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Press releases Saturday 04 September 2004

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(1) Do measures to control MRSA work?

(2) Frequent alcohol drinking in middle age harms the brain

(3) NHS increasingly dependent on overseas trained doctors

(4) Compulsory vaccination against terrorist attack is unjustified

(5) New blood pressure targets are unachievable for most patients

(1) Do measures to control MRSA work?

(Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature)
http://bmj.com/cgi/content/full/329/7465/533

(Editorial: Controlling MRSA infection in hospitals)
http://bmj.com/cgi/content/full/329/7465/521

Proof that MRSA control policies in hospitals work is poor, show researchers in this week's BMJ.

But they stress that, although better studies are urgently needed, isolation measures should continue until further research establishes otherwise.

The level of hospital acquired MRSA continues to rise globally. National guidelines in many countries recommend patient isolation to control its spread, but the effectiveness of these measures has never been tested scientifically.

The team analysed 46 studies on MRSA isolation policies published between 1966 and 2000. No conclusions could be drawn in a third of studies, while major weaknesses in others means that plausible alternative explanations for reducing MRSA cannot be excluded, say the authors.

Six studies provided stronger evidence. Four showed that concerted efforts including isolation measures can substantially reduce the spread of MRSA, even when endemic. Yet, in two others, isolation wards failed to prevent endemic MRSA. "These studies indicate a need to investigate precisely how such isolation measures should be used," they add.

Despite all the limitations of existing studies, a lack of evidence of an effect should not be mistaken for evidence of lack of effect, say the authors. "Having considered the evidence, we believe isolation measures recommended in national guidelines should continue until further research establishes otherwise."

"We do need better studies, but we must have faith in the strength of common sense and practical experience when it comes to evaluating infection control measures," adds Dr Andreas Voss, an expert from The Netherlands, where MRSA levels are low.

The fact that The Netherlands and Scandinavia are still able to control MRSA by employing the most intensive "search and destroy" measures should not be ignored. The argument that efforts to control MRSA are insufficient and costly could not be further from the truth, he concludes.

Contacts:

[Paper]: Sheldon Stone, Senior Lecturer, Royal Free and University College Medical School, London, UK
Email: s.stone@rfc.ucl.ac.uk
or
Dr Ben Cooper, Postdoctoral Research Fellow
Tel (via Health Protection Agency press office): +44 (0)20 7339 1320

[Editorial]: Professor Andreas Voss, Head of Infection Control, University Medical Centre St Radboud, Nijmegen, The Netherlands
Email: a.voss@mmb.umcn.nl
or
Dr Jan Kluytmans, Senior Clinical Microbiologist, Amphia Hospital, Breda, The Netherlands
Email: jkluytmans@amphia.nl

(2) Frequent alcohol drinking in middle age harms the brain

(Alcohol drinking in middle age and subsequent risk of mild cognitive impairment and dementia in old age: a prospective population based study)
http://bmj.com/cgi/content/full/329/7465/539

Frequent alcohol drinking in midlife is linked to mild mental (cognitive) impairment in old age, claims a study in this week's BMJ.

The risk of dementia is also higher with heavier drinking, but only among those carrying a particular gene (apolipoprotein e4 allele) a known genetic risk factor for dementia.

The study involved 1,018 men and women aged 65-79 years whose physical and mental health was monitored for an average of 23 years. Alcohol consumption was recorded and blood samples were taken to determine apolipoprotein E genotypes.

Participants who drank no alcohol and those who drank alcohol frequently (several times a month) were both twice as likely to have mild cognitive impairment in old age than those who drank infrequently (less than once a month).

Only carriers of the apolipoprotein e4 allele had an increased risk of dementia with increasing alcohol consumption, suggesting that this particular gene may modify the effect of alcohol on the brain. These data indicate that frequent alcohol drinking has harmful effects on the brain, and this may be more pronounced if there is genetic susceptibility, say the authors.

Although these results agree with previous claims that light to moderate drinking might have a protective effect on the brain compared to total abstention and heavy drinking, the authors stress that an explanation for this remains to be clarified.

"We therefore do not want to encourage people to drink more alcohol in the belief that they are protecting themselves against dementia," they conclude.

