- Email: [email protected]
Mown down under
752
medical authorities or the police if they think it is necessary. His doctors did not, and the case led to a debate about whether legislation was adequate. Besides, the doctors later refused to deliver the man’s and women’s records to the police, which then tried to obtain them through a court order (see Lancet Sept 19, 1992,p 719). The trial began on Feb 26, with charges of exposing 23 women’s lives to danger (none became infected with the virus) and having sexual relations with two minors. Because his doctors gave testimonies, the prosecution abandoned the attempt to see the records. The man denied knowledge of being HIV positive, saying that he understood the doctors had told him that he was HIV-2 negative; he blamed the misunderstanding on language difficulties. Since the doctors said that the test they used at the time could not distinguish between type 1 and type 2 viruses, the three judges agreed that the defendant was aware of his condition and of the risks of transmission. He was ordered to pay DKr 15 000 ([1500) compensation to each of the minors, though not to the women because they had chosen not to use spenmicides during sexual intercourse. The defence has appealed, on the basis of a parliamentary decision in 1988 to abolish punishment for spreading certain venereal diseases and, it argues, AIDS. Cláudio
Csillag
Pharmacoeconomical with the truth With drug costs in 1991 at 12-9% of total UK National Health Service spending, together with ever increasing demographic and technological demands on resources, the NHS is rapidly becoming financially unsustainable. Where will the inevitable axe fall? At the first Drug and Therapeutics Bulletin conference on drug costs and treatment choices, Dr Joe Collier (editor of DTB) identified the drug budget as the largest part of total NHS spending that was amenble to pruning. Through the Pharmaceutical Price Regulation Scheme (PPRS), he argued, large companies can set their prices to achieve a maximum allowable profit of 17-21 % of their total capital expenditure. 90% of companies achieve this target. Industry’s success, on the background of relatively low UK drug consumption, suggests that artificially high prices are now forcing the NHS to ration in other areas of care. The government recognises that escalating drug costs must be slowed. They plan to provide incentive schemes to non-fundholding general practitioners: savings on drug expenditure will be made available for other primary care services. Dr lain Chalmers (Cochrane Centre, Oxford) pointed out that without reliable data on (comparative) efficacy from well-designed clinical trials, perhaps included in a rolling meta-analysis, cost assessment becomes meaningless. He discussed two paradoxes of clinical research: studies that are needed do not get done (eg, testing whether a procedure does or does not improve care) and research that is not needed is still undertaken (eg, placebo-controlled trials of new antibiotics for serious infection after caesarean section). At the International Business Communications meeting on the economic evaluation of medicines, emphasis was placed on shifting the argument from costs of pharmaceuticals to outcome measures (cost-utility analysis). Pharmacoeconomics is a growth industrytwo new journals, Health Economics and PharmacoEcorwmics, have recently appeared-and some observers clearly see it as a means of providing accurate data to doctors and managers on what is value for money. As Prof Alan Maynard (University of York) indicated, there are few data on which to make reliable decisions about setting priorities in a market with infinite demand but finite resources. Variations in clinical practices are enormous, the scientific basis for much of patient care is almost non-existent, and the institutions of medicine and doctors themselves are fiercely resistant to change. The short-term solution might be to target drug costs, but the long-term answer has to do with clinical issues and the organisation of the NHS. As Nicholas Wells (Glaxo, UK) bluntly put it, pharmaceutical costs are not the problem. The enthusiasm for pharmacoeconomics, however, is due to industry’s defensive concern about their large demand on NHS resources. The truth about this enterprise slipped out in Anita Wilson’s (Wellcome Foundation, UK) discussion on the role of clinical trials in pharmacoeconomic analysis. The aim of
pharmacoeconomics, she claimed, was to support company products and to overcome threats from reduced patent lives, generic and diminishing research and development returns. Economic data derived from phase III trials are handled in-house and might not be subject to the statistical rigour applied to other end-points under investigation. If the economic results fail to demonstrate what the company had hoped for, then such data could be excluded from the final publication. Wilson frankly admitted that one of her difficulties was to decide which department pharmacoeconomics should be linked to: medical or marketing. Are economic analyses simply going to become yet another arm of a
competition,
pharmaceutical company’s promotional strategy? Richard Horton
Mown down under In the northern hemisphere snowdrops are in bloom and the daffodils are beginning to appear, while in the southern hemisphere summer draws to a close. Soon it will be time to take the mower from the potting shed and give the lawn its first, or last, trim of the year. Those intending to venture into the garden should be aware of the health hazards associated with cutting the grass. In Perth, Australia, five men died suddenly between October, 1991, and August, 1992, while mowing the lawn.’ The men, aged between 48 and 74 years, were all found at necropsy to have severe coronary arteriosclerosis. Two were using self-propelled roller-type mowers and two were using petrol-engined rotary mowers that required pushing (the type of mower is not known in the fifth case), and they had been at their tasks for between 20 and 75 min. It seems likely that the physical exertion associated with cutting the grass led to these men’s deaths. A report from New Zealand describes foot injuries associated with use of "hover" mowersThirty-four such accidents were reported in the Wellington area between 1983 and 1991, and Paterson and Horne were able to contact seventeen of the victims. A certain amount of carelessness seems to have been involved in the accidents, since sixteen occurred on steep slopes and eight subjects were wearing only sports shoes or sandals, both factors that the manufacturers of air-cushion mowers warn against. Fifteen patients required hospital admission, eight had all or part of a big toe amputated, and fifteen reported post-traumatic pain. Most patients had to modify their jobs and recreational activities in some way, and two were forced to change their occupations. Clearly, cutting the grass should be left to the fit and well shod.
