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《英国医生杂志》
Vaccination of elderly people can prevent herpes zoster
Herpes zoster and its deeply unpleasant complication, post-herpetic neuralgia, occur more frequently with increasing age, a phenomenon explained by waning cell mediated immunity to the virus. Although antiviral therapy reduces the severity and duration of the rash, it is ineffective in preventing the development of post-herpetic neuralgia. The results of a large randomised controlled trial of vaccination against Varicella zoster virus in people aged over 60 suggest that prevention may be better than cure.
Credit: NEW ENGLAND JOURNAL OF MEDICINE
Compared with placebo, vaccination with live attenuated Varicella zoster vaccine reduced the incidence of herpes zoster by 51.3% and of post-herpetic neuralgia by 66.5%. No severe adverse reactions occurred, although transient local symptoms, mainly varicella-like rashes at the site of injection, were common. With an annual incidence of herpes zoster in the placebo group of about 1 in 100, the number needed to treat is large. But the accompanying editorial reckons that, at around $2000 (￡1100; 1630) per quality adjusted life year gained, the vaccine is cost effective and the benefits of vaccination against Varicella zoster virus may be greater for adults than children.
New England Journal of Medicine 2005;352: 2271-84
Another genetic influence on warfarin metabolism found
Despite the difficulty of getting the daily dose right for individual patients, warfarin is used worldwide for preventing thromboembolism. A staggering two million prescriptions are written every year in the United States alone. Individual variation in the required dose is influenced by a patient's health, weight, diet, and use of other drugs. Genetic variants in the cytochrome P450 enzyme system, responsible for the metabolic clearance of the drug, also contribute. Patients with the less active *2 and *3 alleles of CYP2C9 require lower maintenance doses, have longer times to dose stabilisation, and are at higher risk for serious and life threatening bleeding.
Polymorphisms in the vitamin K epoxide reductase complex 1 gene (VKORC1) have now been shown to affect response to warfarin too. In a retrospective study of 186 US patients of European origin, about 25% of the variance in warfarin dose was explained by haplotypes of this gene. Confidence that this is more than a chance finding is greatly strengthened by the fact that the investigators were able to replicate the results in a second, larger group.
New England Journal of Medicine 2005;352: 2285-93
New treatment helps people with complicated grief
Opinions differ on whether complicated grief (prolonged intense feelings of disbelief, anger, bitterness, loss, and longing after bereavement) is a pathological condition or yet another example of the medicalisation of the human predicament. But it's certainly common, incapacitating, and difficult to treat. A group of investigators in the United States designed a psychotherapeutic strategy specifically for this condition and, despite the complexity of the intervention, succeeded in testing its efficacy against standard interpersonal psychotherapy in a randomised trial. Symptoms improved in both groups, but a higher proportion improved among those receiving the new treatment, and improvement tended to occur earlier in that group too.
The new intervention was implemented by experienced psychotherapists. It centres on the idea that coping with bereavement entails both adjustment to the loss and restoration of a satisfying life. Techniques included retelling the story of the death, imagining conversations with the deceased, and using questionnaires intended to prompt both positive and negative reminiscence. To help restore normal life, patients were encouraged to consider what they would like for themselves if their grief was not so intense. The therapist then helped patients to make concrete plans and identify ways to know that they were working towards their goals. Participants received 16 sessions over an average period of 19 weeks. Outcomes were evaluated blind by an independent assessor and by self report.
Credit: JAMA
Despite the superiority of the new treatment, only about half the participants showed improvement. And questions remain whether the intervention will work outside a research setting.
JAMA 2005;293: 2601-8
Meta-analysis finds antichlamydial treatment of no benefit in preventing coronary heart disease
Numerous studies have shown that indicators of infection with Chlamydia pneumoniae are associated with atherosclerosis and coronary heart disease, although arguments continue about how strong the relation is and whether it is causal. From a practical point of view, the important question is whether treating chlamydia is beneficial in the secondary prevention of coronary artery disease. So far, the results of trials have been inconsistent. A systematic review and meta-analysis now make things clearer. Eleven prospective, randomised, placebo controlled trials of antichlamydial antibiotic treatment for patients with coronary artery disease were identified. These trials randomised a total of nearly 20 000 people. When pooled, the data showed no effect of antibiotics on all cause mortality, rates of myocardial infarction, or a combined end point of myocardial infarction and unstable angina.
