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This week in BMJ Saturday 25 January 1997

Low dose aspirin with heparin improves prognosis in women with recurrent miscarriages

Recurrent miscarriage may represent a defective haemostatic response to pregnancy. Women with phospholipid antibodies, lupus anticoagulant, and cardiolipin antibodies have a miscarriage rate of 90%, attributed to placental thrombosis, in pregnancies in which no pharmacological treatment is given. On p 253 Rai et al report a randomised controlled trial of low dose aspirin and combined low dose aspirin and heparin in women with recurrent miscarriages and phospholipid antibodies. In women given aspirin alone the rate of live births was 40% but in those given aspirin and heparin it was 70%. The long term use of low dose heparin resulted in few side effects.

Cardiac services are used least by those who need them most

The recent Health of the Nation report on variations suggested that health authorities should carry out equity audits to determine whether healthcare resources are being used in relation to need. A questionnaire survey by Payne and Saul (p 257) found that the prevalence of symptoms of angina across a health district varied widely and in relation to deprivation. When they linked the results with health event data they found that people with angina symptoms in deprived areas were much less likely to have had revascularisation than those in affluent areas.

More beds is not the answer to shortage of acute psychiatric beds

Acute psychiatric units have high levels of bed occupancy, leading to shortages in availability. Shepherd et al (p 262) examined the relation between bed use, social deprivation, and availability of beds in a nationally representative group of acute psychiatric units. They found that occupancy was related to social deprivation and total availability of acute beds. However, a quarter of inpatients (and two thirds of those with stays of more than six months) did not need continuing admission. Reasons preventing discharge were lack of suitable accommodation, domiciliary based community support, and long term rehabilitation places. The authors suggest that some patients should be relocated in more suitable accommodation with intensive community support. Simply providing more acute beds is not the answer.

Neuroleptic drugs hasten decline in cognitive function in dementia

Neuroleptic drugs are used to treat behavioural problems in patients with dementia, but they may cause more rapid decline in cognitive function. To investigate this McShane et al (p 266) undertook a longitudinal study and found that the rate of cognitive decline in patients with dementia, taking neuroleptics was twice that in those not taking the drugs. Furthermore, the start of neuroleptic treatment was associated with an increase in the rate of cognitive decline. Cortical Lewy body pathology at necropsy did not explain the association. The authors recommend regular review of the need for neuroleptic drugs.

Risk of stroke is related to quality of blood pressure control

There have been few studies in routine primary care of what constitutes "hypertension" in relation to stroke or of the quality of control of blood pressure in stroke cases. Du et al (p 272) conducted a population based case-control study of the risk of stroke in relation to quality of hypertension control in routine general practice across east Lancashire health district with a participating population of 388,821 aged under 80. About 21% of strokes were thus attributable to inadequate control with treatment, or 46 first events yearly per 100,000 population aged 40-79. In routine practice detection and then consistent control of blood pressure to <150/90 mm Hg is required for optimal stroke prevention.