John McConnell 1. Cooke CT, Margolius KA. Sudden death while lawnmowing. Med JAust 1992; 157: 720. 2. Paterson S, Home G. Air cushion mower foot injuries N Z Med J 1992; 105: 456.
Burps bust bolus blockage unusual for various beverages to be taken for what is as "medicinal purposes", among them blackcurrant and hot chocolate drinks, whisky, brandy, Coca-Cola, and Guinness. Wait a minute, rewind-surely not Coca-Cola, the drink that makes the world sing in perfect harmony? Indeed yes, Coca-Cola. According to Karanjia and Rees,l this fizzy drink is an effective method of clearing bolus obstruction in the oesophagus. In 13 episodes of bolus obstruction in 8 patients with benign oesophageal stricture, Coca-Cola administered before endoscopy in 6 episodes cleared the obstruction before the instrument was inserted. In 5 of the other 7 episodes in which Coca-Cola was not given, the bolus had to be removed piecemeal, the endoscope having to be passed at least twice in each case. In 2 cases endoscopy had to be abandoned, but the Coca-Cola did the trick. The authors speculate that fizzy drinks, including champagne for those who can afford it, might penetrate the bolus and induce its disintegration with the release of carbon dioxide within the bolus. They add that if the drink were to seep through the bolus, the release of gas from the stomach "might dislodge the bolus at eructation". A case of one burp and it’s gone? It is
not
euphemistically described
Pia Pini 1. Karanjia ND, Rees M The use of Coca-Cola m the management of bolus obstruction in
benign oesophageal
stricture
Ann R Coll
Surg 1992, 75: 94-95.
medical authorities or the police if they think it is necessary. His doctors did not, and the case led to a debate about whether legislation was adequate. Besides, the doctors later refused to deliver the man’s and women’s records to the police, which then tried to obtain them through a court order (see Lancet Sept 19, 1992,p 719). The trial began on Feb 26, with charges of exposing 23 women’s lives to danger (none became infected with the virus) and having sexual relations with two minors. Because his doctors gave testimonies, the prosecution abandoned the attempt to see the records. The man denied knowledge of being HIV positive, saying that he understood the doctors had told him that he was HIV-2 negative; he blamed the misunderstanding on language difficulties. Since the doctors said that the test they used at the time could not distinguish between type 1 and type 2 viruses, the three judges agreed that the defendant was aware of his condition and of the risks of transmission. He was ordered to pay DKr 15 000 ([1500) compensation to each of the minors, though not to the women because they had chosen not to use spenmicides during sexual intercourse. The defence has appealed, on the basis of a parliamentary decision in 1988 to abolish punishment for spreading certain venereal diseases and, it argues, AIDS. Cláudio
Csillag
Pharmacoeconomical with the truth With drug costs in 1991 at 12-9% of total UK National Health Service spending, together with ever increasing demographic and technological demands on resources, the NHS is rapidly becoming financially unsustainable. Where will the inevitable axe fall? At the first Drug and Therapeutics Bulletin conference on drug costs and treatment choices, Dr Joe Collier (editor of DTB) identified the drug budget as the largest part of total NHS spending that was amenble to pruning. Through the Pharmaceutical Price Regulation Scheme (PPRS), he argued, large companies can set their prices to achieve a maximum allowable profit of 17-21 % of their total capital expenditure. 90% of companies achieve this target. Industry’s success, on the background of relatively low UK drug consumption, suggests that artificially high prices are now forcing the NHS to ration in other areas of care. The government recognises that escalating drug costs must be slowed. They plan to provide incentive schemes to non-fundholding general practitioners: savings on drug expenditure will be made available for other primary care services. Dr lain Chalmers (Cochrane Centre, Oxford) pointed out that without reliable data on (comparative) efficacy from well-designed clinical trials, perhaps included in a rolling meta-analysis, cost assessment becomes meaningless. He discussed two paradoxes of clinical research: studies that are needed do not get done (eg, testing whether a procedure does or does not improve care) and research that is not needed is still undertaken (eg, placebo-controlled trials of new antibiotics for serious infection after caesarean section). At the International Business Communications meeting on the economic evaluation of medicines, emphasis was placed on shifting the argument from costs of pharmaceuticals to outcome measures (cost-utility analysis). Pharmacoeconomics is a growth industrytwo new journals, Health Economics and PharmacoEcorwmics, have recently appeared-and some observers clearly see it as a means of providing accurate data to doctors and managers on what is value for