In Other Journals

Charmed

In chronic heart failure, a Lancet commentary advises that patients whose ejection fraction is 40% or less should be prescribed angiotensinreceptor blockers in addition to ACE inhibitors, β-blockers and/or spironolactone.¹ Further, angiotensin-receptor β-blockers should be used as an alternative drug in patients with intolerance to ACE inhibitors, and considered in patients whose ejection fraction is more than 40%. The author was commenting on four papers reporting the results of the CHARM — the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity — program.² CHARM, involving more than 7000 adults with chronic heart failure living in 26 countries including Australia, found that the angiotensinreceptor blocker candesartan reduced cardiovascular deaths and hospital admissions for heart failure.

1. Lancet 2003; 362: 754-755

2. Lancet 2003: 362: 759-781

Horsing around

Wearing a helmet while horse riding will protect the head and skull; however, it may not protect the rider’s neck, spine and face from injury, according to a study from Sydney’s Prince of Wales Hospital complex. Nevertheless, those who do not use a helmet are at greater risk of injury. The study analysed injuries occurring in 429 patients who presented after horse-riding accidents. Although more professional riders were represented among the injured, recreational riders were more likely to sustain a serious injury and require admission.

Aust N Z J Surg 2003; 73: 567-571

Prescribing matters

Vigorous debate abounds about whether direct-to-consumer advertising (DTCA) of drugs helps or harms patient health and healthcare systems.^1,2 Now, evidence adds to opinion-based argument, with North American researchers saying that exposure to DTCA increases the rate at which patients ask for advertised drugs, but not doctors’ responses to such requests^.3

The researchers surveyed 78 doctors and 1431 adult patients in primary care settings in Sacramento, California, where DTCA is legal, and in Vancouver, Canada — where although it is arguably illegal there is some exposure to DTCA. Patients in Sacramento were more likely to have seen ads for prescribed drugs, and 7.2% requested such drugs — compared with 3.3% of patients in Vancouver. The prescribing rate for patient-requested advertised drugs was similar in both cities — about 75% — despite frequent doctor ambivalence about choosing this treatment for other, similar patients.

As well as having an effect on product choice, DTCA appeared to increase prescribing volume overall; however, the study did not evaluate treatment appropriateness.

1. www.nzma.org.nz/journal/ 116-1180/556/

2. CMAJ 2003; 169: 425-427

3. CMAJ 2003; 169: 405-412

Unearthing the past

Iraqi villagers near the city of Hilla recently used a backhoe to dig up thousands of human remains, gouging and commingling countless skeletons. US forensic and human rights experts have expressed concern about this and other, more official approaches to the exhumation of mass graves in Iraq — where 290 000 people have been reported missing over the past 20 years. They want a comprehensive strategy put in place that takes into account the legal needs of possible future criminal trials and the technical complexities of identification, as well as the humanitarian needs of the families of those who disappeared.

JAMA 2003; 290: 663-666

Leave out the excess

A meta-analysis of eight randomised controlled trials has suggested that, in the GP setting, screening for excessive alcohol use to find cases and then using a brief intervention is not an effective strategy. Only 25 in 1000 screened patients will qualify for intervention and only two or three of these are likely to benefit.

BMJ 2003; 327: 536-542

"Terminal sedation"

Dutch health minister Clémence Ross has drawn a distinction between euthanasia and “terminal sedation” that has been welcomed by doctors in the Netherlands, according to a news report in the BMJ. Euthanasia involves giving medication at a patient’s request that will result in his or her death in a short time; whereas terminal sedation is giving drugs that reduce consciousness in dying patients so that they are no longer aware of their surroundings and suffering. Ross was rejecting a call from the Dutch attorney general for euthanasia and terminal sedation to be covered by the same legal controls. The news report said a recent study suggested that up to 10% of all deaths in the Netherlands occur following terminal sedation.

BMJ 2003; 327: 465