERAPY
(Patients' perspectives on electroconvulsive
therapy:
systematic review)
http://bmj.com/cgi/content/full/326/7403/1363
(Editorial: Electroconvulsive therapy)
http://bmj.com/cgi/content/full/326/7403/1343
Around 11,000 people receive electroconvulsive
therapy
in England each year, yet controversy
exists as to
whether treatment is beneficial and whether
patients are
satisfied with it.
A study in this week's BMJ finds that at
least one third of
patients report persistent memory loss
after
electroconvulsive therapy. This conflicts
with the current
statement from the Royal College of Psychiatrists
that
over 80% of patients are satisfied with
treatment and that
memory loss is not clinically important.
Researchers reviewed 35 studies to ascertain
patients'
views on electroconvulsive therapy. Twenty-six
were
carried out by doctors in psychiatric
units (clinician led
studies) and nine were undertaken by patients
or with in
collaboration with them (patient led studies).
The level of positive responses varied
widely between
studies. Patient led studies reported
lower rates of
perceived benefit than clinician led studies.
The rate of reported persistent memory
loss varied
between 29% and 55% but, unlike levels
of perceived
benefit, the rate did not seem to depend
on whether
studies were clinical or patient based,
with relatively high
levels being reported by both types of
study.
Given these findings, it is not surprising
that disputes can
arise and that organisations should emerge
that provide
support for those who feel their treatment
has not been
beneficial, say the authors.
They conclude that the current statement
from the Royal
College of Psychiatrists is unfounded.
Contact:
Diana Rose, Senior Researcher, Institute
of Psychiatry,
London, UK
Email: d.rose{at}iop.kcl.ac.uk
(3) NEW TREATMENT
APPROACH MAY HELP
PATIENTS WITH ECZEMA
(Twice weekly fluticasone propionate
added to emollient
maintenance treatment to reduce
risk of relapse in atopic
dermatitis: randomised, double blind,
parallel group
study)
http://bmj.com/cgi/content/full/326/7403/1367
For patients with eczema, applying fluticasone
propionate cream twice a week, alongside
daily
emollient treatment, significantly reduces
the risk of
relapse, say researchers in this week's
BMJ.
The study involved 376 patients with moderate
to severe
eczema from 39 dermatology clinics in
six countries. All
patients were experiencing a 'flare' of
their condition.
Patients applied fluticasone propionate
(cream or
ointment; once or twice daily) for four
weeks to stabilise
their condition. A total of 295 patients
whose eczema
was brought under control then entered
a maintenance
phase, applying fluticasone propionate
or a placebo
(emollient alone) twice weekly for up
to 16 weeks. All
patients continued to apply emollient
on a daily basis
with a bath oil as needed.
After 16 weeks in the maintenance phase,
the disease
remained under control in 133 patients
(87 using
fluticasone propionate and 46 using emollient
alone).
Average time to relapse was six weeks
for emollient
alone compared with more than 16 weeks
for fluticasone
propionate.
Patients who applied fluticasone propionate
cream were
six times less likely to have a relapse
than patients
applying emollient alone. The groups showed
no
differences in adverse events.
Surprisingly, this course of treatment
also addresses
concerns about long term exposure to steroids
because,
by producing longer remission periods,
it should reduce
the need for intensive treatment, as is
often required to
control flares, say the authors.
Whether or not this maintenance strategy
can be applied
to other topical corticosteroids of lower
potency remains
to be established, they conclude.
Contact:
John Berth-Jones, Consultant Dermatologist,
Walsgrave
Hospital, Coventry, UK
Email: johnberthjones{at}aol.com
(4) CONCERN OVER
UNCONTROLLED USE OF
HIV DRUGS
(Antiretroviral treatment in developing
countries: the peril
of neglecting private providers)
http://bmj.com/cgi/content/full/326/7403/1382
(Editorial: Preventing HIV)
http://bmj.com/cgi/content/full/326/7403/1342
Uncontrolled use of antiretroviral drugs
in developing
countries could accelerate HIV resistance,
warn
researchers in this week's BMJ.
Most people in developing countries who
suspect they
have a sexually transmitted infection
seek care in the
private sector because of the stigma attached,
and
evidence of uncontrolled use is already
emerging among
largely unregulated private providers,
says Ruairi Brugha
of the London School of Hygiene and Tropical
Medicine.
These treatment practices will accelerate
HIV resistance,
so it is important to take account of
private providers
and regulate their behaviour. Unless treatment
is properly
controlled, these drugs could rapidly
become useless.
"The goal of an AIDS-free world is too
important to risk
failure through ideological disputes over
public or private
sector approaches at the local or global
level. Each can
learn from the other, and the state should
be the
guarantor of quality, wherever people
seek care," he
concludes.
Three other articles in this week's BMJ
explore the
issues surrounding HIV. The first recommends
a "back
to basics" approach to preventing HIV,
while in the
second, a researcher in child health and
former Ugandan
government peace minister assess how to
make the best
use of resources to care for orphans of
AIDS in Africa.
The final article discusses 10 important
lessons from
Africa that could limit the spread of
HIV in India.
"The behaviour that surrounds implementation
of
prevention strategies must be overcome,"
says Arthur
Ammann, President of Global Strategies
for HIV
Prevention, in an accompanying editorial.
"We know
how to prevent every method of HIV transmission
but
without more extensive progress, we are
deluding
ourselves into thinking that the epidemic
can be
controlled," he concludes.
Contacts:
Paper: Ruairi Brugha, Senior Lecturer in
Public Health,
Health Policy Unit, Department of Public
Health and
Policy, London School of Hygiene and Tropical
Medicine, UK
Email: ruairi.brugha{at}lshtm.ac.uk
Editorial: Arthur Ammann, President, Global
Strategies
for HIV Prevention, California, USA
Email: GlobalHIV{at}AOL.com
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