Treatment of hypertension

β-blockers have been used widely in the treatment of hypertension and are recommended as first-line drugs in hypertension guidelines. However, a preliminary analysis has shown that atenolol is not very effective in hypertension. The paper aimed substantially to enlarge the data on atenolol and analyse the effect of different β blockers.

The Cochrane Library and PubMed were searched for β blocker treatment in patients with primary hypertension. Data were then entered into the Cochrane Collaboration Review Manager package and were summarised in meta-analyses. 13 randomised controlled trials (n=105 951) were included in a meta-analysis comparing treatment with β blockers with other antihypertensive drugs. Seven studies (n=27 433) were included in a comparison of β blockers and placebo or no treatment. The relative risk of stroke was 16% higher for β blockers (95% CI 4–30%) than for other drugs. There was no difference for myocardial infarction. When the effect of β blockers was compared with that of placebo or no treatment, the relative risk of stroke was reduced by 19% for all β blockers (7–29%), about half that expected from previous hypertension trials. There was no difference for myocardial infarction or mortality.

In comparison with other antihypertensive drugs, the effect of β blockers is less than optimum, with a raised risk of stroke. Hence, we believe that β blockers should not remain first choice in the treatment of primary hypertension and should not be used as reference drugs in future randomised controlled trials of hypertension.

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Sprouts are for life not just for Christmas

Whether consumption of cruciferous vegetables protects against lung cancer is unclear, largely because of potential confounding factors. The authors therefore studied the role of cruciferous vegetables in lung cancer, using a new technique which includes stratifying by GSTM1 and GSTT1 status, two genes implicated in the elimination of isothiocyanates, the likely chemopreventative compound.

In 2141 cases and 2168 controls, weekly consumption of cruciferous vegetables protected against lung cancer in those who were GSTM1 null (odds ratio=0·67, 95% CI 0·49–0·91), GSTT1 null (0·63, 0·37–1·07), or both (0·28, 0·11–0·67). No protective effect was seen in people who were both GSTM1 and GSTT1 positive (0·88, 0·65–1·21). Similar protective results were noted for consumption of cabbage and a combination of broccoli and brussels sprouts. These data provide strong evidence for a substantial protective effect of cruciferous vegetable consumption on lung cancer.

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NICE to issue faster guidance

The National Institute for Health and Clinical Excellence (NICE), which advises the NHS in England on the use of medical treatments, has developed a more rapid process for assessment that will be used initially for lifesaving medicines, including several cancer drugs.

The new "single technology appraisal" process will enable NICE to develop guidance on drugs selected for rapid assessment within eight weeks—much more quickly than the current average of 18 months. It will initially be applied to lifesaving drugs that have already been licensed and to new lifesaving medicines close to the time that they first become available.

In the faster appraisal system, NICE will ask for a single submission of evidence from the manufacturer of the drug being appraised. The institute will then independently assess this evidence and move rapidly to the final stage of the process—in which organisations can appeal against the decision—in cases for which the draft recommendations are in agreement with the drug's licence. Currently, after deciding the scope of the appraisal, NICE commissions an independent academic centre to report on the published evidence, which is then considered by an independent committee.

Their appraisal is widely circulated for comment before the final guidance is produced. Patients' and carers' groups, bodies representing health professionals, and the manufacturers of the drug being appraised are also invited to submit evidence.

The new appraisal process will initially be applied to 14 drugs—13 of which are cancer drugs—that have already been referred to NICE. These include docetaxel (Taxotere) for breast cancer; paclitaxel (Taxol) for breast cancer; rituximab (MabThera) for non-Hodgkin's lymphoma; trastuzumab (Herceptin) for breast cancer; and bortezomib (Velcade) for multiple myeloma.

NICE estimates that the more rapid process will result in guidance being published 6-15 months earlier than with the existing process, with more than half of appraisals being published at least eight months earlier.

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Patient safety in the NHS has improved

The study, based on surveys of NHS trusts, found that not enough was being done to share lessons and solutions that had been learnt from previous adverse events. As many as half of the incidents in which NHS patients are unintentionally harmed could be avoided if lessons were properly shared, the watchdog concluded.

A Safer Place for Patients by the Audit Office reports on findings from 256 NHS acute, ambulance, and mental health trusts. The National Audit Office found a year on year increase in incidents related to patient safety—a trend it put down to the drive to encourage staff to report adverse events.

According to the surveys, patients reported about 980 000 incidents and near misses in 2004-5. The estimated cost to the NHS of these incidents is some £2bn a year. Falls and injuries were the most common incidents to be reported. But staff see this as having no direct link to the quality of care provided, the National Audit Office said.

But under-reporting was still significant for deaths and serious incidents—events that staff were more concerned to report. The office estimated that 22% of incidents went unreported—mainly medication errors and incidents leading to serious harm.

There had been improvements in encouraging doctors to report adverse incidents. This group is seen as most likely to overlook the need to do so. Some trusts had, as part of their performance management regimes, introduced a review of doctors' attitudes towards patient safety and evidence of reporting adverse events.

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