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Press releases Saturday 18 September 2004
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(1) DOUBTFUL POST-MORTEM EVIDENCE MAY LEAD TO MISCARRAIGES OF JUSTICE
(2) HIB INFECTIONS ON THE RISE IN ADULTS DESPITE CHILD VACCINATION PROGRAMME
(3) WHAT ARE YOU ON? — THREE OUT OF FIVE ISRAELI CLINICIANS STILL USING PLACEBOS
(4) POVERTY
NOT STRONGLY LINKED TO WINTER DEATHS IN THE ELDERLY
(1) DOUBTFUL POST-MORTEM EVIDENCE MAY LEAD TO MISCARRAIGES OF JUSTICE
(Forensic science in the dock)
http://bmj.com/cgi/content/full/329/7467/636
The science of measuring drug levels in the blood after death is far from robust and based on flawed evidence— leading to likely miscarraiges of justice and conspiracy theories, say forensic scientists in this week's BMJ.
For living patients doctors can determine the toxicology—drug concentration levels—of a patient through straightforward tests, involving factors such as how drugs were administered and number of doses taken.
But for dead subjects such information is almost never available, say the authors, so conclusions about drug levels are often incomplete. In addition the way blood behaves after death — what happens when it stops circulating for instance—confuses toxicology measurements. Chronic drug use also muddles matters, inducing 'tolerance' which can be factored into toxicology measurements for living patients but cannot be measured in dead bodies. Despite these concerns however, forensic scientists continue to draw conclusions based on comparisons with living subjects.
These problems and others make it impossible to determine accurately whether the cause of death was solely caused by drug concentrations. Furthermore, if drug levels at the time of death are impossible to determine, pathologists cannot make judgements on the amount of drugs taken into the body before death. Yet these projections are often produced in court as evidence.
This continued reliance on flawed scientific methods can be highly misleading, say the authors, and almost certainly results in miscarraiges of justice. Such unreliable evidence also contributes to false perceptions of conspiracy and cover up. An example of such confusion is that following the death of Government weapons expert David Kelly, where differences of opinion have been expressed in public over the interpretation of the toxicology results, say the authors.
Contact:
Professor A Robert Forrest Professor of Forensic Toxicology, University
of Sheffield, Sheffield, UK
Email: R.Forrest@sheffield.ac.uk
(2) HIB INFECTIONS ON THE RISE IN ADULTS DESPITE CHILD VACCINATION PROGRAMME
(Trends in Haemophilus influenzae type b infections in adults
in England and Wales: surveillance study)
http://bmj.com/cgi/content/full/329/7467/655
Cases of the Hib infection (haemophilus influenzae type b) among children and adults have risen in recent years, despite a vaccination programme which initially proved successful, say researchers in this week's BMJ.
The Hib vaccine became part of the routine immunisation programme for babies in 1992, cutting deaths from the disease amongst children significantly and reducing infection rates. In 1992 for instance 21.91 cases per 100,000 children were reported, dropping to 0.65 by 1998.
Adults—most of whom were not immunised—also benefited, with Hib infections in the population at large also dropping—from 0.17 cases per 100,000 to 0.03 in the same period. Although infection in adults is rare, infection rates are higher among the age groups in regular contact with children, suggesting that adults usually catch infection from these young children, say the authors.
From 1998 however Hib cases in children started to rise significantly, mostly among those who were immunised in the programme as babies—though infection rates remain well below those seen before vaccination was introduced. Among adults rates have now reached levels higher than before the vaccination programme was introduced (0.27 cases per 100,000 in 2003, compared with 0.17 in 1992.)
The apparent fall in the effectiveness of the initial vaccination programme for children may be due to several factors, say the researchers, including issues with the vaccine used, which has now been changed. For adults the situation was more complex. They had initially benefited from 'herd immunity' say the authors, where the drop in infection rates among children resulted in reduced exposure to the disease for adults, and consequently fewer infections. But adults' reduced exposure to the disease also meant their antibody levels—or 'natural' immunity - was no longer being boosted. When the disease began to rise once again amongst children, some adults found themselves less equipped than before to fight the infection.
Monitoring the Hib immunisation strategy quickly exposed trends and problems with the programme, say the authors, prompting swift corrective action—in this case resulting in the implementation of a national booster vaccination programme for children younger than four years, which should once again benefit adults. Such high quality surveillance systems are vital, say the authors, in the fight against immunisable diseases.
