Press releases Monday 22 November to Friday 26 November 2010

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) Binge drinking may lead to higher risk of heart disease
• (2) Age restriction on emergency stroke treatment should be lifted, say researchers
• (3) Retirement reduces tiredness and depression
• (4) A high BMI in childhood linked to greater heart disease risk in adolescence
• (5) Experts question whether patients will use performance data to choose their care

(1) Binge drinking may lead to higher risk of heart disease

(Research: Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME))
http://www.bmj.com/cgi/doi/10.1136/bmj.c6077
(Editorial: Alcohol and heart disease)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5957

Belfast's binge drinking culture could be behind the country's high rates of heart disease, according to a paper published on bmj.com today.

The study, which compares drinking patterns of middle aged men in France and Belfast, finds that the volume of alcohol consumed over a week in both countries is almost identical. However, in Belfast alcohol tends to be drunk over one or two days rather than regularly throughout the week as in France.

The research also finds that the average amount of alcohol consumed in Belfast over the weekend is around 2-3 times higher than in France.

The link between alcohol consumption and heart disease and premature death has already been established says the paper. What remains unclear, argue the authors, is the role of drinking patterns and the type of alcohol consumed.

The researchers, led by Dr Jean-Bernard Ruidavets from Toulouse University, investigated whether drinking patterns in Northern Ireland and France were linked to the known disparity in heart disease between these two culturally diverse countries.

Over a ten year period, Ruidavets and colleagues assessed the alcohol consumption of 9,758 men from three centres in France (Lille, Strasbourg and Toulouse) and Belfast. The participants were free from heart disease when the research started in 1991 and were between the ages of 50 to 59.

The participants were divided into never drinkers, former drinkers, regular drinkers and binge drinkers. The 'drinkers' were asked via interviews and questionnaires about the volume of alcohol they consumed on a weekly and daily basis and also about the type of beverage. Cardiovascular risk factors, such as age, tobacco use, level of physical activity, blood pressure, and waist circumference were also taken into account.

The results show that the men who "binge" drink had nearly twice the risk of heart attack or death from heart disease compared to regular drinkers over the 10 years of follow up.

In the study, binge drinking is defined as excessive alcohol consumption (over 50g) drunk over a short period of time, for example on one day during the weekend (50g of alcohol equates to 4-5 drinks, and a drink to 125ml of wine or a half pint of beer).

The researchers write: "We found that alcohol consumption patterns differed radically in the two countries: in Belfast most men's alcohol intake was concentrated on one day of the weekend (Saturday), whereas in the three French centres studied alcohol consumption was spread more evenly throughout the entire week." They add: "the prevalence of binge drinking, which doubled the risk of ischaemic heart disease compared with regular drinking, was almost 20 times higher in Belfast than in the French centres."

Another reason for the higher risk of heart disease in Belfast, say the authors, could be that more people tend to drink beer and spirits than wine. In France, wine is the main alcoholic drink of choice and established research has concluded that drinking a moderate about of wine can protect against heart disease.

Ruidavets and colleagues conclude that the research has important public health implications, especially given that binge drinking is on the rise amongst younger people in Mediterranean countries. They say: "The alcohol industry takes every opportunity to imbue alcohol consumption with the positive image, emphasising its beneficial effects on ischaemic heart disease risk, but people also need to be informed about the health consequences of heavy drinking."

In an accompanying editorial, Annie Britton from University College London says binge drinking does not just increase the risk of heart disease but is also linked to other health problems such as cirrhosis of the liver and several kinds of cancer. It causes problems to society too.

She says public health messages aimed at middle aged men should stress that the protective effects of alcohol may not apply to them if they binge drink and they could be putting themselves at a higher risk of having a heart attack. When it comes to young people, Britton argues that they "are unlikely to take much notice of the findings about patterns of alcohol consumption and risk of heart disease, at a time when their risk of heart disease is low . . . they are more likely to respond to anti-binge drinking messages that focus on the risk of alcohol poisoning, injuries, assaults, and regretful risky sexual encounters."

Contacts:
Jean Ferrières, Department of Cardiology B and Department of Epidemiology, Toulouse University Hospital, France
Email: jean.ferrieres@cict.fr
Annie Britton, Senior Lecturer in Epidemiology, Department of Epidemiology and Public Health, University College London, UK
Email: ruth.howells@ucl.ac.uk

(2) Age restriction on emergency stroke treatment should be lifted, say researchers
(Research: Thrombolysis in very elderly people: controlled comparison of SITS International Stroke Thrombolysis Registry and Virtual International Stroke Trials Archive)
http://www.bmj.com/cgi/doi/10.1136/bmj.c6046
(Editorial: Intravenous thrombolysis for stroke)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5891

Thrombolysis (giving anti-clotting drugs within three hours of an acute stroke) is effective in patients aged 40 to 90 years and should not be restricted in elderly patients, as current guidelines advise, concludes a study published on bmj.com today.

