BMJ No 7122 Volume 315 Saturday 13 December 1997 This Week in BMJ | Editor's Choice | Press releases Editorials 1553 Transmission of Creutzfeldt-Jakob disease in corneal grafts Bruce Allan, Stephen Tuft 1554 The emerging role of statins in the prevention of coronary heart disease Matthew F Muldoon, Michael H Criqui 1556 Management of head and neck cancer in Britain J S Tobias 1557 Hazardous drugs in developing countries David B Menkes 1558 Developing http://www.bmj.com Tony Delamothe News 1559 Europe agrees ban on tobacco advertising AMA chief forced to resign UK government bans sale of beef on the bone Spirometry best for assessing COPD White paper puts GPs in NHS driving seat Caldicott report urges reform of data handling South African row over denial of treatment Doctors stage hunger strike in Australia Men in south of England live longer Drug company loses battle to stop article Ethical guide for surgeons launched Herpes virus linked to multiple sclerosis Canada creates new blood service Diabetes drug withdrawn in UK Papers 1565 Systematic overview of co-proxamol to assess analgesic effects of addition of dextropropoxyphene to paracetamol A Li Wan Po, W Y Zhang 1571 Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review P M Rothwell, J Slattery, C P Warlow 1577 The West of Scotland coronary prevention study: economic benefit analysis of primary prevention with pravastatin J Caro, W Klittich, A McGuire, I Ford, J Norrie, D Pettitt, J McMurray, J Shepherd for the West of Scotland Coronary Prevention Study Group 1582 Epileptic seizures after a first stroke: the Oxfordshire community stroke project John Burn, Martin Dennis, John Bamford, Peter Sandercock, Derick Wade, Charles Warlow 1588 Rate of RhD sensitisation before and after implementation of a community based antenatal prophylaxis programme Stewart Mayne, John H Parker, Trevor A Harden, Sandra D Dodds, Judith A Beale 1589 Management of cancers of the head and neck in the United Kingdom: questionnaire survey of consultants Dympna Edwards, N W Johnson, D Cooper, K A A S Warnakulasuriya General practice 1590 Effect of doctors' ethnicity and country of qualification on prescribing patterns in single handed general practices: linkage of information collected by questionnaire and from routine data Paramjit S Gill, Anthony Dowell, Conrad M Harris Clinical review 1595 Science, medicine, and the future: Vaccines and vaccination Paul-Henri Lambert, Claire-Anne Siegrist 1598 Lesson of the week: Lumbar puncture still has an important role in diagnosing subarachnoid haemorrhage Jonathan Wasserberg, Philip Barlow 1600 ABC of palliative care: The last 48 hours Jim Adam 1599 Correction: Science, medicine, and the future: Obesity treatment John Wilding Education and debate 1604 Personal paper: Gene therapy for cancer - managing expectations Alan A Melcher, Ignacio Garcia-Ribas, Richard G Vile 1608 Your letter failed to win a place... Eyal Shahar Commentary: The editor's decision is final Liz Crossan, Richard Smith 1610 Meta-analysis: Beyond the grand mean? George Davey Smith, Matthias Egger, Andrew N Phillips Letters 1615 Use of statins P Enoch; R L Akehurst; P Sheridan and others; W Bennett and others; A S Wierzbicki and T M Reynolds; A M Davis; D P Mikhailidis and A F Winder; J McMurray and others; A P Wakeman and R H Leach; D Lewis; E J Wallis and others; J Betteridge and others; J Kjekshus and T R Pedersen; T M Reynolds and others 1620 NHS bonds could be alternative to private finance initiative for NHS H Keen and others 1620 Guidelines are needed for evaluations that use cluster approach D Elbourne 1621 Evidence based advertising? L Blondeel; G Leighton and M E Telford; P Hamet; J Mindell and T Kemp; S Crane; S Smart and C Williams 1623 Advertisements for donepezil T Greenhalgh; K Stein and others; H Boothby and others; P Hooper and A M Whitehead; R W Jones and others; D Wilkinson and others 1625 Quiet room is needed in hospitals for prayer and reflection A Sheikh 1625 Correction: Deaths from cervical cancer began falling before screening programmes were established A E Raffle 1625 Correction: Reduction in use of temazepam is factor in deaths related to overdose T C Gilhooly Obituaries 1626 F J Arroyo-Vacas, P H Brakenbury, J Hirtenstein, A U MacKinnon, D N Matthews Medicopolitical digest 1627 UK emergency services Drink driving limits Outstanding accident claims Data Protection Registrar and GPs Views & reviews Soundings 1628 Blocking a bed Colin Douglas Personal views 1628 What have I achieved? Hugh Watson The truth is out there Anita Forrest Out of the closet Jackie Napier Medicine and books 1631 Community Based Teaching Ed Susan L Deutsch J B Cookson Asthma P J Barnes John Rees Minerva 1632 S2 Career Focus Classified supplement Recruiting in hard times Joan Rogers Editor's choice Forces on prescribing The forces that decide whether a doctor will prescribe emerge as the theme of this issue. The first piece of evidence comes from a systematic review that examines the common belief that paracetamol combined with dextropropoxyphene is a better analgesic than paracetamol alone (p 1565). Combination products account for three quarters of all paracetamol issues in British teaching hospitals, and the authors of the review quote a Lancet letter which praised combination treatment. "Cynics would point out," write the review authors, "that similar claims can be made for the use of tiger bones in rheumatic pain." The review shows that paracetamol alone is as good as paracetamol in combination but gives no data on tiger bones. The debate around the advice from Britain's Standing Medical Advisory Committee on the use of statins to prevent coronary artery disease is deafening. In response to an editorial that criticised the guidelines as unhelpful we are publishing 14 letters (p 1615), including one from "103 professors, consultants, and specialists" (p 1620). There is agreement that statins are effective treatment but little agreement on whom to treat. This is an argument about cost effectiveness. The letters do not agree; nor do three evaluations of the cost effectiveness of statin treatment - one of which we publish on p 1577. Ironically, as one letter points out, "The body of evidence on effectiveness, individual benefit ... cost effectiveness ... and the population and cost implications of treatment policies is arguably stronger than for any treatment in wide use" (p 1618). Better evidence doesn't necessarily make for easier decisions, but an editorial calls for better ways to assess risk in individual patients (p 1554). Despite the confusion, sales of statins in the United States grew by 29% in 1997 to $3.7bn (£2.3bn). Advertising no doubt helped increase the sales. Twelve letters discuss the BMJ's position on advertising, with many lambasting the journal for not insisting on "evidence based advertising" (p 1621). The journal, says one correspondent, "should carry only advertisements for drugs that are backed by sound scientific evidence of their worth over other comparable products" (p 1622). We make our case on p 1625. One consolation is that 18 authors take the Drug and Therapeutics Bulletin to task for its "eccentric, idiosyncratic, and uninformed" review of donezepil in Alzheimer's disease (p 1625). One final factor that surely should influence prescribing is the closeness of the patient to death. In "The last 48 hours" Jim Adam writes that "previously 'essential' drugs such as antihypertensives, corticosteroids, antidepressants, and hypoglycaemics are often no longer needed and analgesic, antiemetic, sedative, and anticonvulsant drugs form the new 'essential' list" (p 1600). Home | Current contents | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline