BMJ No. 7052 Volume 313 Saturday 3 August 1996
Objective - To investigate if extracts of Hypericum perforatum (St John's wort) are more effective than placebo in the treatment of depression, are as effective as standard antidepressive treatment, and have fewer side effects than standard antidepressant drugs.
Design - Systematic review and meta-analysis of trials revealed by searches.
Trials - 23 randomised trials including a total of 1757 outpatients with mainly mild or moderately severe depressive disorders: 15 (14 testing single preparations and one a combination with other plant extracts) were placebo controlled, and eight (six testing single preparations and two combinations) compared hypericum with another drug treatment.
Main outcome measures - A pooled estimate of the responder rate ratio (responder rate in treatment group/responder rate in control group), and numbers of patients reporting and dropping out for side effects.
Results - Hypericum extracts were significantly superior to placebo (ratio = 2.67; 95% confidence interval 1.78 to 4.01) and similarly effective as standard antidepressants (single preparations 1.10; 0.93 to 1.31, combinations 1.52; 0.78 to 2.94). There were two (0.8%) drop outs for side effects with hypericum and seven (3.0%) with standard antidepressant drugs. Side effects occurred in 50 (19.8%) patients on hypericum and 84 (52.8%) patients on standard antidepressants.
Conclusion - There is evidence that extracts of hypericum are more effective than placebo for the treatment of mild to moderately severe depressive disorders. Further studies comparing extracts with standard antidepressants in well defined groups of patients and comparing different extracts and doses are needed.
Projekt "Munchener Modell",
Ludwig-Maximilians-Universitat,
Kaiserstrasse 9,
80801 Munich,
Germany
Klaus Linde,
scientific assistant
Wolfgang Weidenhammer,
biostatistician
Dieter Melchart,
project leader
San Antonio
Cochrane Center,
Audie L Murphy Memorial Veterans Hospital,
San
Antonio,
TX 78284,
USA
Gilbert Ramirez,
codirector
Cynthia D Mulrow,
professor of
medicine
Private Practice for Neurology and Psychiatry,
80796 Munich
Andrej Pauls,
consultant psychiatrist
Correspondence to: Dr Linde.
Design - Double blind, randomised, controlled trial.
Setting - University Hospital.
Subjects - 38 (two groups of 19) patients scheduled for endoscopic cholanpancreatography.
Interventions - Metoprolol 100 mg or placebo as premedication two hours before endoscopy.
Main outcome measures - Heart rate, arterial oxygen saturation by continuous pulse oximetry, ST segment changes during endoscopic cholangiopancreatography (an ST segment deviation >1 mV was defined as myocardial ischaemia), electrocardiogram monitored continuously with a Holter tape recorder.
Results - All patients had increased heart rate during endoscopy compared with rate before endoscopy, but heart rate during endoscopy was significantly lower in the metoprolol group compared with the placebo group (P = 0.0002). Twenty one patients (16 placebo, 5 metoprolol; P = 0.0008) developed tachycardia (heart rate > 100/min) during the procedure, and 11 patients (10 placebo, 1 metoprolol; P = 0.003) developed myocardial ischaemia. One patient in the placebo group had an acute inferolateral myocardial infarction. In the 10 other patients with signs of myocardial ischaemia during endoscopy the ST deviation disappeared when the endoscope was retracted. In all patients myocardial ischaemia was related to increases in heart rate, and 10 of the 11 patients had tachycardia coherent with myocardial ischaemia.
Conclusions - Metoprolol prevented myocardial ischaemia during endoscopic cholangiopancreatography, probably through lowering the heart rate. Thus, tachycardia seems to be a key pathogenic factor in the development of myocardial ischaemia during endoscopy.
Department of Surgery,
Sundby Hospital,
DK-2300 Copenhagen S,
Denmark
Jacob Rosenberg,
senior registrar
Helle Overgaard,
senior
registrar
Mette Andersen,
senior registrar
Svend Schulze,
chief surgeon
Holter
Laboratory,
Department of Cardiology,
Hvidovre University Hospital,
DK-2650 Hvidovre,
Denmark
Verner Rasmussen,
consultant
Correspondence to: Dr J
Rosenberg,
Department 235,
Hvidovre University Hospital,
DK-2650
Hvidore,
Denmark
Design - Single centre, blinded, prospective study of patients admitted with chest pain.
Setting - Coronary care unit of a district general hospital.
Subjects - 460 patients admitted with chest pain and followed up for a median of three years. 183 patients had a final diagnosis of unstable angina.
Main outcome measures - Cardiac death, need for coronary revascularisation, or readmission with non-fatal myocardial infarction as first events.
