Press releases Monday 2 March to Friday 6 March 2009

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 website (http://www.bmj.com).

(1) UK black women have double the risk of pregnancy complications
(2) Modern medicine turning elderly fit people into patients
(3) Expert warns of "staggering" consequences of new data-sharing proposals
(4) Increased exercise in middle age prolongs life
(5) Concerns over safety of drugs to delay early labour
(6) New diabetes target will waste resources and may be harmful

(1) UK black women have double the risk of pregnancy complications
(Research: Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities)
http://www.bmj.com/cgi/doi/10.1136/bmj.b542
(Editorial: Inequalities in maternal health)
http://www.bmj.com/cgi/doi/10.1136/bmj.b357

In the UK, black Caribbean and black African women have twice as much risk of experiencing severe pregnancy complications than white women, according to research published today on BMJ.com.

The study, the first of its kind undertaken in the UK, also found that Pakistani women have a significantly higher risk of severe pregnancy-related health problems than white women. Today's research reflects previous studies carried out in the US, Canada and the Netherlands.

Using the UK Obstetric Surveillance System (UKOSS), Dr Marian Knight from the University of Oxford and her team, investigated 686 cases of severe pregnancy-related complications out of a total of 775,186 maternities between February 2005 and February 2006. Complications included hysterectomy after childbirth, fits with high blood pressure (eclampsia) or blood clots in the lungs (pulmonary embolism).

Dr Knight's research concludes that non-white women are one and half times more at risk of experiencing severe pregnancy-related complications than white women. This risk doubles for black Caribbean and black African women.

There is an overall estimated risk of severe complications of 89 cases per 100,000 maternities. The authors conclude that for white women this risk is around 80 cases per 100,000 maternities, 126 cases for non-white women as a whole, 188 cases for black African woman and 196 for black Caribbean women.

Knight argues that the increased risk for non-white women may be because of pre-existing medical factors or because of care during pregnancy, labour and birth and is unlikely to be due to the socio-economic situation of the woman or whether she smoked or was obese. She says the research "highlights to clinicians and policy-makers the importance of tailored maternity services and improved access to care for ethnic minority women."

The authors believe that one possible reason for the higher risk of complications is access to care. A number of studies have previously indicated that this was a contributing factor to ethnic differences in health. A recent national survey of women's experience of maternity care in the UK reported that women from black and minority ethnic groups were more likely to recognise their pregnancy later, access care later and as a result book antenatal care later than white women. These women also said they did not feel they were treated with respect and talked to in a way they understood by staff during pregnancy, labour and birth and postnatal care.

In an accompanying editorial, Wendy Pollock from the University of Melbourne believes that routine collection of more detailed data is key to improving knowledge. She says that one unresolved question is whether ethnicity itself is directly relevant to poor maternal outcomes, or whether it is a surrogate marker for other factors like low socioeconomic status, low level of education and poor nutrition. Ethnicity is a "blunt marker when each ethnic grouping is so diverse," she argues.

Pollock also makes the point that more resources need to be directed to raising awareness about the dangers of delaying childbearing beyond the age of 35 years.

She says: "The additional burden placed on the health of these women needs further investigation because women over 40 are up to eight times more likely to have a pregnancy related death than those in their early 20s. For this group of women, improving access to maternity services is not the solution. However, defining and communicating the risk of delaying childbirth for society may speed policy movements that could support earlier childbearing, such as paid maternity leave and flexible arrangements for return to work."

Contacts:
Research: Marian Knight, Senior Clinical Research Fellow, National Perinatal Epidemiology Unit, University of Oxford, UK
Email: marian.knight@npeu.ox.ac.uk

Editorial: Dr Wendy Pollock, Honorary Fellow & Sessional Lecturer, School of Nursing & Social Work, University of Melbourne, Australia
Email: pollockw@unimelb.edu.au


(2) Modern medicine turning elderly fit people into patients
(Personal view: Let's not turn elderly people into patients)
http://www.bmj.com/cgi/doi/10.1136/bmj.b873

Modern medicine is turning healthy elderly people into patients, warns a senior doctor in an article published on bmj.com today.

Michael Oliver, Professor Emeritus of Cardiology at the University of Edinburgh, argues that many people over 75 are "started on pills" for high blood pressure or diabetes or high cholesterol with little consideration of the actual benefits to the individual.

He believes that preventive action may be irrelevant and even harmful in the elderly.

For example, about 75 elderly people with mild hypertension may have to be treated in order to prevent one from having a stroke. Therefore, the other 74 will be committed to treatment for life, he explains.

Oliver puts this trend down to many causes, including over enthusiastic and uncritical interpretation of guidelines, the demands of government health economics, and the endless pressures from pharmaceutical companies.

Instead of making several measurements or investigating possible causes, the conclusion is to tell the person that he or she has raised blood pressure and that it must be treated, he writes. Yet the actual evidence for benefit of treating any risk factor in those over 75 needs much more careful consideration when applied to an individual.

He suggests that guidelines should not be regarded as commandments to investigate and treat, and that the balance between the risks of treatment and the untreated risk are explained fully to the individual.

