BMJ NO 7076 Volume 314 Saturday 25 January 1997

This Week in BMJ | Editor's Choice | Press releases | Advertisement details

Editorials

239 Gulf war illness Anthony David Susan Ferry Simon Wessely

241 Outbreaks of E coli R L Salmon

242 Pig transplants postponed Peter J Morris

243 Cervical Carotid or vertebral artery dissection Stavia Blunt Clare Galton

245 Antiphospholipid (Hughes') syndrome Munther A Khamashta Charles Mackworth-Young

246 Time to look again at sight tests Richard Wormald Scott Fraser Catey Bunce

247 London's mental health services in crisis Max Marshall

News

Xenotransplantation regulatory body for UK * Hay fever drug banned in US* ECT clinics are below standard * Penningtion inquiry on E coli reports *Move to bring back medical officer of health * French patient contracts AIDS from surgeon * Police could bug surgeries * Surrogate mother refuses to five up baby * EU register of bad doctors proposals * Communication and junior doctors' concerns * Emergency care too focused on 999 calls * Genetics shop to open in Manchester airport * US medicine moves towards UK solution

Papers

253 Randomised controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies) R Rai, H Cohen, M Dave, L Regan

257 Variations in use of cardiology services in a health authority: comparison of coronary artery revascularisation rates with prevalence of angina and coronary mortality Nick Payne, Carol Saul

262 Relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units, and alternative residential options: a cross sectional survey, one day census data, and staff interviews G Shepherd, A Beadsmoore, C Moore, P Hardy, M Muijen

266 Do neuroleptic drugs hasen cognitive decline in dementia? Prospective study with necropsy follow up Rupert McShane, Janet Keene, Kathy Gedling, Christopher Fairburn, Robin Jacoby, Tony Hope

271 Evaluating the reliability of causes of death in published clinical research R D Start, J P Bury, A G Strachan, S S Cross, J C E Underwood

General Practice

272 Case-control study of stroke and the quality of hypertension control in north west England Xianglin Du, Kennedy Cruickshank, Roseanne McNamee, Mohamad Saraee, Joan Sourbutts, Alison Summers, Nick Roberts, Elizabeth Walton, Stephen Holmes

Information in practice

277 Information needed to decide about cardiovascular treatment in primary care John Robson

281 Women's need for information before attending genetic counselling for familial breast or ovarian cancer: a questionnaire, interview, and observational study N Hallowed, F Murton, H Statham, J M Green, M P M Richards

284 Netlines Mark Pallen

Clinical review

285 Fortnightly review: Screening for asymptomatic colorectal cancer Hugh E Mulcahy, Michael J G Farthing, Diarmuid P O'Donoghue

291 Lesson of the week: Carotid dissection causing stroke in a child with migraine V Ganesan, F J Kirkham

292 Grand round - Queen Elizabeth Medical Centre, Birmingham: Systemic lupus erythematosus P Cockwell

Education and debate

296 Funding the NHS: Is the NHS sustainable? Anthony Harrison, Jennifer Dixon, Bill New, Ken Judge

Letters

299 Suspension of nurse who gave drug on consultants instructions D M D White; J Hillam; M Harper; M Vernon and others; A Valmana and J Rutherford; J Scott and E R L Williams

301 Criticism of study of childhood leukaemia near French nuclear reprocessing plant is unfounded J-F Viel

301 Study design and nature of diabetes may explain findings of Finnish study N Chaturvedi and J H Fuller

301 Data on eligibility for thrombolytic treatment can indeed be generalised J K French and H D White

302 Promoting health in prisons J M Hall; D Acheson

302 Do fetuses feel pain? P McCullagh; P J Saunders

303 Computerised automatic warnings about drug interactions are now available I H Stockley

303 Differences in mortality between African Caribbean and European people with non-insulin dependent diabetes I O Azuonye; V S Raleigh and P Roderick; M C Gulliford; N Chaturvedi and others

305 IgA content of immunoglobulin preparation was overstated J P Sheard

305 High voltage power lines and risk of cancer M J O'Carroll; P Verkasalo and others

306 Doctors, nurses, and terminal care J C Hughes; P Stuos and R Kennedy

306 Treating shackled patients I C Finlay and others; S J Pearce; V Nathanson

307 Correction: Metabolic effects of antihypertensive treatment should not be overstated P H Winocour

Obituaries

308 S A Khan, B H Pentney, H M Archibald, R Cooper, F T Doleman, M Harris, M A Hussain, A W Jowett, R B Laidlaw, F E O'Connor-Wilson, T Richardson, A S Rogen, T E Tasker, P J Watson

Medicopolitical digest

310 NHS should be self sufficient in manpower * BMA counselling service * Mature medical students * Guidance on primary care bill

Views & reviews

Personal views

311 Burns Night dos and don'ts James Drife

A sense of belonging Krishna Kumar

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Medicine and the media

312 Di braves minefield Vivienne Nathanson

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Medicine and books

313 Managing Scarcity: Priority Setting and Rationing in the National Health Service Rudolf Klein, Patricia Day, Sharon Redmayne
Iona Heath

Health Effects of Exposure to Low Level Ionising Radiation Ed William R Hendee, F Marc Edwards
Cameron Bowie

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Minerva

314

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S2 Career Focus

Responding to change John Bennett

Editors Choice

Do no harm and do more good for those who need it most

"Do no harm?' Medicine's first rule. But it can be so easy to do harm. On p 266 a group from Oxford investigate the effects of neuroleptic drugs on elderly patients with dementia. In the United States - perhaps because of its "grey panther" movement - there has been great anxiety about the overprescribing of neuroleptic drugs to elderly people in nursing homes. Federal laws prohibit their use for behaviour such as wandering, restlessness, or insomnia. In Britain the anxiety is just beginning, but a BMJ paper showed that many people in nursing homes were being prescribed neuroleptics and that in nine cases out of 10 they were prescribed inappropriately

Now the Oxford group show in a prospective study of 71 subjects that the 16 who were prescribed neuroleptics had a decline in their cognitive score twice that of those not prescribed the drugs. The authors cannot be certain that it was the drugs that hastened the decline - rather than the condition for which they were described - but it probably was. How might the drugs cause the decline? The mechanism may be reduced attention, unrecognised episodes of delirium, enlargement of the caudate nucleus, an increased tendency to develop the neurofibrillary tangles of Alzheimer's disease, or impairment of neurotransmitter responses. The authors recommend regular review of the need for patients to continue taking neuroleptic drugs.

Even if doctors aren't doing harm they may not be doing as much good as they might - because they are concentrating on the wrong patients. This is Julian Tudor Hart's famous inverse care law: "The availability of good medical care tends to vary inversely with the need for it in the population served." Or, as the Bible puts it: "Unto every one that hath shall be given, and he shall have abundance; but from him that hath not shall be taken away even that which he hath." An editorial and two papers in this week's BMJ show that the inverse care law applies to screening for glaucoma (p 246), cardiology services (p 257), and availability of psychiatric beds (p 262). Krishna Kumar gives a personal and Indian perspective to the inverse care law. He describes the temptation to leave Bihar, one of India's poorest states, and settle in Delhi or London (p 311). He resisted.

Finally, doctors may do harm with stupid advice. One hundred years ago the BMJ was warning of the dangers of bicycling (p 276). It was linked with many conditions, including appendicitis. An American practitioner suggested the systematic removal of the appendix in childhood "as a prophylactic measure". The BMJ thought that the proposal merited serious consideration "in these days when bicycling is so fashionable." What will look so stupid in 2097? Our dire warnings against ecstasy?