Press releases Monday 16 November to Friday 20 November 2009

Please remember to credit the BMJas 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) Pre-eclampsia linked to thyroid problems
(2) School closures and work absence will affect UK economy most during flu pandemic
(3) New score will help identify those most at risk of fractures
(4) Should politics and the NHS go their separate ways?

(1) Pre-eclampsia linked to thyroid problems
(Research: Pre-eclampsia, soluble fms-like tyrosine kinase 1, and the risk of reduced thyroid function: nested case-control and population based study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4336

Women who develop pre-eclampsia during pregnancy are more likely than other women to have reduced thyroid function (hypothyroidism), finds a study published on bmj.com today. It may also put women at a greater risk of thyroid problems later in life.

Pre-eclampsia is a serious condition where abnormally high blood pressure and other disturbances develop in the second half of pregnancy. Hypothyroidism is caused by insufficient production of hormones by the thyroid gland.

Although the exact cause of pre-eclampsia is still unclear, studies suggest that certain proteins may be responsible. Levels of these proteins rise during the last two months of normal pregnancy and increase to very high concentrations in women with pre-eclampsia. Studies also suggest that women with a history of pre-eclampsia have an increased risk of future cardiovascular and kidney (renal) disease.

So a research team based in the United States and Norway compared thyroid function in women who developed pre-eclampsia during pregnancy with those whose blood pressure remained normal. They also tested whether pre-eclampsia in a previous pregnancy was associated with risk of reduced thyroid function in later life.

Their findings are based on thyroid function tests from 140 healthy pregnant women taking part in a US trial who developed pre-eclampsia, 140 matched controls in the same trial who did not develop pre-eclampsia, and 7,121 women in a Norwegian study who were monitored for around 20 years after their first pregnancy.

In the US study, levels of thyroid stimulating hormone measured just before delivery were twofold higher in women who developed pre-eclampsia during pregnancy compared with those who did not.

This was strongly associated with excess levels of a particular protein (tyrosine kinase), which plays a key role in the pathogenesis of pre-eclampsia.

In the Norwegian study, women who developed pre-eclampsia in their first pregnancy were more likely than other women to have high concentrations of thyroid stimulating hormone many years after the pregnancy. The association was particularly strong if pre-eclampsia had occurred in two pregnancies.

The authors conclude that women who develop pre-eclampsia are at a greater risk of hypothyroid function during their pregnancy and women with a history of pre-eclampsia are at greater risk of hypothyroid function many years later.

These findings could have important implications for the subsequent care of women with pre-eclampsia, they add. Not only should they be followed closely for the development of cardiovascular and renal disease, but consideration should also be given to monitoring for the development of reduced thyroid function and clinically important hypothyroidism.

Treatment might also prevent early cardiovascular disease in women with a history of pre-eclampsia, they say.

Further research is needed to understand how exercise therapy results in better outcome, they conclude.

Contact:

Dr Richard Levine, Senior Investigator, Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Division of Epidemiology, Statistics, and Prevention Research, National Institutes of Health, Bethesda, Maryland, USA
Email: levinerj@mail.nih.gov

(2) School closures and work absence will affect UK economy most during flu pandemic
(Research: The economy-wide impact of pandemic influenza on the UK: a computable general equilibrium modelling experiment)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4571
(Editorial: The economic impact of pandemic influenza)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4888

School closures and absence from work are likely to have more impact on the UK economy during a flu pandemic than the disease itself, regardless of its severity, say researchers on bmj.com today.

Having sufficient stocks of effective vaccine will also play a major role in mitigating the cost of a pandemic.

Preparedness planning for a pandemic must try to minimise both the health and economic effects of a pandemic. Fear induced behavioural changes or government sanctioned absences from work or school in response to a flu pandemic could have a substantial economic impact, and these losses may not be balanced by large health benefits.

So, as one part of a large research project on the behavioural aspects of pandemic influenza, a team of researchers from the London School of Economics, London School of Hygiene and Tropical Medicine, and the University of Edinburgh, used a computer model to estimate the potential impact of pandemic influenza on the UK economy.

Using data for the 2004 UK economy, they replicated various disease scenarios, vaccination programmes, school closures, and "prophylactic absenteeism" where healthy people avoid social contact, including going to work.

The results show that pandemic influenza itself, even a high fatality pandemic, would reduce gross domestic product by less than 4.5% (around £70bn).

However, two factors will compound the disease’s impact, say the authors. Firstly, a pandemic in the near future would impose additional strain on an economy that is already stretched by recession, exaggerating the effect of recession and slowing economic recovery.

Secondly, school closures and prophylactic absenteeism, whether imposed by government or the result of fear of infection in the population, could greatly increase the economic impact of a pandemic while providing questionable health gains. Caution might therefore be advised in pursuing these policies except in exceptional circumstances, say the authors.