Herpes zoster and its deeply unpleasant complication, post-herpetic neuralgia, occur more frequently with increasing age, a phenomenon explained by waning cell mediated immunity to the virus. Although antiviral therapy reduces the severity and duration of the rash, it is ineffective in preventing the development of post-herpetic neuralgia. The results of a large randomised controlled trial of vaccination against Varicella zoster virus in people aged over 60 suggest that prevention may be better than cure.
Credit: NEW ENGLAND JOURNAL OF MEDICINE
Compared with placebo, vaccination with live attenuated Varicella zoster vaccine reduced the incidence of herpes zoster by 51.3% and of post-herpetic neuralgia by 66.5%. No severe adverse reactions occurred, although transient local symptoms, mainly varicella-like rashes at the site of injection, were common. With an annual incidence of herpes zoster in the placebo group of about 1 in 100, the number needed to treat is large. But the accompanying editorial reckons that, at around $2000 (￡1100; 1630) per quality adjusted life year gained, the vaccine is cost effective and the benefits of vaccination against Varicella zoster virus may be greater for adults than children.
New England Journal of Medicine 2005;352: 2271-84
Another genetic influence on warfarin metabolism found
Despite the difficulty of getting the daily dose right for individual patients, warfarin is used worldwide for preventing thromboembolism. A staggering two million prescriptions are written every year in the United States alone. Individual variation in the required dose is influenced by a patient's health, weight, diet, and use of other drugs. Genetic variants in the cytochrome P450 enzyme system, responsible for the metabolic clearance of the drug, also contribute. Patients with the less active *2 and *3 alleles of CYP2C9 require lower maintenance doses, have longer times to dose stabilisation, and are at higher risk for serious and life threatening bleeding.
Polymorphisms in the vitamin K epoxide reductase complex 1 gene (VKORC1) have now been shown to affect response to warfarin too. In a retrospective study of 186 US patients of European origin, about 25% of the variance in warfarin dose was explained by haplotypes of this gene. Confidence that this is more than a chance finding is greatly strengthened by the fact that the investigators were able to replicate the results in a second, larger group.
New England Journal of Medicine 2005;352: 2285-93
New treatment helps people with complicated grief
Opinions differ on whether complicated grief (prolonged intense feelings of disbelief, anger, bitterness, loss, and longing after bereavement) is a pathological condition or yet another example of the medicalisation of the human predicament. But it's certainly common, incapacitating, and difficult to treat. A group of investigators in the United States designed a psychotherapeutic strategy specifically for this condition and, despite the complexity of the intervention, succeeded in testing its efficacy against standard interpersonal psychotherapy in a randomised trial. Symptoms improved in both groups, but a higher proportion improved among those receiving the new treatment, and improvement tended to occur earlier in that group too.
The new intervention was implemented by experienced psychotherapists. It centres on the idea that coping with bereavement entails both adjustment to the loss and restoration of a satisfying life. Techniques included retelling the story of the death, imagining conversations with the deceased, and using questionnaires intended to prompt both positive and negative reminiscence. To help restore normal life, patients were encouraged to consider what they would like for themselves if their grief was not so intense. The therapist then helped patients to make concrete plans and identify ways to know that they were working towards their goals. Participants received 16 sessions over an average period of 19 weeks. Outcomes were evaluated blind by an independent assessor and by self report.
Credit: JAMA
Despite the superiority of the new treatment, only about half the participants showed improvement. And questions remain whether the intervention will work outside a research setting.
JAMA 2005;293: 2601-8
Meta-analysis finds antichlamydial treatment of no benefit in preventing coronary heart disease
Numerous studies have shown that indicators of infection with Chlamydia pneumoniae are associated with atherosclerosis and coronary heart disease, although arguments continue about how strong the relation is and whether it is causal. From a practical point of view, the important question is whether treating chlamydia is beneficial in the secondary prevention of coronary artery disease. So far, the results of trials have been inconsistent. A systematic review and meta-analysis now make things clearer. Eleven prospective, randomised, placebo controlled trials of antichlamydial antibiotic treatment for patients with coronary artery disease were identified. These trials randomised a total of nearly 20 000 people. When pooled, the data showed no effect of antibiotics on all cause mortality, rates of myocardial infarction, or a combined end point of myocardial infarction and unstable angina.