Results - 62 (34%) unstable angina patients were troponin T positive. This group had significantly increased incidence rates of subsequent cardiac death (12 cases (19%) versus 14 (12%)), coronary revascularisation (22 (35%) versus 26 (21%)), death or revascularisation (33 (53%) versus 40 (33%)), and death or non-fatal myocardial infarction (18 (29%) versus 21 (17%)) compared with the troponin T negative group. In multiple logistic regression troponin T status was a highly significant predictor for the end points coronary revascularisation and cardiac death or revascularisation as first events.
Conclusion - Troponin T in the serum of patients with unstable angina identifies a subgroup at higher risk of subsequent cardiac events and its measurement aids in risk factor stratification. The increased risk extends to two years after admission. Prospective randomised trials are required to identify optimum therapeutic strategies for this subgroup.
Academic Unit of Cardiovascular
Medicine,
Charing Cross and Westminster Medical School,
Fifth Floor,
South Wing,
Charing Cross Hospital,
London W6 8RF
Peter
Stubbs,
lecturer in cardiovascular medicine
Mark
Noble,
Garfield Weston professor of cardiovascular medicine
Mayday University Hospital,
London CR7 7YE
Paul Collinson,
consultant chemical pathologist
West Middlesex University Hospital,
London TW7 6AF
David Moseley,
senior medical laboratory scientific
officer
Trevor Greenwood,
consultant physician
Correspondence to: Dr Stubbs.
Design - National survey of 25% random sample of community (high street) pharmacies through postal questionnaire, with four mailings.
Setting - England and Wales.
Subjects - 1 in 4 sample of all 10,616 community pharmacies, stratified by family health services authority.
Main outcome measures - Data were collected on each prescription for controlled drugs currently being dispensed by pharmacies to misusers, describing the drug, form, dose, source (general practice or hospital; and NHS or private), and numbers of dispensing pick ups a week.
Results - Methadone was the opiate most commonly dispensed to misusers (96.0% of 3,846 opiate prescriptions). 79.6% of methadone prescriptions were for the oral liquid form, 11.0% for tablet, and 9.3% for injectable ampoules. More than one third of all methadone prescriptions were for weekly or fortnightly pick up, with a further third being for daily pick up. Tablets and ampoules were even less likely to be dispensed on a daily basis. Private prescriptions were significantly more likely than NHS ones to be for tablets or ampoules, to be for substantially higher daily doses, and to be collected on a weekly or fortnightly basis.
Conclusions - The distinctively British practice of prescribing injectable methadone was found to be widespread and, contrary to guidance, to be as prevalent in non-specialist as specialist settings. In view of the frequent crushing and injecting of methadone tablets, clearer more authoritative guidance is needed on the contexts in which injectable methadone (tablets as well as ampoules) should be prescribed and on the responsibilities for monitoring and supervision which should be attached.
National Addiction Centre,
Institute of Psychiatry and Maudsley Hospital,
London SE5 8AF
John Strang,
professor of the addictions
Janie Sheridan,
research pharmacist
School of Pharmacy,
London WC1N 1AX
Nick Barber, professor of the practice of pharmacy
Correspondence to: Professor Strang.
Design - Self completion questionnaire (four mailings) to a random 1 in 4 sample of all community pharmacies, stratified by family health services authority.
Setting - England and Wales.
Subjects - Data provided by pharmacist in charge of the dispensary, on service provision at the pharmacy.
Main outcome measures - Quantitative reports of current activity levels for (a) dispensing of controlled drugs to drug misusers, (b) sale of needles and syringes, (c) needle and syringe exchange.
Results - 74.8% response rate (1984/2654). In 1995, 50.1% (992/1980) of pharmacies were dispensing controlled drugs (mostly methadone), compared with 23.0% (562/2457) in 1988; 34.5% (677/1962) of pharmacies were selling injecting equipment, compared with 28.0% (676/2434) in 1988; 18.9% (366/1937) were providing a needle exchange service, compared with 3.0% (65/2415) in 1988.
Conclusion - Activity levels increased substantially across all three service areas. Increased activity included greater individual activity as well as higher proportions of pharmacies participating. The network of community pharmacies represents an underused point of contact for this Health of the Nation target population.
National Addiction
Centre,
Institute of
Psychiatry and Maudsley
Hospital,
London
SE5 8AF
Janie Sheridan,
research
pharmacist
John Strang,
professor of the addictions
Alan Glanz,
lecturer
Centre for Pharmacy
Practice,
School of
Pharmacy,
London
WC1N 1AX
Nick Barber,
professor of the practice of pharmacology
Correspondence to: Dr Sheridan.