Online First articles may not be available until 09:00 (UK time) Friday.

Press releases Saturday 10 February 2007

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's web site (http://bmj.com).

(1) Combination of drugs should be stockpiled to fight flu pandemic, say experts
(2) New smear test policy puts young women at risk, say doctors
(3) Abortion - where do we draw the line?

(1) Combination of drugs should be stockpiled to fight flu pandemic, say experts
(Role of combination antiviral therapy in pandemic influenza and implications)
(Editorial: Preparing for the next flu pandemic)
http://www.bmj.com/cgi/content/full/334/7588/293
http://www.bmj.com/cgi/content/full/334/7588/268

A combination of antiviral drugs should be stockpiled for use in an influenza pandemic, say researchers in this week±s BMJ.

We currently have two classes of drugs that are effective against influenza viruses: the ion channel inhibitors (amantadine and rimantadine) and the neuraminidase inhibitors (oseltamivir and zanamivir).

Although ion channel inhibitors are effective against several strains of influenza viruses, they are not being widely stockpiled for a future flu pandemic because they cause unacceptable side effects and their use is associated with a rapid emergence of resistance.

But researchers argue that combining the two types of drugs may reduce side effects and the risk of resistance, and could play an important role in our armoury against a future flu pandemic.

In laboratory tests, the combination of ion channel and neuraminidase inhibitors reduced the emergence of resistance and even prevented the emergence of resistant strains of the highly pathogenic avian influenza H5N1 virus.

Ion channel inhibitors are also considerably cheaper than neuraminidase inhibitors, so the cost implications of maintaining stocks of both types of drug are therefore modest, say the authors. These drugs are also chemically stable, giving them a long shelf life.

The World Health Organisation recently recommended combined use of ion channel and neuraminidase inhibitors against the H5N1 strain, but this recommendation was deemed weak because of a lack of good evidence. Adequately sized trials of such combinations are therefore urgently needed, they add.

Several countries including the US, UK, and Greece are already stockpiling ion channel inhibitors. Other countries should consider following suit, say the authors. Failure to stockpile both types of antiviral drugs could prove costly.

An accompanying editorial discusses new guidelines on the clinical management of pandemic flu and says that the United Kingdom is well advanced in its preparations for a flu pandemic.

Contacts:
Paper: Sotirios Tsiodras, Lecturer in Infectious Diseases, University of Athens Medical School, Athens, Greece
Email: gtsiodras@med.uoa.gr

Editorial: Wei Shen Lim, Consultant Respiratory Physician, Nottingham University Hospitals, Nottingham, UK
Email: weishen.lim@nuh.nhs.uk

(2) New smear test policy puts young women at risk, say doctors
(Letter: Women under 25 should be offered cervical screening)
http://www.bmj.com/cgi/content/full/334/7588/273

Last month, the BMJ reported a fall in the number of young women attending smear tests. Now, two senior doctors warn that a new policy not to screen women aged 20-24 may be a factor in falling coverage and could increase the risk of cancer developing in young women.

Prevalence of carcinoma in situ (a precursor to cancer known as CIN3) has increased in women aged 20-24, write consultants Amanda Herbert and John Smith. This new policy will add more than 3000 women with untreated CIN3 to the larger numbers failing to accept their invitations later on, they warn.

The authors accept that CIN may regress, that invasive cervical cancer (ICC) is rare in women under 25, and that screening does little to reduce its incidence in such young women. However, they argue that ICC can develop within a couple of years of missed cell analysis, failure to investigate cell abnormalities, or incomplete treatment, emphasising the importance of treating high-grade CIN when it is found.

Screening in the UK has been highly successful and, since 1988, incidence and mortality have fallen by more than 40% despite increased risk of disease. This has been achieved by treating high-grade CIN, particularly CIN3, in young women, say the authors. The peak prevalence of CIN3 is in women aged 25-29 amongst whom the fall in coverage has been greatest.

