||News From BMJ
Multiple Vaccinations And Gulf War Syndrome
Hotopf M, David A, Hull L, Ismail K, Unwin C, Wessely S
Gulf War Research Unit, Guy's, King's College, and St Thomas's School of Medicine, King's College London, London SE5 8AZ.
Objectives: To explore the relation between ill health after the Gulf war and vaccines received before or during the conflict. To test the hypothesis that such ill health is limited to military personnel who received multiple vaccines during deployment and that pesticide use modifies any effect.
Design: Cross sectional study of Gulf war veterans followed for six to eight years after deployment.
Setting: UK armed forces.
Participants: Military personnel who served in the Gulf and who still had their vaccine records.
Main outcome measures: Multisymptom illness as classified by the Centers for Disease Control and Prevention; fatigue; psychological distress; post-traumatic stress reaction; health perception; and physical functioning.
Results: The response rate for the original survey was 70.4% (n=3284). Of these, 28% (923) had vaccine records. Receipt of multiple vaccines before deployment was associated with only one of the six health outcomes (post-traumatic stress reaction). By contrast five of the six outcomes (all but post-traumatic stress reaction) were associated with multiple vaccines received during deployment. The strongest association was for the multisymptom illness (odds ratio 5.0; 95% confidence interval 2.5 to 9.8).
Conclusion: Among veterans of the Gulf war there is a specific relation between multiple vaccinations given during deployment and later ill health. Multiple vaccinations in themselves do not seem to be harmful but combined with the "stress" of deployment they may be associated with adverse health outcomes. These results imply that every effort should be made to maintain routine vaccines during peacetime.
News From BMJ
Intensive Blood Glucose Control Policy In Patients With Type 2 Diabetes: Economic Analysis
Gray A, Raikou M, McGuire A, Fenn P, Stevens R, Cull C, Stratton I, Adler A, Holman R, Turner R
Health Economics Research Centre, Department of Public Health, University of Oxford, Institute of Health Sciences, Headington OX3 7LF.
Objective: To estimate the cost effectiveness of conventional versus intensive blood glucose control in patients with type 2 diabetes. Design: Incremental cost effectiveness analysis alongside randomised controlled trial. Setting: 23 UK hospital clinic based study centres.
Participants: 3867 patients with newly diagnosed type 2 diabetes (mean age 53 years).
Interventions: Conventional (primarily diet) glucose control policy versus intensive control policy with a sulphonylurea or insulin.
Main outcome measures: Incremental cost per event-free year gained within the trial period.
Results: Intensive glucose control increased trial treatment costs by £ 695 (95% confidence interval £555 to £836) per patient but reduced the cost of complications by £957 ( £233 to £1681) compared with conventional management. If standard practice visit patterns were assumed rather than trial conditions, the incremental cost of intensive management was £478 (- £275 to £1232) per patient. The within trial event-free time gained in the intensive group was 0.60 (0.12 to 1.10) years and the lifetime gain 1.14 (0.69 to 1.61) years. The incremental cost per event-free year gained was £1166 (costs and effects discounted at 6% a year) and £563 (costs discounted at 6% a year and effects not discounted). Conclusions: Intensive blood glucose control in patients with type 2 diabetes significantly increased treatment costs but substantially reduced the cost of complications and increased the time free of complications.
News From BMJ
Patient Preference Regarding Therapy For Atrial Fibrillation
Protheroe J, Fahey T, Montgomery AA, Peters TJ
Division of Primary Health Care, Department of Social Medicine, University of Bristol, Bristol BS8 2PR.
Objective: To investigate the impact of patients' preferences for the treatment of atrial fibrillation, by using individualised decision analysis combining probability and utility assessments into a decision tree.
Design: Observational study based on interviews with patients. Setting: Eight general practices in Avon.
Participants: 260 randomly selected patients aged 70-85 years with atrial fibrillation.
Main outcome measures: Patients' treatment preferences regarding anticoagulation treatment (warfarin) after individualized decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription. Results: Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval 50% to 71%) would prefer anticoagulation treatment-considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa=0.25 or less). Of 38 patients whose decision analysis indicated a preference for anticoagulation, 17 (45%) were being prescribed warfarin; on the other hand, 28 (47%) of 59 patients were not being prescribed warfarin although the results of their decision analysis suggested they wanted to be.
Conclusions: In the context of shared decision making, individualised decision analysis is valuable in a sizeable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published guideline recommendations. Decision analysis as a shared decision making tool should be evaluated in a randomised controlled trial.
News From BMJ
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