Thrombolysis for acute ischaemic stroke has proven benefits, but it is currently not recommended for patients over 80 years because of a lack of trial data for this group. Effective treatments, however, should not be withheld from older people in the absence of compelling data suggesting unacceptable risk or proved lack of benefit, especially as the proportion of older people is rapidly rising in developed countries.

So a team of researchers across Europe assessed the effect of age on response to thrombolysis in over 29,000 patients.

They collated data on 23,334 patients who underwent thrombolysis and 6,166 patients who did not undergo thrombolysis. Patients were divided into two groups - those aged 80 years or less and those over 80.

Functional outcomes (ability to carry out usual daily activities) at 90 days were measured using a recognised scoring scale.

Patients who underwent thrombolysis had significantly better outcomes than untreated patients, irrespective of age.

Although increasing age was associated with poorer outcomes, the researchers found significant benefits of thrombolysis in patients aged 40 to 90 years. Patients aged over 80 derived similar benefit from treatment as younger patients.

The authors conclude that treatment guidelines should be revised to remove the age restriction in use of thrombolytic therapy for acute stroke. They say age alone should not be a barrier to treatment.

These views are supported in an accompanying editorial by Dr Laurent Derex from the Neurological Hospital in Lyon, France.

He warns that elderly patients may be especially vulnerable to subjective judgments of the benefit of optimal stroke care, particularly when medical resources are limited. He calls for quality improvement strategies "to ensure that elderly people, who have the highest risk of stroke, have equal access to effective treatment."

Contacts:
Research: Kennedy Lees, Professor of Cerebrovascular Medicine, Acute Stroke Unit, University Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary and Faculty of Medicine, University of Glasgow, Scotland, UK
Email: k.r.lees@clinmed.gla.ac.uk
Editorial: Laurent Derex, Neurologist, Department of Neurology, Neurological Hospital, Creatis UMR CNRS 5515, Inserm U 630, Lyon, France
Email: laurent.derex@chu-lyon.fr

(3) Retirement reduces tiredness and depression
(Research: Effect of retirement on major chronic conditions and fatigue: French GAZEL occupational cohort study)
http://www.bmj.com/cgi/doi/10.1136/mj.c6149
(Editorial: Is early retirement good for your health?)
http://www.bmj.com/cgi/doi/10.1136/mj.c6089

Retirement leads to a substantial reduction in mental and physical fatigue and depressive symptoms, finds a study published on bmj.com today. However, the research also concludes that retirement does not change the risk of major chronic illnesses such as respiratory disease, diabetes and heart disease.

The authors, led by Dr Hugo Westerlund from Stockholm University, say their research findings have important implications given that people will be working for longer and retiring later in life.

Retirement is a major life transition, says the study. But the results of various studies investigating the health effects of retirement have been inconsistent with some suggesting a beneficial effect and others concluding the reverse.

This large scale population based study is ground-breaking as it observes participants for a long period of time (15 years) and for 7 years prior to retirement and 7 years post retirement. The research is based on almost 190,000 observation years.

The participants were drawn from a large French cohort study and included 11,246 men and 2,858 women who were surveyed annually from 1989 to 2007. The researchers argue that "a major strength of this study is that it is based on repeated yearly measurements over an extended time period."

Most participants were married (89%) and belonged to higher or middle employment grades. They all retired on a statutory basis - 72% between the ages of 53 and 57 inclusive - and all participants had retired by the age of 64. In the year before retirement, one in four (25%) participants had suffered from depressive symptoms and 728 (7%) were diagnosed with one or more of the following: respiratory disease, diabetes, heart disease or stroke.

Unmarried respondents and those in low employment grades had higher odds of physical (but not mental) fatigue.

The results show that retirement is linked with a substantial decrease in both mental and physical fatigue, with a smaller but significant decrease in depressive symptoms. However, the research also shows there is no association between retirement and chronic disease. As expected, say the authors, these diseases gradually increased with age.

The authors believe there are a number of explanations for the findings: "if work is tiring for many older workers, the decrease in fatigue could simply reflect removal of the source of the problem ... furthermore, retirement may allow people more time to engage in stimulating and restorative activities, such as physical exercise," they write.

They conclude that their research results "indicate that fatigue may be an underlying reason for early exit from the labour market and decreased productivity, and redesign of work, healthcare interventions or both may be necessary to enable a larger proportion of older people to work in full health."

In an accompanying editorial, Alex Burdorf, a professor in the determinants of public health in the Netherlands, says the study "is unique in that annual health measurements were carried out several years before and after retirement."

