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Press releases Saturday 23 June 2007

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(1) Questions over drugs to prevent heart complications during surgery

(2) Rickets prevention message is not getting through, warn doctors

(3) Doctors warn of deficiencies in antenatal HIV testing

(4) Should doctors go to patients± funerals?

(1) Questions over drugs to prevent heart complications during surgery
(Editorial: ± blockers and statins in non-cardiac surgery)
http://www.bmj.com/cgi/content/short/334/7607/1283

The use of drugs to prevent heart complications during surgery is called into question in this week's BMJ.

Globally, about 100 million adults have non-cardiac surgery (ie. on any part of the body other than the heart) each year. Around 1% are at risk of cardiac complications, such as heart attacks and strokes, and about one in four will die each year.

Two types of drugs - β blockers and statins - are regularly given to patients to prevent such complications. They are given shortly before, during, or after surgery (the perioperative stage) to help lower blood pressure

But doctors in Australia now warn that the benefit of using these drugs at this time remains unclear.

They cite several large international studies that found no benefit from perioperative β blockers.

Two studies from Denmark and the UK reported no reduction in death or several other serious complications, such as heart attack, heart failure, and stroke 30 days after surgery in patients receiving ± blockers. Another study found no benefit six months after surgery, and a trial currently under way has so far not reported any beneficial effects.

However, all studies did report significantly higher rates of important side effects with β blockers, including slow heart beat (bradycardia) and very low blood pressure (hypotension). This has led to calls to examine the widespread use of perioperative β blocking drugs.

Like β blockers, statins have also been advocated to reduce the risk of perioperative cardiac complications, write the authors. Non-randomised trials suggest that statins confer benefit, but the evidence remains weak, and to prove a strong overall survival benefit would require a "gold-standard" randomised controlled trial of more than 12,000 patients.

The benefits of statins in reducing cardiac complications in the general population and high risk patients are well known, but robust evidence to confirm that these drugs are valuable in routine perioperative use has not been published, they say.

So, on the basis of the evidence currently available, what should practising clinicians do?

They suggest that patients already receiving β blockers or statins before surgery should continue with treatment. But no patient should start taking statins or ± blockers in the perioperative period specifically to reduce the likelihood of perioperative cardiac events.

Contacts:
Contact: Stephen Bolsin, Associate Professor and Specialist, Department of Clinical & Biomedical Sciences, University of Melbourne, Australia
Email: steveb@barwonhealth.org.au

(2) Rickets prevention message is not getting through, warn doctors
(Letter: Prevention message is not getting through
http://www.bmj.com/cgi/content/short/334/7607/1288-a

The message about preventing vitamin D deficient rickets in children is not getting through, warn senior doctors in this week's BMJ.

For over ten years, the UK government has recommended universal use of vitamin supplements to all breastfeeding infants to prevent rickets, write Scott Williamson and Stephen Greene from Ninewells Hospital in Dundee.

Yet, in the past four months, they have diagnosed vitamin D deficient rickets in five infants in Tayside.

None of these children or mothers had received vitamin D supplementation and their families were unaware of the need of this.

The recommendation is particularly important for those of Asian, African, Afro-Caribbean, or Middle Eastern origin with reduced exposure to sunlight, say the authors, as increased skin pigmentation makes it more difficult to synthesise vitamin D.

Vitamin D deficiency can cause rickets, poor tooth formation, convulsions, and stunted growth. It has also been linked to an increased risk of health problems in later life.

The authors argue that the NHS Direct website is ambiguous about the need for vitamin supplements.

The Scientific Advisory Committee on Nutrition has just published a position statement on vitamin D, with particular reference to preventing rickets, which highlights the need for a public health campaign and emphasises the need to supplement infants in high risk groups.

"We must disseminate the message to all health visitors and general practitioners across the UK," they conclude.

Contact:
Stephen Greene, Consultant Paediatrician, Ninewells Hospital, Dundee, Scotland Email: s.a.greene@dundee.ac.uk

(3) Doctors warn of deficiencies in antenatal HIV testing
(Letter: HIV and pregnancy: Are we doing enough?)
http://www.bmj.com/cgi/content/short/334/7607/1287-b

The current antenatal HIV screening system fails to take into account the ongoing risk of exposure, warn doctors in this week's BMJ. Last month, the BMJ reported that rates of mother to child transmission of HIV are dramatically reduced by antiretroviral use, caesarean section, and avoidance of breastfeeding. However, none of these interventions can take place without awareness of the mother±s HIV status, argue two senior doctors from Warwickshire Hospital in Coventry.

In the United Kingdom, all antenatal clinics routinely offer HIV testing. Most mothers accept screening, but two recent cases, they say, highlight the deficiencies in the existing system.

In 2006, two infants were diagnosed with HIV within a few weeks of one another. Both mothers had had antenatal screening, and both tested HIV negative.

The authors warn that women who seroconvert during pregnancy (develop antibodies in their blood as a result of infection) are at a greater risk of transmitting HIV to their babies as the mother±s viral load is at its highest at this stage.

Alternatively, they explain, both patients may have been tested during the serological window period (the stage immediately after infection when the virus cannot be detected).

They point out that the information leaflet on HIV testing produced by the Department of Health does not include an explanation about the HIV window period, and retesting is not routinely offered to those at higher risk.

Following these two cases, local antenatal services have altered their HIV testing policies to offer repeat testing of high risk individuals at 32 weeks of pregnancy and midwives are being advised to consider ongoing risks in all women, they say.

Contact tracing as is currently offered to HIV positive women should be offered to high risk HIV negative women as well.

They also suggest that high risk women who initially refuse testing in pregnancy should be offered counselling by trained health advisers, with mechanisms in pace to offer testing again later in their pregnancy.

"We see this as a safety net for those let down by the current antenatal system," they conclude.

Contact:
P S Allan, Consultant, Department of Genitourinary Medicine, Coventry and Warwickshire Hospital, Coventry, UK
Email: sris.allan@coventrypct.nhs.uk

(4) Should doctors go to patients± funerals?
(Personal View: Should doctors go to patients± funerals?)
http://www.bmj.com/cgi/content/short/334/7607/1322

Some years ago, Professor Bruce Arroll started to attend his patients± funerals. In this week±s BMJ, he and a colleague explain why other doctors should consider going to their patients± funerals.

Attending the funeral of a patient allows the doctor to gain a complete picture of a patient±s life and is a positive and affirming experience, they write.

To many, having a doctor attend a loved one±s funeral validates and emphasises the worth of that person.

It also highlights that in most cases our responsibility to the departed person extends to caring for their family in the wake of their death, they say. Being present at a funeral service can pave the way for the family to have an opportunity to talk about their experiences surrounding the death.

They acknowledge that regular funeral attendance will not fit all doctors.

It may also be wise to avoid funerals when the family is unhappy with care, they say, but suggest that asking the family for their permission to attend might facilitate reconciliation.

"Primary care providers usually have long term relationships with patients and their families, and we would argue that it is important to witness the end of the life journey of an individual," they write. "Our experience indicates that there are personal and family benefits to be gained and little to be lost."

Contact:
P S Allan, Consultant, Department of Genitourinary Medicine, Coventry and Warwickshire Hospital, Coventry, UK
Email: sris.allan@coventrypct.nhs.uk

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