Press releases Monday 22 June to Friday 26 June 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) Monitoring bone density in older women is unnecessary and potentially misleading
(2) Longer life linked to specific foods in Mediterranean diet
(3) Antibiotic prescribing should be standardised across Europe to help tackle resistance
(4) Screening prevents aneurysm deaths, but questions remain over cost effectiveness
(1) Monitoring bone density in older women is unnecessary and potentially misleading
(Research: Value of routine monitoring of bone mineral density after starting bisphosphonate treatment: secondary analysis of trial data)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2266
(Editorial: Monitoring bone mineral density during antiresorptive treatment for osteoporosis)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1276
Monitoring bone mineral density in postmenopausal women taking osteoporosis drugs (bisphosphonates) is unnecessary and potentially misleading, concludes a study published on bmj.com today.
Osteoporosis is a major public health problem, particularly in older women because bone density falls after the menopause as oestrogen levels dwindle. Low bone mineral density is an important risk factor for fractures.
Some guidelines recommend regular monitoring of bone mineral density in postmenopausal women, but it is costly and some experts question whether it is able to show how a patient is responding to treatment.
So researchers based in Australia and the USA assessed the need for monitoring by estimating how much the effects of the drug alendronate (a widely used bisphosphonate) differ between individuals.
They analysed data from the Fracture Intervention Trial (FIT), a large randomised trial that compared the effects of alendronate with placebo in over 6,000 postmenopausal women with low bone mineral density. Bone density of the hip and spine was measured at the start of the study and then again one, two and three years later.
After three years of therapy, almost all (97.5%) women treated with alendronate showed at least a modest increase in hip bone mineral density. Moreover, this treatment effect did not vary substantially between individuals. This, say the authors, makes monitoring individuals' response to treatment unnecessary.
Another reason often given for monitoring is to improve adherence to treatment. However, most problems occur within three months of starting treatment - much earlier than the first measurement at one year, explain the authors. Evidence also shows that discussing problems with a healthcare professional a few months after starting treatment improves adherence.
Monitoring bone mineral density in postmenopausal women in the first three years after starting treatment with a bisphosphonate is unnecessary and, because of the potential to mislead, is best avoided, they conclude.
These findings strengthen the case against routine monitoring of bone mineral density during the first few years of treatment, writes Juliet Compston, Professor of Bone Medicine at the University of Cambridge, in an accompanying editorial. The clear implication for clinical practice is that patients may be given inappropriate advice if changes in bone mineral density are used to monitor treatment.
She concludes: "Routine monitoring of bone mineral density during the first few years of antiresorptive treatment cannot be justified because it may mislead patients, lead to inappropriate management decisions, and waste scarce healthcare resources."
Contacts:
Research: Professor Les Irwig, Screening and Test Evaluation Program, School of Public Health, The University of Sydney, NSW, Australia
Email: lesi@health.usyd.edu.au
Editorial: Juliet Compston, Professor of Bone Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
Email: jec1001@cam.ac.uk
(2) Longer life linked to specific foods in Mediterranean diet
(Research: Anatomy of the health effects of the Mediterranean diet, The Greek EPIC prospective cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2175
(Editorial: Genetic discrimination in Huntington's disease)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1281
Some food groups in the Mediterranean diet are more important than others in promoting health and longer life according to new research published on bmj.com today.
Eating more vegetables, fruits, nuts, pulses and olive oil, and drinking moderate amounts of alcohol, while not consuming a lot of meat or excessive amounts of alcohol is linked to people living longer.
However, the study also claims, that following a Mediterranean diet high in fish, seafood and cereals and low in dairy products were not indicators of longevity.
While several studies have concluded that the Mediterranean diet improves chances of living longer, this is the first to investigate the importance of individual components of the diet.
Professor Dimitrios Trichopoulos at the Harvard School of Public Health explains that they have surveyed over 23,000 men and women who were participants in the Greek segment of the European Prospective Investigation into Cancer and Nutrition (EPIC).
