Stroke: physical and financial pathology
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7339.0/h (Published 23 March 2002) Cite this as: BMJ 2002;324:hAll rapid responses
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Editor,
Am I alone in finding the confusion between lack of evidence
for one course of action and positive evidence for another being
misinterpreted as the superiority of course B over course A disturbing? I
refer to the leader "Preventing Stroke" 1.
This quite correctly recognises that there is no evidence permitting
generalisation of the outcome with ramipril to all angiotensin converting
enzyme inhibitors. What it, however, fails to recognise is that just
because a drug has been used in a study it cannot be assumed to be the
only drug with this action. Much medical practice is based upon the
concept of class effect, indeed the very value of lowering blood pressure
as a treatment is justified in many cases by reference to trials which
used drugs which are not currently used at doses which ceased to be
practice even before the use of these drugs was discontinued. If the
concept of class effect is to be jettisoned and sacrificed on the altar of
evidence base then we will have to accept that medical practice will be
dictated by the ability of pharmaceutical companies to sponsor trials, and
their serendipitous (as far as their shareholders are concerned) choice of
trials to sponsor.
The authors of the HOPE study very correctly declare their source of
funding and competing interests, would it not be appropriate for the same
acknowledgement to be made in respect of the leading article even if such
declaration did not immediately apply to the authors of this article?
Brian Mansfield
General Practitioner
Beckington Family Practice, Beckington, Somerset BA11 5SE
brian.mansfield@beckingtonfamilypractice.nhs.uk
1 Scrader J, Luders S: Preventing stroke high risk patients should
receive ramipril irrespective of their blood pressure. BMJ 2002; 324 : 687
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Competing interests: No competing interests
Humility and candor offer no salary, no perk, nor promise of
gain. Technical healthcare with it's focus in image,
commerce and ordinary denial is understandably disinclined
to pull back the curtain on strategic prejudices that
support its perceived fragile claims upon the vast public
purse. BMJ's forthright competing interests question is a
graceful and necessary social policy assertion for
authenticity and openness.
Competing interests: No competing interests
Sirs,
once again, “our dear” BMJ (Editor’s choice, Stroke: physical and
financial pathology, BMJ 2002;324, 23 March ) deals with an interesting
argument, unfortunately nowadays difficult to resolve: stroke
prevention.In my opinion, in stroke prevention as well as in all other
similar prevention “enterprises”, including the future italian Prevenzione
Globale del Rischio Cardiovascolare, there is a fundamental mistake at
starting point: we dare speak of “global” prevention in “all” individuals,
independently from the real efficaciousness of diet, in the etimological
sense, and/or drugs therapy, but especially ignoring or overlooking the
actual existence of different biophysical-semeiotic “constitutions”, which
involve exclusively some individuals, but surely not all: “diabetic
constitution” (1), e.g., "hypertensive, dyslipidemic, arteriosclerotic
constitution”, a.s.o. (See the site, HONCode ID N° 233736
http://digilander.iol.it/semeioticabiofisica). In addition, as far as
Ramipril action mechanisms are concerned, we have to consider its
favorable and very “complex”influences also on the microcirculation of
brain, analogously to what occurs in the kidney, under such treatment. In
a few words, we must know that, in healthy, the microcirculatory bed shows
autonomous and autoctonus, non-linear dynamics in both small arteries and
arterioles (vasomotility), according to Hammersen, as well as in
nutitional capillaries and post-capillaries venules (vasomotion) (1, 2).
By contrast, in individuals “at real risk” for well-defined disorders,
microcirculation deterministic chaos is already slightly and
characteristically impaired since birth, clearly in a “silent” form,
exclusively in those tissues, which “can” in the future be involved by
precise diseases (Congenital Acidosis Enzyme-Metabolic Histangiopathy =
conditio sine qua non of diseases) (4). Ultimately, in diseased organs
such “chaotic-deterministic” microcirculatory behaviour is almost
completely lost and consequently local parenchymal oxygenation appears to
be worsened, reduced, due to a large variety of factors, when evaluated at
the bed side by Biophysical Semeiotics. Interestingly, some, but not all,
ACE-inhibitors act ameliorating blood-flow in brain, kidney, heart,
a.s.o., microcirculatory bed, beside their more known action on the large
arteries.
Sergio Stagnaro MD. Active Member NYAS.
1) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and
Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298.
[PubMed –indexed for MEDLINE].
2) Stagnaro-Neri M., Moscatelli G., Biophysical Semeiotics: deterministic
Chaos and biological Systems. Gazz. Med. It. Arch. Sc. Med. 155, 125,1996.
3) Stagnaro-Neri M., Stagnaro S., Deterministic chaotic biological system:
the microcirculatoory bed. Theoretical and practical aspects. Gazz. Med.
It. – Arch. Sc. Med. 153, 99, 1994.
4) . Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica. Una
Patologia Mitocondriale Ignorata. Gazz Med. It. – Arch. Sci. Med. 144,
423, (Infotrieve)
Competing interests: No competing interests
Pharmaceutical industry has taken over American medicine
The news that German doctors among others are "currently being
investigated for alleged undue financial advantages ... over excessive
marketing activites by SmithKline Beecham" (BMJ 2002;324 :693 (23
March)) caused an attack of convulsive laughter.
The pharmaceutical industry
spends in excess of 16 billion American dollars/year (NY Times) on
"aggressive marketing" of drugs. They have not only taken over continuting
education in the U.S. (Relman AS. JAMA April 18, 2001-Vol 285, No 15) they
have taken over medical education with "free gifts." I have spent over
forty years teaching medical students, residents and young faculty. Every
day they carry on them some drug advertisement. Drastic action must be
taken before the profession is totally discredited. How about NO DRUG
ADVERTISING in the BMJ, JAMA, Lancet and the NEJM?
Competing interests: No competing interests