Bureaucratic demands for documentation can lead to over-diagnosis, over-treatment and unnecessary anxiety, he concludes.

Contact:
Michael Oliver, Professor Emeritus of Cardiology, University of Edinburgh, Scotland, UK
Email: michaeloliver@mac.com

(3) Expert warns of "staggering" consequences of new data-sharing proposals
(Editorial: Amendments to the Coroners and Justice Bill)
http://www.bmj.com/cgi/doi/10.1136/bmj.b895

The health consequences of the government's new data-sharing proposals could be "staggering" warns an expert in an editorial published on bmj.com today.

Dr Vivienne Nathanson, Director of Professional Activities at the British Medical Association (BMA) expresses concerns about Clause 152 of the Coroners and Justice Bill which, in its current form, appears to grant the government unprecedented powers to access people's confidential medical records, and share them with third parties.

Simply it means that laws that currently limit health data sharing could be set aside, including the protections of the Data Protection Act, says Dr Nathanson. Even the Venereal Diseases Regulations and the provisions of the Human Fertilisation and Embryology Act would not be immune to the potential for removal.

Health data is not privileged in the manner of legal information, but for many years it has been recognised as special, and as sensitive, she writes. Research shows that patients expect the health professional with whom they share information will hold it in confidence, and share it sparingly and on a need to know basis, usually those also involved in offering them care.

Yet Dr Nathanson believes that data in the current draft of the Bill suggests blindness to the special sensitivity of health data.

If the current draft legislation goes through with minimal changes, the effect could be to to undermine doctor and patient confidence in the future control of data that neither is willing to record the most sensitive information, she warns.

She concludes: "This week many of the leading medical organisations have written a joint letter to the Justice Secretary seeking the complete removal of health data from the provisions of the Bill. We are seeking a meeting, to provide him with the reasons behind our concerns and to emphasise why we can see no problems in the health sector to which this legislation is an acceptable solution."

Contact:
Dr Vivienne Nathanson, Director of Professional Activities, British Medical Association, London, UK
Email: pressoffice@bma.org.uk

(4) Increased exercise in middle age prolongs life
(Research: Total mortality after changes in leisure time physical activity in 50 year old men: 35 year follow-up of population based cohort)
http://www.bmj.com/cgi/doi/10.1136/bmj.b688

Increased physical activity in middle age prolongs life, though it may take five to 10 years before an effect is seen, concludes a study published on bmj.com today.

Physical activity is beneficial for health, but about half of all middle aged men in the West do not take part in regular physical activity. It is not yet known whether an increase in exercise later in life reduces death rates.

So researchers in Sweden examined how changes in physical activity levels after middle age influence mortality and compared them with the effect of stopping smoking.

The study involved 2,205 men aged 50 in 1970-3 and living in Uppsala, Sweden. Participants completed a survey on leisure time physical activity and were categorised into low, medium or high activity groups. Participants were re-examined at ages 60, 70, 77, and 82 years and changes in physical activity were recorded. Other information, such as body mass index, blood pressure, cholesterol levels, smoking status and alcohol use, was also collated at each survey.

At age 50, almost half of the men reported a high level of physical activity, corresponding to at least three hours of recreational sports or heavy gardening a week. Just over one third (36%) reported medium activity, corresponding to walks and cycling, and 15% were sedentary.

Overall mortality rates were highest among sedentary men and lowest among the most active men.

However, during the first five years of follow-up, the mortality rate was higher in men who had increased their level of physical activity than in men with unchanged high physical activity. But the number of such deaths was relatively small, so the researchers have not emphasised this finding.

But after 10 years, the mortality rate in these men was reduced to the same level as men with unchanged high physical activity. This reduction in mortality was similar to the effect of stopping smoking.

After adjusting for other risk factors, the researchers estimate that men who reported high levels of physical activity from age 50 were expected to live 2.3 years longer than sedentary men and 1.1 years longer than men who reported medium levels of physical activity.

Increased physical activity prolongs life among middle aged and older men, though there might be a period of 5-10 years before an effect is seen on total mortality, write the authors. This effect is the same as smoking cessation. They suggest further research should investigate whether and to what extent increased physical activity affects mortality in the period soon after the change, while the effects in other age groups and in women also need to be studied.

Contacts:
Liisa Byberg, Researcher, Department of Surgical Sciences, Section of Orthopaedics, and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
Email: liisa.byberg@surgsci.uu.se
Or
Karl Michaëlsson, Senior Lecturer, Department of Surgical Sciences, Section of Orthopaedics, and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
Tel: +46 (0)18 611 9545

(5) Concerns over safety of drugs to delay early labour
(Research: Adverse drug reactions to tocolytic treatment for preterm labour: prospective cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b744
(Editorial: Tocolytics and preterm labour)
http://www.bmj.com/cgi/doi/10.1136/bmj.b195

The use of certain drugs to delay preterm labour is associated with a high rate of serious adverse reactions, finds a study published on bmj.com today.

Preterm labour is the main cause of perinatal illness and death (the period just before, during or shortly after birth) in the developed world.