money. As Prof Alan Maynard (University of York) indicated, there are few data on which to make reliable decisions about setting priorities in a market with infinite demand but finite resources. Variations in clinical practices are enormous, the scientific basis for much of patient care is almost non-existent, and the institutions of medicine and doctors themselves are fiercely resistant to change. The short-term solution might be to target drug costs, but the long-term answer has to do with clinical issues and the organisation of the NHS. As Nicholas Wells (Glaxo, UK) bluntly put it, pharmaceutical costs are not the problem. The enthusiasm for pharmacoeconomics, however, is due to industry’s defensive concern about their large demand on NHS resources. The truth about this enterprise slipped out in Anita Wilson’s (Wellcome Foundation, UK) discussion on the role of clinical trials in pharmacoeconomic analysis. The aim of
pharmacoeconomics, she claimed, was to support company products and to overcome threats from reduced patent lives, generic and diminishing research and development returns. Economic data derived from phase III trials are handled in-house and might not be subject to the statistical rigour applied to other end-points under investigation. If the economic results fail to demonstrate what the company had hoped for, then such data could be excluded from the final publication. Wilson frankly admitted that one of her difficulties was to decide which department pharmacoeconomics should be linked to: medical or marketing. Are economic analyses simply going to become yet another arm of a
competition,
pharmaceutical company’s promotional strategy? Richard Horton
Mown down under In the northern hemisphere snowdrops are in bloom and the daffodils are beginning to appear, while in the southern hemisphere summer draws to a close. Soon it will be time to take the mower from the potting shed and give the lawn its first, or last, trim of the year. Those intending to venture into the garden should be aware of the health hazards associated with cutting the grass. In Perth, Australia, five men died suddenly between October, 1991, and August, 1992, while mowing the lawn.’ The men, aged between 48 and 74 years, were all found at necropsy to have severe coronary arteriosclerosis. Two were using self-propelled roller-type mowers and two were using petrol-engined rotary mowers that required pushing (the type of mower is not known in the fifth case), and they had been at their tasks for between 20 and 75 min. It seems likely that the physical exertion associated with cutting the grass led to these men’s deaths. A report from New Zealand describes foot injuries associated with use of "hover" mowersThirty-four such accidents were reported in the Wellington area between 1983 and 1991, and Paterson and Horne were able to contact seventeen of the victims. A certain amount of carelessness seems to have been involved in the accidents, since sixteen occurred on steep slopes and eight subjects were wearing only sports shoes or sandals, both factors that the manufacturers of air-cushion mowers warn against. Fifteen patients required hospital admission, eight had all or part of a big toe amputated, and fifteen reported post-traumatic pain. Most patients had to modify their jobs and recreational activities in some way, and two were forced to change their occupations. Clearly, cutting the grass should be left to the fit and well shod.
John McConnell 1. Cooke CT, Margolius KA. Sudden death while lawnmowing. Med JAust 1992; 157: 720. 2. Paterson S, Home G. Air cushion mower foot injuries N Z Med J 1992; 105: 456.
Burps bust bolus blockage unusual for various beverages to be taken for what is as "medicinal purposes", among them blackcurrant and hot chocolate drinks, whisky, brandy, Coca-Cola, and Guinness. Wait a minute, rewind-surely not Coca-Cola, the drink that makes the world sing in perfect harmony? Indeed yes, Coca-Cola. According to Karanjia and Rees,l this fizzy drink is an effective method of clearing bolus obstruction in the oesophagus. In 13 episodes of bolus obstruction in 8 patients with benign oesophageal stricture, Coca-Cola administered before endoscopy in 6 episodes cleared the obstruction before the instrument was inserted. In 5 of the other 7 episodes in which Coca-Cola was not given, the bolus had to be removed piecemeal, the endoscope having to be passed at least twice in each case. In 2 cases endoscopy had to be abandoned, but the Coca-Cola did the trick. The authors speculate that fizzy drinks, including champagne for those who can afford it, might penetrate the bolus and induce its disintegration with the release of carbon dioxide within the bolus. They add that if the drink were to seep through the bolus, the release of gas from the stomach "might dislodge the bolus at eructation". A case of one burp and it’s gone? It is
not
euphemistically described
Pia Pini 1. Karanjia ND, Rees M The use of Coca-Cola m the management of bolus obstruction in
benign oesophageal
stricture
Ann R Coll
Surg 1992, 75: 94-95.