Participants were given dietary and lifestyle questionnaires when they enrolled onto the study and they were subsequently followed up for around 8.5 years with interviews. Their diets were rated from 0 to 10 based on the level of conformity to a traditional Mediterranean diet.
As part of the interview process, participants were also asked about their smoking status, levels of physical activity and whether they had ever been diagnosed with cancer, diabetes and heart disease.
The authors maintain that when high intake of vegetables, low intake of meat or moderate alcohol intake were excluded from the rating system, the benefits of following a Mediterranean diet were substantially reduced. They also note that there are clear benefits in combining several of the key components, for example high consumption of vegetables and olive oil.
Professor Trichopoulou, lead author of the study, concludes that the main reasons why the Mediterranean diet can lead to living longer are moderate consumption of ethanol (mostly in the form of wine during meals, as traditionally done in the Mediterranean countries), low consumption of meat and meat products, and high consumption of vegetables, fruits and nuts, olive oil and legumes.
Contacts:
Professor Dimitrios Trichopoulos, Harvard School of Public Health, Boston, USA
Email: dtrichop@hsph.harvard.edu
Or
Professor Antonia Trichopoulou, University of Athens Medical School, Athens, Greece
Email: http://www.bmj.com/cgi/doi/10.1136/bmj.b2337
(3) Antibiotic prescribing should be standardised across Europe to help tackle resistance
(Research: Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2242
Antibiotic prescribing for respiratory illnesses should be standardised across Europe to help reduce inappropriate prescribing and resistance, say experts in a study published on bmj.com today.
Antibiotic resistance is a major health care problem worldwide. Inappropriate antibiotic prescribing, particularly for respiratory illnesses, has been blamed for driving the problem. There is also good evidence that most antibiotic prescriptions do not help otherwise healthy patients with common respiratory tract infections get better any quicker.
So researchers of the EU funded Network of Excellence GRACE (www.grace-lrti.org) set out to describe variation in antibiotic prescribing for acute cough across Europe, and its impact on recovery.
The study involved 3,402 adults with a new or worsening cough or a possible lower respiratory tract infection. Patients were recruited from 14 primary care research networks in 13 European countries (Wales, England, The Netherlands, Spain, Germany, Hungary, Belgium, Poland, Italy, Sweden, Norway, Finland and Slovakia).
Medical history, existing conditions, symptoms and their management, including antibiotic prescription, and temperature were recorded for each patient. Clinicians then rated the severity of their symptoms using a recognised scoring scale.
Patients also recorded and rated the severity of their symptoms for 28 days using symptom diaries.
Overall, antibiotics were prescribed for 53% of patients, but prescribing ranged from 21% to nearly 90% across the networks. For example, patients in Slovakia, Italy, Hungary, Poland and Wales were at least twice as likely to be prescribed antibiotics than the overall average, while patients in Norway, Belgium and Sweden were at least four times less likely to be prescribed antibiotics than the overall average.
Major differences in the decision whether or not to prescribe an antibiotic remained, even after the researchers adjusted for symptoms, duration of illness, smoking, age, temperature, and existing conditions (co-morbidity).
Furthermore, this variation in antibiotic prescribing was not associated with clinically important differences in patient recovery.
There were also marked differences between networks in the choice of antibiotic. Amoxicillin was overall the most common antibiotic prescribed but this ranged from 3% of prescriptions in Norway to 83% in England. These differences may be due to different guidelines and habits in different countries, say the authors.
This is the largest study of its kind, and the results suggest that management of acute cough is an issue that is appropriate for standardised international care pathways promoting conservative antibiotic prescribing, conclude the authors.
Professor Chris Butler, of Cardiff University, who led the study, said: "This international collaborative research showed that the big differences in antibiotic prescribing between countries are not justified on clinical grounds. It therefore identifies a major opportunity for greater standardisation of care across Europe."