ICC is more difficult to prevent in young women because there are less screening opportunities to treat precancerous lesions before they become invasive, they add.

They believe that decisions about treatment of CIN should be based on a balance between risk of progression, likelihood of regression and risk of treatment. Women should be informed about the risk of high-grade CIN, its greater frequency in young women, the importance of surveillance, and the fact that an epidemic of cervical cancer has been prevented by screening women when they were young.

General practitioners and clinics should not be prevented from screening women whom they believe to be at risk if those women themselves want to be screened, they conclude.

Contacts:
Amanda Herbert, Consultant Histopathologist and Cytopathologist, Guy±s and St Thomas± NHS Foundation Trust, London, UK
Email: Amanda.herbert@kcl.ac.uk

John Smith, Consultant Histopathologist and Cytopathologist, Royal Hallamshire Hospital, Sheffield, UK

(3) Abortion - where do we draw the line?
(Feature: Where do we draw the line?)
http://www.bmj.com/cgi/content/full/334/7588/285

The 40th anniversary in October this year of the passing of the UK Abortion Act is certain to be marked by attempts to reopen the debate about lowering the upper limit for legal terminations. In a special report in this week±s BMJ, journalist Jonathan Gornall examines current arguments for reform.

Any challenge to the upper limit of 24 weeks poses big questions about viability, infant suffering, and the capabilities of neonatal care, writes Gornall ± and the danger is that this vital debate is taking place increasingly on emotional rather than scientific grounds.

The ProLife Alliance can take much of the credit for having put abortion back on the public and political agenda over the past decade. The organisation was set up in 1996 as a political party to show ±the reality of abortion± and was also behind the ultimately failed attempt in 2003 by Joanna Jepson, a trainee vicar, to have police prosecute two doctors over the late abortion of a fetus with a cleft lip and palate.

Now the alliance has turned its attention away from pictures of dead babies to 4D ultrasound images of live ones in the womb.

The technique was pioneered by Stuart Campbell, head of obstetrics and gynaecology at St George±s Hospital, London, who is convinced that his 4D images have undermined the validity of the current time limit for abortion.

But Maria Fitzgerald, professor of developmental neurobiology at University College London and scientific director of the WellChild Pain Research Centre says it is wrong to suggest that the fetus might feel pain in the same way as the born child.

But whether or not fetuses feel pain in the same way as infants, another debate is raging over the survival rates of extremely premature infants and the viability of such survivors.

The British Medical Association believes that the 1967 Abortion Act is a humane piece of legislation, and guidelines recently issued by the Nuffield Council on Bioethics suggest that below 22 weeks, ±no baby should be resuscitated.± Its proposals came as a disappointment to anti-abortion campaigners.

Most recently, the anti-choice lobby has been emphasising the risk to the physical or mental health of women who have abortions.

If the upper limit for abortion is reduced this year, it seems it will be in response to public opinion informed not by scientific and medical realities but by sentimental pictures ± and on the back of occasionally misleading polls, writes Gornall.

A Conservative MP is currently promoting a bill to reduce the abortion limit to 20 weeks, and this seems to represent the anti-choice lobby±s best chance of lowering the upper limit in the act±s anniversary year. But there is concern that her position seems to reflect the ethical and medical confusion that threatens to overwhelm clear debate in the year ahead.

Forty years after the law was changed, the pro-choice lobby ask why shouldn±t abortion be treated like any other operation, where the doctor gives one the information to make an informed choice about whether to undergo surgery? They believe we need to move the focus from the fetus to the woman, Gornall concludes.

Contact:
Jonathan Gornall, freelance journalist, London, UK
Email: Jgornall@mac.com

FOR ACCREDITED JOURNALISTS

Embargoed press releases and articles are available from:

Public Affairs Division, BMA House, Tavistock Square London WC1H 9JR

(contact: pressoffice@bma.org.uk)

and from:

the EurekAlert website, run by the American Association for the Advancement of Science(http://www.eurekalert.org)