Tocolytic drugs are used to delay delivery for up to 48 hours. This allows time for doctors to give steroids to speed up the baby's lung development and to enable the mother to be transferred to a centre with a neonatal intensive care unit.

Drugs most often used include beta agonists and nifedipine (to relax smooth muscles including the uterus) and atosiban and indometacin (to inhibit hormones involved in labour). But it is still unclear whether tocolysis is safe for both mother and baby, so the use of these drugs to stop labour remains controversial.

So researchers assessed the incidence of serious maternal complications in 1920 women treated with tocolytic drugs for preterm labour at 28 hospitals in the Netherlands and Belgium. The most commonly used drug was atosiban (42%), followed by nifedipine (34%), beta agonists (14%), and indometacin (8%).

Over an 18 month period, all adverse reactions were recorded and classified as either serious or mild and according to how the drugs were given (singly, combined, or sequentially).

The overall incidence of adverse effects was low (0.7%) but combined treatment or a single treatment with a beta agonist led to a higher incidence of serious adverse drug reactions. No serious reactions were reported for atosiban or indometacin.

Atosiban had the best safety profile but is considerably more expensive than nifedipine.

Based on their findings, the authors suggest that combined treatment and treatment with beta agonists should be discouraged. They also call for further trials to test the effectiveness and safety of nifedipine and atosiban.

In an accompanying editorial, researchers say that this study serves as a timely reminder that the decision to use tocolysis should not be taken lightly. "After 30 years of research we still do not know whether tocolysis benefits the fetus, so the choice of which drug to use remains a secondary question. The real dilemma is whether or not we should treat at all," they write.

The old assumption that "keeping the baby inside longer must be a good thing" can no longer go unchallenged, they conclude.

Contacts:
Research: Roel de Heus, Registrar of Obstetrics and Gynaecology, Department of Perinatology and Gynaecology, University Medical Centre Utrecht, Netherlands
Email: R.deHeus-2@umcutrecht.nl

Editorial: Dr Andrew Carlin, Director of Maternal Fetal Medicine, John Hunter Hospital, Newcastle, Australia
Email: Andrew.Carlin@hnehealth.nsw.gov.au
Or
Jane Norman, Chair of Maternal and Fetal Health, Reproductive and Developmental Sciences, University of Edinburgh, Scotland, UK
Tel: via PA, Karen Witherspoon +44 (0)131 242 2694 or via Tara Womersley, Edinburgh University Press office +44 (0)131 650 9836

(6) New diabetes target will waste resources and may be harmful
(Editorial: Tight control of blood glucose in long standing type 2 diabetes)
http://www.bmj.com/cgi/doi/10.1136/bmj.b800

A new target for tighter control of blood glucose in older adults with type 2 diabetes is not supported by evidence and may even be harmful, warn two senior doctors in an editorial published on bmj.com today.

From April 2009 the quality and outcomes framework (QOF) - the system that rewards UK general practices for delivering quality care -will require general practitioners to lower blood glucose levels in half of their patients with type 2 diabetes to below 7% to earn the same amount that they are currently paid for achieving a target of 7.5%.

The average practice that achieves this level of performance will be paid around £3000 (Euro 3375; $4250), write Richard Lehman, a general practitioner in Oxfordshire, and Harlan Krumholz, Professor of Medicine at Yale University School of Medicine.

As a result, tens of thousands of patients will need to be given additional oral treatment or will be treated with insulin, they warn.

Treatment with insulin brings with it an increased risk of hypoglycaemia (when blood glucose levels drop below normal and brain function is affected) and the additional costs of daily blood glucose monitoring and the insulin itself, they explain. It may also result in people who drive for a living losing their job if the new target leads them to be treated with insulin.

This new target was agreed on by NHS employers and the general practitioners' committee of the British Medical Association (BMA) in October 2008, ironically just when evidence was gathering that tight glucose control in established type 2 diabetes has little benefit and can even be harmful.

For example, three important trials published during the past year show that intensive blood glucose control in patients with long standing type 2 diabetes does not provide substantial benefit and may increase the risk of adverse outcomes.

The idea that tight glycaemic control for everyone would improve outcomes was a hypothesis that needed to be tested 30 years ago, say the authors, but in the wake of the three recent studies, it is certainly "time to challenge conventional wisdom."

"We need better evidence to evaluate the balance of risk and benefit for individual patients, and we need to move away from the simplistic idea that the value of a particular drug or strategy can be predicted by its glycaemic lowering effects," they write.

The QOF in the UK has been a successful driver of evidence based improvement in the care of diabetes, particularly tight control of blood pressure and the prescription of cholesterol lowering drugs (statins). But by encouraging tighter glycaemic control in all patients with type 2 diabetes, regardless of disease duration and the drugs used to achieve control, the new QOF target encourages an outdated strategy and one that may not provide a net benefit to patients, they argue.

They believe the change of target from 7.5% to 7% should be withdrawn before it wastes resources and possibly harms patients.

Contacts:
Richard Lehman, General Practitioner, Hightown Surgery, Banbury, Oxfordshire, UK
Email: richard.lehman@nhs.net

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(contact: pressoffice@bma.org.uk)

and from:

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