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Press releases Saturday 12 May 2007

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(1) Cognitive therapy can reduce post-traumatic stress in survivors of terrorist attacks

(2) Should women take cholesterol lowering drugs to prevent heart disease?

(3) Is the UK prepared for pandemic flu?

(4) Doctor warns of radiation exposure "epidemic"

(1) Cognitive therapy can reduce post-traumatic stress in survivors of terrorist attacks
(Post-traumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: randomised controlled trial)
BMJ Online First

Cognitive therapy is an effective treatment for post-traumatic stress disorder related to acts of terrorism and other civil conflict, finds a study published on bmj.com today.

Recent NICE guidelines recommend cognitive behaviour therapy as a treatment of choice (alone or in conjunction with drugs) for post-traumatic stress disorder. However, this recommendation is largely based on trials focusing on non-terrorism related traumatic events, such as road traffic crashes and rape. Little is known about how to best treat those traumatised by terrorist incidents.

So researchers at the Northern Ireland Centre for Trauma and Transformation undertook the first controlled trial aimed at assessing the effectiveness of cognitive therapy for people affected by terrorism and other civil conflict.

The trial involved 58 people with chronic post-traumatic stress disorder, mostly resulting from multiple traumas linked to terrorism and other civil conflict.

Patients were split into two groups, the first received immediate cognitive therapy while the other group were placed on a 12 week waiting list, followed by treatment.

Levels of post-traumatic stress disorder and depression were measured at the start of the trial and at the end of the treatment period. Work and social functioning was also assessed in both groups. Further assessments were carried out after one, four and 12 months.

At 12 weeks, patients in the immediate therapy group showed significant and substantial reductions in the symptoms of post-traumatic stress disorder and depression. In contrast, patients in the waiting list group showed no change.

The therapy group also had improved levels of work and social functioning. Thirty-eight per cent of those in the waiting list group deteriorated during the 12 week period compared to just seven per cent the therapy group. The treatment gains made were well maintained at the follow-up assessments.

The improvements made by those in the therapy group varied between individuals. The authors suggest this may be in part due to the complexity of the problems and in part due to the methods of the therapist. It is recommended that therapists involved in this sort of therapy are given sufficient training and ongoing supervision.

They conclude that cognitive therapy is effective in the treatment of post-traumatic stress disorder related to terrorism and other civil conflict.

Contacts:
Michael Duffy, Director, Cognitive Therapy Course, University of Ulster at Magee, Londonderry, Northern Ireland
Email: m.duffy1@ulster.ac.uk

David Clark, Professor of Psychology, Institute of Psychiatry, Kings College London, UK
Email: d.clark@iop.kcl.ac.uk

(2) Should women take cholesterol lowering drugs to prevent heart disease?
(Head to Head: Should women be offered cholesterol lowering drugs to prevent cardiovascular disease?)
http://www.bmj.com/cgi/content/full/334/7601/982

Women in western countries are more likely to die from heart disease than from cancer. In this week±s BMJ, two experts debate whether women should be offered cholesterol lowering drugs as a preventive treatment.

For women who are at moderately high risk of heart disease, use of drugs should not be ruled out, argues Professor Scott Grundy from the University of Texas.

There is general agreement that both men and women with established cardiovascular disease are at high risk and should get intensive cholesterol lowering therapy.

The essential question here is whether women as well as men should be considered for drug therapy when they do not have established cardiovascular disease, but who are deemed to be at moderately high risk, according to the guidelines.

Trials involving both men and women at moderately high risk have shown overall risk reduction from cholesterol lowering therapy, but not enough women were included to provide a definitive result, he explains.

Until a large-scale clinical trial is carried out to test the efficacy of cholesterol lowering in women at moderately high risk, drug therapy should be avoided in most lower risk women, he says. But in those who have multiple cardiovascular risk factors and who are projected to be at moderately high risk, use of drugs should not be ruled out.

But GP Malcolm Kendrick disagrees. Not only do statins fail to provide any overall health benefit in women, they represent a massive financial drain on health services, he says.

He believes the evidence of benefit is not strong enough. He points out that, to date, none of the large prevention trials has shown a reduction in overall mortality in women, and one suggested that overall mortality may actually be increased. This, he says, raises the important question whether women should be prescribed statins at all.