Burdorf believes further research is needed to corroborate the findings as they contradict other studies and says "it is too early to make definite claims about positive and negative benefits from retirement at a particular age." The author agrees, however, that efforts are needed to improve and adapt working conditions "to help elderly workers maintain good health."

Contacts:
Research: Dr Hugo Westerlund, Associate Professor of Psychology, Stress Research Institute, Stockholm University, Sweden
Email: hugo.westerlund@stress.su.se
Editorial: Alex Burdorf, Professor in determinants of public health, Department of Public Health, Eramus MC, Rotterdam, Netherlands
Email: a.burdorf@erasmusmc.nl

(4) A high BMI in childhood linked to greater heart disease risk in adolescence
(Research: Association between general and central adiposity in childhood, and change in these, with cardiovascular risk factors in adolescence: prospective cohort study)
http://www.bmj.com/cgi/doi/10.1136/mj.c6224

Children who have a high body mass index (BMI) between 9 and 12 years of age are more likely to have high blood pressure, cholesterol and blood insulin levels (all risk factors for developing heart disease) by the time they reach adolescence, according to a study published on bmj.com today.

Reassuringly, say the authors, children with a high BMI who shed the weight by the time they reach adolescence have better heart disease risk profiles than those who remain overweight.

It was well known that greater childhood or adolescent obesity is linked to a higher risk of heart disease in later life. However, this is the first study to investigate the link between BMI, waist circumference, and fat mass at age 9-12 and heart disease risk factors at age 15-16.

A total of 5,235 children took part in the study, led by Professor Debbie Lawlor from the University of Bristol. The children were part of the Avon Longitudinal Study of Parents and Children (ALSPAC), which has tracked the health of more than 14,000 children since birth.

The researchers assessed the childrens' BMI, waist circumference, and fat mass between the ages of 9 to 12.

When the children reached adolescence (15-16 years of age) their blood pressure, cholesterol, glucose and insulin levels were tested. Positive results in these tests are risk factors for heart disease.

The results show that a high BMI at age 9-12 was associated with adverse heart disease risk factors at age 15-16, even when the analysis was adjusted for a wide range of other factors. Interestingly, waist circumference or fast mass measurements were not linked with adolescent heart disease risk factors any more strongly than BMI.

It is reassuring, say the authors, that overweight children who change to normal weight by the time they reach adolescence have better heart disease risk profiles than overweight children.

However they conclude: "Our findings highlight the need to shift the whole childhood population distribution of adiposity downwards and to develop interventions that safely and effectively reduce weight and improve cardiovascular risk factors in overweight/obese children."

Contact:
Debbie Lawlor, Professor of Epidemiology, School of Social and Community Medicine, University of Bristol, UK
Email: d.a.lawlor@bristol.ac.uk

(5) Experts question whether patients will use performance data to choose their care
(Analysis: How do patients use information on health providers?)
http://www.bmj.com/cgi/doi/10.1136/mj.c5272

Expectations are high that the public will use performance data to choose their health providers and so drive improvements in quality. But in a paper published on bmj.com today, two experts question whether this is realistic.

They think patient choice is not at present a strong lever for change, and suggest ways in which currently available information can be improved to optimise its effect.

Research conducted over the past 20 years in several countries provides little support for the belief that most patients behave in a consumerist fashion as far as their health is concerned, say Martin Marshall and Vin McLoughlin from The Health Foundation.

Although patients are clear that they want information to be made publicly available, they rarely search for it, often do not understand or trust it, and are unlikely to use it in a rational way to choose the best provider, they write.

They suspect that these problems are not just due to inadequate data, but may be the result of "unrealistic expectations" and "inappropriate assumptions" by advocates of public disclosure where health decisions are concerned.

They argue that the public "has a clear right to know how well their health system is working, irrespective of whether they want to use the information" and they suggest several ways in which currently available performance data could be made more useful.

For example, it is important that users perceive the information as coming from a trusted source, they say. It also needs to be of interest to the target audience and presented in a visually attractive way.

Patients also need to know how the NHS works before they can realistically judge comparative performance data, they add, while personal stories can also be compelling and influential when used alongside numeric data.

"In this paper, we present a significant challenge to those who believe that providing information to patients to enable them to make choices between providers will be a major driver for improvement in the near or medium term," they write. "We suggest that, for the foreseeable future, presenting high quality information to patients should be seen as having the softer and longer term benefit of creating a new dynamic between patients and providers, rather than one with the concrete and more immediate outcome of directly driving improvements in quality of care."

Contact:
Martin Marshall, Clinical Director and Director of Research and Development, The Health Foundation, London, UK
Email: martin.marshall@health.org.uk

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
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BMA House, Tavistock Square, London WC1H 9JP

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
http://intranet.bmj.com/departments/dept-bmj/bmj-team-resources/web-team-resources/General_blogging_principles.doc