Finally, the cost of vaccinations is likely to be less than the economic savings gained from vaccination, even in the mildest of pandemics, and in the event of a high or extreme fatality pandemic a matched vaccine might be the only method to avoid the unprecedented economic effects of behavioural change.

The authors acknowledge that the evidence base for these estimates is highly imperfect, but they conclude that balancing school closure against "business as usual" and obtaining sufficient stocks of effective vaccine are more important factors in determining the economic impact of an influenza pandemic than is the disease itself.

In an accompanying editorial, researchers from the University of York say that the current outbreak of swine flu has already been costly, in terms of substantial advance purchases of costly treatments and vaccines, and payments to GPs to provide them. But if these investments are effective, and the spread of the disease is restricted, significant financial benefits may result.

Hopefully the challenging scenarios outlined in this paper will help policy makers to plan for pandemic influenza and to make good investment decisions, averting potentially serious damage to the NHS and to the UK economy, they write.

Treatment might also prevent early cardiovascular disease in women with a history of pre-eclampsia, they say.

Further research is needed to understand how exercise therapy results in better outcome, they conclude.

Contacts:

Research: Richard Smith, Professor of Health System Economics, Health Policy Unit, Department of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, UK
Email: Richard.Smith@lshtm.ac.uk

Editorial: Professor Alan Maynard, Director of the York Health Policy Group, Department of Health Studies, University of York, UK
Email: akm3@york.ac.uk

(3) New score will help identify those most at risk of fractures
(Research: Predicting risk of osteoporotic fracture in men and women in England and Wales: prospective derivation and validation of QFractureScores )
http://www.bmj.com/cgi/doi/10.1136/bmj.b4229

Two new scores for predicting osteoporotic fracture could help to identify high risk patients who are most likely to benefit from interventions to reduce their risk, concludes a study published on bmj.com today.

Osteoporotic fracture is a major cause of illness and a considerable burden to health services. Guidelines suggest a targeted approach for identifying high risk patients, so the challenge is now to improve the methods of identifying those patients who are most likely to benefit from interventions to reduce their risk of fracture.

So researchers from the University of Nottingham set out to develop and validate two new fracture risk algorithms (QFractureScores) for estimating the individual risk of osteoporotic fracture or hip fracture over 10 years. They also tested its performance against the established FRAX (fracture risk assessment) algorithm.

Using data from a general practice research database, they tracked over two million healthy men and women, registered at 357 general practices in England and Wales over a period of 15 years to June 2008, recording first hip, distal radius or vertebral fracture. All the participants were aged between 30 and 85 at the start of the study.

QFractureScores potentially improved on other algorithms by including additional risk factors, such as falls, type 2 diabetes, cardiovascular disease and use of hormone replacement therapy.

And because QFractureScores were developed in the clinical setting in which they will be used, they are likely to provide more appropriate risk estimates of fracture risk in the UK population, write the authors.

The results also suggest that the QFractureScores are likely to be at least as effective at identifying patients at high risk of hip fracture within primary care as the FRAX algorithm.

They conclude: "These new algorithms can predict risk of fracture in primary care populations in the UK without laboratory measurements and are therefore suitable for use in both clinical settings and for self assessment (www.qfracture.org). QFractureScores could be used to identify patients at high risk of fracture who might benefit from interventions to reduce their risk."

Contact:

Julia Hippisley-Cox, Professor of Clinical Epidemiology and Clinical Practice, University of Nottingham, Nottingham, UK
Email: julia.hippisley-cox@nottingham.ac.uk

(4) Should politics and the NHS go their separate ways?
(Personal View: The Department and the NHS - time for separation or for a new settlement?)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4881

Former head of the NHS and ex Permanent Secretary at the Department of Health, Nigel Crisp, argues that the time has come for the health service to part company from politics and politicians.

In Crisp’s Personal View, published on bmj.com today, he says that by separating the two, "politicians would be free to concentrate on the wider issues of health rather than on running the NHS".

According to Crisp, the wider issues like smoking, equality of access to services, the regulation of practitioners, the ethics of stem cell research and assisted dying will have the biggest long term impact on society’s health.

Nigel Crisp believes that for many years, including his time running the NHS, it was right for the Department of Health to run the health service, whose "very survival was in doubt". However, he now maintains that "whilst their roles are too close for complete separation, the time is ripe for a new settlement between the Department and the NHS that respects the distinct roles and capabilities of each partner".

Three tests would apply before any new settlement goes ahead, says Crisp. The first test would assess "whether the Government’s health strategy is fully integrated into its wider economic and social strategies"; the second would ask whether the Department has the expertise to oversee and develop the wider health issues and the third would ensure that effective accountability in the NHS exists, both to patients and the taxpayer.

Crisp concludes that the tests are all linked and need to be "addressed together with determination and clarity of vision - none can be ducked."

Contact:

Lord Crisp is currently overseas, but can be contacted via mobile: +44 (0)7771 927 408

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