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THE LANCET • Vol 358 • November 24, 2001 1787

SCIENCE AND MEDICINE

Renewed interest in leucocyte count as prognostic indicator after AMI

Researchers report this monththat a high white blood cell

count on admission to hospital isassociated with a poor prognosisafter acute myocardial infarction(AMI) in elderly patients.

In an observational study,Harlan Krumholz (Yale UniversitySchool of Medicine, New Haven,CT, USA) and colleagues foundthat patients in the highest quintileof leucocyte counts, taken within 24h of hospital admission, had a threetimes higher risk of dying within30 days than those in the lowest quintile (32·3% vs 10·3%).Although the reason for this associ-ation is unclear, the leucocytecount “was a remarkably strongpredictor of outcome”, saysKrumholz, “and from a clinicalpoint of view, our study says to car-diologists, ‘here is something youmight want to look at as part of aprognostic work-up’”.

The use of leucocyte counts as aprognostic indicator after AMI

goes back to the 1970s, but, saysKrumholz, “it fell off everyone’sradar screen as other tests becameavailable”. To re-examine theissue, the investigators took advan-tage of data that were collected aspart of a national initiative toimprove care for Medicare benefi-ciaries. In this effort, the casenotes for every US Medicarebeneficiary hospitalised for AMIover an 8-month period wereabstracted. “This gave us theopportunity to look at which fac-tors are most strongly associatedwith prognosis in the elderly”,explains Krumholz. 153 231patients aged 65 years or olderwere evaluated and, after adjust-ment for confounding factors, aleucocyte count in the highestquintile proved to be a strong,independent predictor of 30-daymortality (odds ratio 2·37 relativeto the lowest quintile, 95% confi-dence interval 2·25–2·49; J Am CollCardiol 2001; 38: 1654–61).

“These results fit in well withwhat we already knew about the useof leucocyte counts as a marker ofrisk for patients with acute AMI”,says Mark Furman (University ofMassachusetts Medical School,Worcester, MA, USA). Indeed, at the recent American HeartAssociation meeting (Anaheim,CA, USA; Nov 11–14), Furmanreported an association betweenleucocyte counts and mortality inunstable angina as well as in AMI.

For now, the mechanism behindsuch associations remains unclear.Furman favours the idea that theleucocyte count is “a crude markerof inflammation, which mightrepresent the extent and stability ofthe atherosclerosis in the coronaryartery”. Only further clinical andbasic research will show whetherthis is the case or whether anincrease in leucocytes is a directcausal factor.

Jane Bradbury

European action on antimicrobial resistance

Multinational initiatives to tacklethe growing problem of

antibiotic resistance were announcedat the European Conference onAntibiotic Use in Europe (Brussels,Belgium; Nov 15–17). Theconference was the launch meetingfor the European Surveillance ofAntibiotic Consumption (ESAC)project, funded by the EuropeanCommission, which will collectinformation on antibiotic use inEuropean Union (EU) memberstates and several other Europeancountries.

Available data on antibiotic con-sumption in Europe must be boughtfrom commercial sources, which donot reveal their collection methods.An analysis of commercially availablefigures (see Lancet 2001; 357:1851–53) showed striking differencesbetween countries. For example,compared with the Netherlands,Denmark, and Sweden, France,Spain, and Portugal use about twiceas many antibiotics per head of popu-lation.

Frank Vandenbroucke, BelgiumMinister for Social Affairs andPensions, asked in a speech at theconference: “what is the added valueto the quality of life of using suchlarge amounts of antibiotics?” Little ifany, most experts would agree, but

ESAC will hopefully provide thebasis for reliable answers to suchquestions in a 2-year project that willrun until October, 2003.

The cost and volume of antibioticconsumption in community andhospital settings will be measured atnational and regional levels. TheESAC database will also containinformation on determinants of antibi-otic use, indicators of good practice,and the strategies used in differentcountries to control antibiotic con-sumption. In addition to the 15 EUmember states, 10 countries havejoined ESAC and collaborators arebeing sought in additional Europeancountries (see www.uia.ac.be/esac/).

The EU has recognised thatconcerted action is necessary toencourage prudent use of anti-microbials in medicine, and theconference coincided with theadoption by the EU of a strategyagainst antimicrobial resistance,which is due to be implemented bythe end of next year. In announcingthe strategy at the meeting, MagdaAelvoet, Belgium Minister of PublicHealth, said that prudent use ofantibiotics is too cautious a term.“What we mean is less use”, sheadded.

John McConnell

News in briefLung-disease mortality is risingMortality due to lung disease in theUK is now greater than that due tocoronary heart disease or non-respi-ratory cancer, according to a newreport published on Nov 21 by theBritish Thoracic Society. Thereport, The Burden of Lung Disease,found that the number of womendying in the UK from lung diseasesincreased by more than a quarterfrom 1984–98, and mortality fromlung cancer in women has nowovertaken breast cancer as a killer ofwomen. Lung cancer is now themost common cancer in men.

Menstrual cycle and diabetesUS researchers report that long orirregular menstrual periods increasea woman’s risk of developing type 2 diabetes in the future. Theresearchers analysed 101 073women taking part in the Nurses’Health Study who had no history ofdiabetes. After adjusting for con-founding factors, they found thatwomen whose cycles were longerthan 40 days, or those who had veryirregular cycles, had about twice therisk of developing type 2 diabetesduring the following 8 years, com-pared with women with a usual cyclelength (JAMA 2001; 286: 2421–26).