This week in the BMJ

Volume 332, Number 7534, Issue of 21 Jan 2006

[Down]Bleeding on warfarin influences doctors' prescribing
[Down]Promotion process for consultants needs examining
[Down]Secondary prevention for CHD increases after framework
[Down]Early treatment for rheumatoid arthritis could virtually cure
[Down]Oncolytic gene therapy is not innocuous

Bleeding on warfarin influences doctors' prescribing

A doctor with a patient who has had a haemorrhage while taking warfarin is less likely to prescribe warfarin to future patients who have atrial fibrillation. In a population based, matched pair analysis, Choudhry and colleagues (p 141) assessed what impact haemorrhage and thromboembolic stroke in atrial fibrillation patients had on future prescribing of warfarin. They found that doctors were less likely to prescribe warfarin after one of their patients had experienced a bleeding event (adjusted odds ratio 0.79, 95% CI 0.62 to 1.00), but warfarin prescribing did not change significantly after a patient not taking warfarin had a stroke.


Figure 1
 Credit: P MARAZZI/SPL

 



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Promotion process for consultants needs examining

The promotion of hospital doctors to consultant level is associated with their sex, country of graduation, previous working hours, and honorary contracts. In a multivariate regression study, Mavromaras and Scott (p 148) analysed NHS administrative data from Scottish hospitals from 1991 to 2000 and found that graduates from outside Scotland, women, and part timers were less likely to be promoted and that an honorary contract and working in non-metropolitan NHS boards helped. They say that as the proportion of women in hospital medicine increases, promotion criteria need to be examined in order to meet government targets of a consultant led NHS.


Figure 1
 Credit: BSIP/LAURENT/H AMERICAIN/SPL

 



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Secondary prevention for CHD increases after framework

Before and after implementation of the national service framework in 2000, uptake of drugs for secondary prevention of coronary heart disease (CHD) has increased considerably in people aged 60-79. In an analysis of two population based studies, Ramsay and colleagues (p 144) examined the use of statins, antiplatelet drugs, and antihypertensive drugs among patients with angina or myocardial infarction before and after the implementation of the framework. The greatest increase was found in use of statins: in 2003, 65% of men and 67% of women with myocardial infarction were receiving statins, compared with 34% and 48% before the framework.


Figure 1
 Credit: A J PHOTO/SPL

 



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Early treatment for rheumatoid arthritis could virtually cure

We now know that inflammation in patients with rheumatoid arthritis should be suppressed as early as possible and treatment has become more effective, but protocols are needed in primary and secondary care for referral of patients with new inflammatory arthritis. In a clinical review on treatment of rheumatoid arthritis (p 152), Emery revisits disease modifying antirheumatic drugs; explores the advantages, opportunities, and problems of biological agents (TNF-{alpha} antagonists); and looks at two new drugs that have been submitted for licence.


Figure 1
 Credit: CHRIS BJORNBERG/SPL

 



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Oncolytic gene therapy is not innocuous

Although gene therapy has huge potential for many conditions, especially cancer, enthusiasm must not cloud judgment about the dangers for patients and for the population of using increasingly diverse, yet relatively untested, replicating oncolytic viruses as vectors for delivery of new genes, argue Chernajovsky and colleagues on page 170. They call for specific guidelines to cover the clinical application of oncolytic viruses (particularly if viruses are genetically modified) at local and international levels and for discussion about how preclinical testing for safety should be carried out.



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