Statins also represent the single greatest drug expenditure in the National Health Service, he says. In 2006, the cost in England was ±625m and is expected to reach ±1bn in 2007. This money could be diverted to treatments of proved value.

Some studies also suggest that statins carry a substantial burden of side effects, he adds.

He concludes that spending hundreds of millions on a treatment that has no proved benefit and may cause serious harm goes against the rationale of evidence based prescribing.

Contact:
Scott Grundy, Center for Human Nutrition, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
Email: scott.grundy@utsouthwestern.edu

Malcolm Kendrick, General Practitioner, Macclesfield, Cheshire, UK
Email: malcolmken@doctors.org.uk

(3) Is the UK prepared for pandemic flu?
(Editorial: UK preparedness for pandemic influenza)
http://www.bmj.com/cgi/content/full/334/7601/965

Giving local authorities responsibility for implementing pandemic flu plans may not be the best policy, says a senior public health doctor in this week±s BMJ.

He warns that, in the event of a pandemic, much of the planning could be redundant.

In the worse case scenario, a pandemic of influenza in the United Kingdom would cause 750,000 excess deaths and cost around ±170bn in the longer term, writes Dr Richard Coker of the London School of Hygiene and Tropical Medicine.

In March, a new draft plan for pandemic flu was published, setting out the government±s strategic approach to limit the domestic spread of a pandemic and minimise harms to health, the economy, and society.

It deals with several previously neglected areas, such as transport and international policy, education and social mixing, drug interventions, and communications. It also makes clear the primary responsibility for planning and responding to any major emergency rests with local organisations.

But the author questions whether timely and effective implementation in a time of crisis can be achieved under a devolved system and whether the documents offer enough guidance for local planners on issues such as how to allocate scarce resources.

Severe acute respiratory syndrome (SARS) taught us that "there should be clarity established beforehand, as to what decisions are taken at what level and by whom during an epidemic," he writes. Government guidance also states that "all organisations and individuals that might have a role to play in emergency response and recovery should be properly prepared and be clear about their roles and responsibilities."

Yet concern persists at local level that current plans for pandemic flu in the UK do not take account of what we have learnt from the experience with SARs.

Ultimately, it will be a remarkable achievement if devolved-operational authority is successful, he says. History suggests that the political imperative in a national (indeed global) crisis will be to centralise strategic and operational authority. If this happens then much of the planning could be redundant and an alternative approach might be needed.

Contact:
Richard Coker, Reader in Public Health, Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK
Email: richard.coker@lshtm.ac.uk

(4) Doctor warns of radiation exposure "epidemic"
(Personal View: CT scanning: too much of a good thing)
http://www.bmj.com/cgi/content/full/334/7601/1006

It is time the medical profession became aware of the epidemic of exposure to diagnostic radiation in patients and did something about it, argues radiologist, Steven Birnbaum, in this week±s BMJ.

And he warns that many doctors, including radiologists, have limited knowledge of the doses and of the potential consequences of the massive increase in diagnostic medical radiation exposure.

He describes his horror as his daughter underwent multiple CT scans after being hit by a car.

"I had seen few examples of radiation overexposure in the community hospital setting in which I work and was beginning to act on this," he says. "Now I saw it happen to my own daughter. I was horrified. I asked the surgical chief resident if any thought had been given to radiation exposure in patients when doctors ordered CT studies."

A spiral scan of the abdomen or pelvis exposes a patient to about 10 mSv of radiation, he explains. The risk of one or two studies is negligible but, in young patients, five or more of these studies may lead to over exposure. However, CT is life saving technology, he says, and carefully balancing the risks and benefits is increasingly important as these studies become easier and faster to do.

In the United States, an estimated 60 million CT studies were done in 2006, yet many doctors have limited knowledge in this area, he adds.

He now gives talks on radiation safety issues to educate clinicians and radiologists, and has been appointed to a panel on radiation dose in medicine of the American College of Radiology. The New Hampshire Radiologic Society has also embraced plans for identifying and monitoring patients who may have been overexposed to radiation from CT scans.

"I have become a zealot in trying to stem this tide," he concludes.

Contact:
Steven Birnbaum, Radiologist, New Hampshire, USA
Email: birn4952@aol.com

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