eMJA: In Other Journals, 2 January 2006

Dual antiplatelet therapy, with clopidogrel added to aspirin, presents a major advance with clear benefit in managing patients with acute myocardial infarction, according to a US expert.1 Sabatine, from the Thrombolysis in Myocardial Infarction (TIMI) Study Group, was commenting on findings from COMMIT — the ClOpidogrel and Metoprolol in Myocardial Infarction Trial; also known as the Second Chinese Cardiac Study.2,3

COMMIT was a randomised, placebo-controlled mega-trial, coordinated by the UK Oxford Clinical Service Unit and conducted in China, which involved more than 45 000 patients with suspected acute myocardial infarction. The trial found that, in a wide range of patients, adding 75 mg clopidogrel daily to aspirin and other standard treatments safely reduced mortality and major vascular events in hospital.2 Clopidogrel may work by preventing re-occlusion of coronary vessels, supporting the “open-artery hypothesis”.

1. Lancet 2005; 366: 1587-1589
2. Lancet 2005; 366: 1607-1621
3. Lancet 2005; 366: 1622-1632

Medicine by media?

Although medical news reports are often castigated as alarmist or as raising unrealistic treatment expectations, Canadian authors say that accurate reporting can also help build a link between research evidence and clinical practice.1 They found that a Canadian Broadcasting Corporation television documentary about Diane-35 (cyproterone acetate) had a greater effect on subsequent prescription rates than a “Dear Health Professional” letter and a safety alert published in CMAJ.2 The documentary conveyed two key messages — that this oral contraceptive had:
• a higher risk of venous thromboembolism than other, similar agents; and
• widespread off-label use as an oral contraceptive agent in women who did not have severe acne.

1. CMAJ 2005; 173: 1313-1315
2. CMAJ 2003; 168: 455-456

Dolphins for depression

Being with bottlenose dolphins is an effective treatment for mild to moderate depression, say UK researchers. They conducted a small, randomised single-blind trial in an appropriate natural setting — Honduras — which compared the anti-depressive effect of being with bottlenose dolphins (Tursiops truncatus) for an hour a day with that of similar water activities sans dolphins (ie, swimming and snorkelling in the coral reef). At 2 weeks, participants who played and swam with and took care of the dolphins had a greater reduction in their depressive symptoms than those who didn’t.

BMJ 2005; 331: 1231

Weight loss and more

Overweight and obese patients at high risk of cardiovascular disease may gain benefit from a new drug on the horizon — rimonabant, a selective cannabinoid-1 receptor blocker.1,2 This drug was studied in a randomised controlled trial involving more than 1000 overweight or obese subjects with untreated dyslipidaemia conducted at 67 sites in eight countries, including Australia. Rimonabant was found to not only lead to moderate weight loss but also to have a beneficial effect on several metabolic variables, including serum high-density lipoprotein cholesterol and triglyceride levels.2 Adverse effects of rimonabant included nausea, anxiety and insomnia.

1. N Engl J Med 2005; 353: 2187-2189
2. N Engl J Med 2005; 353: 2121-2134

Flight operations

Would you fly on an aeroplane without a pilot? What about undergoing an operation without an anaesthesist in the theatre? New Zealand author Guise raised this interesting analogy, between a pilot flying a plane and an anaesthetist attending to a patient during a surgical procedure, when responding to a press report that the Chairman of a NZ government advisory group had claimed that doctors were no longer necessary to perform cataract surgery. Guise pointed out that to the inexperienced observer, a group of highly skilled professionals conducting their work in a quiet, efficient, safe manner — be it in a plane or an operating theatre — can give the impression that the procedure is simple and, therefore, does not require highly trained staff. However, the cost of complications in either setting, even if they occur infrequently, can be high.

Clin Exp Ophthalmology 2005; 33: 451-452

A PBS for America?

Recent US legislation (the Medicare Prescription Drug Improvement and Modernization Act) will introduce a voluntary program of prescription drug coverage to the States. However, drug price negotiations will be in the hands of managed care organisations and pharmacy benefit managers rather than government. By way of assistance and advice, Australian authors have compared and contrasted the well established drug evaluation systems in Australia (the Pharmaceutical Benefits Scheme, PBS) and the UK (The National Institute for Health and Clinical Excellence, NICE). Both the PBS and NICE make decisions using formal measures of cost-effectiveness. Advantages of NICE were considered to include its independence from government; and its ability to commission drug evaluations, whereas the Australian system is reliant on pharmaceutical companies to perform assessments of new drugs. However, neither system re-evaluates older, potentially cost-ineffective drugs.

JAMA 2005; 294: 2630-2632

Dr Ann Gregory, MJA

The Medical Journal of Australia eMJA