Contact:

Miia Kivipelto, Researcher, Aging Research Center, Karolinska Institute, Stockholm, Sweden
Email: miia.kivipelto@uku.fi

Online First
(3) NHS increasingly dependent on overseas trained doctors

(Country of training and ethnic origin of UK doctors: database and survey studies)
http://bmj.bmjjournals.com/cgi/reprint/bmj.38202.364271.BE

NHS hospitals have become increasingly dependent on doctors who have trained abroad, particularly in areas where posts have been hard to fill, according to a study published on bmj.com today.

Researchers at Oxford University analysed trends in the UK medical workforce.

They found that doctors who trained abroad now represent nearly a quarter (24%) of consultants appointed since 1991. These doctors, many of whom are from non-white ethnic groups, have helped to staff some of the less popular specialties, such as geriatric medicine, psychiatry, and learning disability.

By contrast, younger generations of UK trained doctors from ethnic minority groups have similar career destinations to those of UK trained white doctors, suggesting that differences in career destinations between white and non-white consultants are linked to having trained abroad rather than ethnic origin.

The percentage of UK medical graduates from ethnic minority groups has increased substantially from about 2% in 1974 and will approach 30% by 2005. White men now comprise little more than a quarter of all UK medical students and are substantially under-represented in the current intakes to UK medical schools.

This raises important questions for policy makers, say the authors: should the ethnic mix of intake into medical schools broadly reflect the ethnic mix of the community from which students are drawn? If so, what should be the mechanisms to achieve such representation?

Contact:

Michael Goldacre, Professor of Public Health, UK Medical Careers Research Group, University of Oxford, UK
Email: michael.goldacre@dphpc.ox.ac.uk

(4) Compulsory vaccination against terrorist attack is unjustified

(Editorial: Bioterrorism and compulsory vaccination)
http://bmj.com/cgi/content/full/329/7465/524

The compulsory use of vaccines to prevent the effects of a bioterrorist attack seems to be based on an unproved threat, according to an editorial in this week's BMJ.

In 1997 the United States began a compulsory anthrax vaccination programme for military personnel. In 2002, a similar programme also involving civilians, was started against smallpox. Yet these programmes rely on old vaccines for which relatively few data exist, writes Tom Jefferson.

For instance, no large scale trial of the US anthrax vaccine (AVA) has ever been conducted, and trials of the current smallpox vaccine have recently been halted because of safety concerns. Despite this, the website of the United States anthrax vaccine immunisation programme claims proved protection against inhalation anthrax, says the author. Newer vaccines are currently being developed but are a long way from field testing.

"Although field trials are expensive and complex, investment in evaluation and in better and safer vaccines surely must be a requisite to have credible compulsory immunisation programmes involving huge numbers of adults of reproductive age," adds the author. "Until such time, the choice of whether to be vaccinated or not should be left to the individual."

Contact:

Tom Jefferson, Cochrane Vaccines Field, Rome, Italy
Email: Toj1@aol.com

(5) New blood pressure targets are unachievable for most patients

(Editorial: Treating hypertension with guidelines in general practice)
http://bmj.com/cgi/content/full/329/7465/523

New blood pressure targets are low enough to be unachievable for most patients, say experts from Aberdeen University in this week's BMJ.

While plenty of strong evidence shows the benefits of lowering blood pressure, targets ? and their ceaseless revision ? are less evidence based, write Neil Campbell and Peter Murchie.

Even in clinical trials, most patients fail to achieve the newer, more stringent targets, while people older than 60 ? the bulk of patients with hypertension in general practice ? and people with diabetes are even less likely to reach this, they add.

Individual patients vary widely in their perception of acceptable risk and side effects when it comes to lowering their blood pressure yet, surprisingly, the patient's role in deciding his or her own blood pressure target receives scant attention in guidelines, they add. "If targets have a role, it is as something to be aimed for, not something that must be achieved at all costs."

Individual patients must be involved in decisions about their care, and this requires effective communication on the subject of risks, benefits, and side effects. Appropriate management of blood pressure should therefore be guided by an informed dialogue between patients and doctors and not by blind pursuit of blood pressure targets, they conclude.

Contacts:

[Wed 1 Sept]: Neil Campbell, Senior Lecturer, Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Aberdeen, Scotland
Email: n.campbell@abdn.ac.uk

[Thurs 2 Sept]: Peter Murchie, Research Training Fellow
Email: p.murchie@abdn.ac.uk

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