Contact:
Dr Mary Ramsay Consultant Epidemiologist Immunisation Department, Health
Protection Agency, London, UK
Email: mary.ramsay@hpa.org.uk
Online First
(3) WHAT ARE YOU ON? — THREE OUT OF FIVE ISRAELI CLINICIANS
STILL USING PLACEBOS
(Questionnaire survey on use of placebo)
http://bmj.bmjjournals.com/cgi/reprint/bmj.38236.646678.55
Three out of five Israeli clinicians report using placebos—inactive treatments or drugs—in treating patients, despite the medical profession's official disapproval of their use, say the authors of a BMJ Online First paper this week.
Over two-thirds of respondents to the researchers' survey admitted they told patients they were receiving genuine medication, and 94% felt placebos were generally or occasionally effective.
The study from Jerusalem surveyed hospital doctors, head nurses and family doctors in community clinics. Circumstances for using placebos varied widely, including diagnosing patients as well as prescribing medication. Respondents also reported using placebos for a wide range of conditions, from anxiety and vertigo, to asthma and even angina.
Significantly only one in twenty respondents felt that placebos should be banned on ethical grounds, while most considered using them in certain circumstances. This raises important ethical questions say the authors, given "the deception involved in administering a placebo".
Within the medical profession placebos are officially frowned upon, and some institutions have banned clinicians from using them. However this study suggests their use is frequent and rising, say the authors. Used wisely, placebos may have a genuine role in treating patients, they suggest. The time has come for the profession to acknowledge their use, so that an open debate on their effectiveness, and the ethics of their application, can take place.
Contact:
Dr Pesach Lichtenberg Lecturer, Department of Psychiatry, Herzog Hospital
and Hadassah School of Medicine, Jerusalem, Israel
Email: licht@cc.huji.ac.il
(4) POVERTY NOT STRONGLY LINKED TO WINTER DEATHS IN THE ELDERLY
(Vulnerability to winter mortality in elderly people in Britain:
population based study)
http://bmj.com/cgi/content/full/329/7467/647
Poverty is not strongly linked to winter deaths in elderly British people, finds new research in this week's BMJ.
Although Britain has a large burden of excess winter deaths, this study suggests that policies to relieve fuel poverty alone may only be partially successful.
Researchers at the London School of Hygiene and Tropical Medicine examined deaths in people aged 75 years or over, focusing on individual risk factors such as social and economic deprivation, sex, home heating, and previous health.
They found a substantial (around 30%) increase in winter death in this age group, but only female sex and a history of respiratory illness (asthma, emphysema, or pneumonia) were associated with winter death. Remarkably, socioeconomic deprivation was not strongly linked with winter death.
Instead, the risk of winter death seemed to be widely distributed in elderly people rather than being heavily concentrated in the most disadvantaged groups. Policy makers may find this at odds with current notions of vulnerability from fuel poverty, say the authors, particularly as the principal risk factor is low indoor temperature. This may be down to the construction of much social housing, and efforts by local authorities to improve home efficiency, suggest the authors.
The findings suggest that public health policies to reduce the burden of winter death in Britain will need to become broader based, and include additional measures to reach all those at risk, they conclude.
Contact:
Dr Paul Wilkinson Senior Lecturer, London School of Hygiene and Tropical
Medicine, London, UK
Email: paul.wilkinson@lshtm.ac.uk
(On the same theme)
http://bmj.com/cgi/content/full/329/7467/660
The influenza vaccination is helping reduce winter deaths amongst the elderly, says research from the London School of Hygiene and Tropical Medicine. In the first report of its kind, the authors conducted a cohort study of 24,535 elderly patients from 73 general practices in Great Britain. They found that death rates for those who had been vaccinated did not rise during periods of high influenza infection in the population at large, though they clearly increased for unvaccinated elderly patients.
Contact:
Dr Ben Armstrong Reader, London School of Hygiene and Tropical Medicine,
London, UK
Email: ben.armstrong@lshtm.ac.uk
(And...)
http://bmj.com/cgi/content/full/329/7467/633
An editorial from Italy argues that what is commonly known as influenza
or the flu is a syndrome, not a disease—which is important for diagnostic
purposes, and when considering measures for dealing with epidemics.
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