Professor Herman Goossens of the University of Antwerp who coordinates the GRACE Network of Excellence added, "This threat of antibiotic resistance is likely to be more acute as GPs face increasing demands to prescribe antibiotics for acute cough amidst the current global H1N1 flu pandemic. This new evidence should prove instrumental in containing antibiotic prescribing."
Contact:
Professor Christopher Butler, Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, Wales
Email: ButlerCC@cardiff.ac.uk
(4) Screening prevents aneurysm deaths, but questions remain over cost effectiveness
(Research: Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2060
(Research: Analysis of cost effectiveness of screening Danish men aged 65 for abdominal aortic aneurysm)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2210
The national aortic screening programme in the UK should, in due course, prevent about half of all aneurysm deaths in men over 65 and will be extremely cost effective for the NHS, conclude researchers in a study published on bmj.com today.
However a second study, also published today, concludes that screening is not cost effective and calls for additional research into the long term outcomes and costs of screening.
Every year in England and Wales about 6,000 men die from a ruptured aortic aneurysm (caused by ballooning of the artery wall), but abdominal aortic aneurysms can be detected with a one-off ultrasound scan. A national screening programme for men aged 65 began in the UK in spring 2009.
In the first study, Simon Thompson from the Medical Research Council and colleagues report 10 year mortality data from The UK Multicentre Aneurysm Screening Study (MASS) involving 67,770 aged 65-74 randomised to be invited to ultrasound screening or not. They also calculated the long term cost effectiveness of the programme in the UK.
Results showed that over 10 years there were about half as many abdominal aortic aneurysm deaths (155) in the invited group compared to the control group (296). The benefit of being invited to screening shown in the early years of follow-up was maintained in later years - reductions in abdominal aortic aneurysm mortality were estimated as 42% at four years, 47% at seven years, and 48% at 10 years.
Further analysis showed that the cost effectiveness of screening became greater over time, with cost per life year gained improving from an estimated £41,000 after four years, £14,000 after seven years, and £7,600 after 10 years. The estimate after 10 years is well below the guideline figure of around £25,000 per life year gained for the acceptance of medical technologies and interventions in the NHS, say the authors.
They conclude that the UK national screening programme for abdominal aortic aneurysm should, in the long term, halve the mortality rate related to abdominal aortic aneurysm in men aged 65 or more, and that it will be a cost effective programme for the NHS.
But in a second study, researchers argue that aneurysm screening is not cost effective. Lars Ehlers from Aarhus University and colleagues used a recognised mathematical model, alongside data from published studies and the Danish Vascular Registry, to calculate expected costs and health outcomes for a hypothetical population of Danish men aged 65 from screening to death.
The estimated cost of screening per quality adjusted life year (QALY - a combined measure of quantity and quality of life) was £43,485. At a willingness to pay threshold of £30,000 the probability of screening being cost effective was less than 30%, say the authors.
"Our estimate is not comparable with previous modelling studies, which in general claim that screening for abdominal aortic aneurysm is cost effective," they write. "We believe our study provides a more realistic estimate of cost effectiveness."
From the evidence in these two papers, it is hard to identify the reasons for the differing findings without further detailed exploration of the models used, says Professor Martin Buxton in an accompanying editorial.
However, the accumulated evidence suggests that a national screening programme in the UK is appropriate and likely to be cost effective, but its costs and outcomes need to be carefully monitored and the data need to be regularly re-analysed to ensure that both the effectiveness and cost effectiveness remain acceptable in the context of changing practice, he concludes.
Contacts:
Research: Professor Simon Thompson, Director, MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
Email: simon.thompson@mrc-bsu.cam.ac.uk
Research: Lars Ehlers, Associate Professor in Health Economics, Institute of Public Health, Aarhus University, Aarhus, Denmark
Email: le@folkesundhed.au.dk
Editorial: Martin Buxton, Professor of Health Economics, Health Economics Research Group, Brunel University, Uxbridge, UK
Email: martin.buxton@brunel.ac.uk
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