1 February 2008 Training on the correct way to lift heavy objects does not prevent back pain Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review BMJ Online First Editorial: Preventing back pain BMJ Online First Training showing the correct way to lift heavy objects does not prevent back injuries, according to a systematic review published on bmj.com today. Back pain is a highly prevalent complaint and a cause of much suffering. In the UK employers have to ensure workers get proper training on how to handle loads correctly and this generally includes advising workers on specific lifting techniques. However this study, which reviewed all the evidence currently available, found no evidence that the advice has any effect. The researchers looked at eleven studies: eight studies dealt with health workers who manually handled patients, the other three looked at baggage handlers and postal workers. All the participants in the studies worked in jobs where there was strain on the back and where there was the potential for alleviating any strain through an intervention such as training. None of the workers in the studies were actively seeking treatment for back pain. The researchers found no difference in back pain in studies where one group received training and the other didn‟t. Training compared to minor advice (a video) showed no effect on back pain after a year. Another trial showed no significant difference in back pain between one group who received training and another who were given back belts to wear. Training and physical exercise were compared in one trial and again no difference in back pain was found during a follow up less than a year later. Finally a group receiving both training and an assistive device was compared to a group receiving training only and another control group which received nothing – there was no difference in back pain at follow up. The researchers say either the advocated techniques do not actually reduce the risk of back injury, or workers do not significantly change their habits enough for it to make any difference. They conclude that we need a better understanding of the relationship between exposure to stresses on the back at work and the subsequent development of back pain in order to develop new and innovative ways of preventing back pain because of lifting. In an accompanying editorial Associate Professor Niels Wedderkopp says the current advice for people with back pain to stay active may not be appropriate for people whose work involves heavy lifting. He says: “A change of job and (prudently) staying active in daily life may be the best way for these patients to regain command of their back and their occupation.”
1 February 2008 Sugary soft drinks linked to increased risk of gout in men Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study BMJ Online First Consumption of sugar sweetened soft drinks and fructose is strongly associated with an increased risk of gout in men, finds a study published on bmj.com today. Gout is a joint disease which causes extreme pain and swelling. It is most common in men aged 40 and older. It is caused by excess uric acid in the blood (hyperuricaemia) which leads to uric acid crystals collecting around the joints. In the United States, levels of gout have doubled over the last few decades, which coincided with a substantial increase in the consumption of soft drinks and fructose (a simple sugar and the only carbohydrate known to increase uric acid levels). Conventional dietary recommendations for gout have focused on the restriction of purines (found in high levels in meat and meat products, especially liver and kidney) and alcohol but with no restriction of sugar sweetened soft drinks. So researchers in the US and Canada examined the relation between intake of sugar sweetened soft drinks and fructose and the risk of gout. They followed over 46,000 men aged 40 years and over with no history of gout. The men completed regular questionnaires on their intake of more than 130 foods and beverages, including sugar sweetened soft drinks and diet soft drinks, over a period of 12 years. Different types of fruits and fruit juices (high in natural fructose) were also assessed. At the start of the study, and every two years thereafter, information on weight, regular use of medications and medical conditions were also recorded. Gout was diagnosed according to American College of Rheumatology criteria. During 12 years of follow-up, the researchers documented 755 newly diagnosed cases of gout. The risk of gout increased with increasing intake of sugar sweetened soft drinks. The risk was significantly increased with an intake level of 5-6 servings per week and the risk was 85% higher among men who consumed two or more servings of sugar-sweetened soft drinks per day compared to those who consumed less than one serving per month. These associations were independent of other risk factors for gout such as body mass index, age, diuretic use, high blood pressure, alcohol intake, and dietary factors. Diet soft drinks were not associated with the risk of gout. Fruit juice and fructose rich fruits (apples and oranges) were associated with a higher risk of gout. However, the authors stress that this finding needs to be balanced against the benefit of fruit and vegetable intake to prevent other chronic disorders like high blood pressure, coronary heart disease, stroke and certain types of cancer. In conclusion, our findings provide prospective evidence that consumption of sugar sweetened soft drinks and fructose is strongly associated with an increased risk of gout, say the authors. Furthermore, fructose rich fruits and fruit juices may also increase the risk. In contrast, diet soft drinks were not associated with the risk of gout.
1 February 2008 Is the obesity epidemic exaggerated? Head to Head: Is the obesity epidemic exaggerated? BMJ Volume 336 pp 244-5 Last week, the UK health secretary declared that we are in a grip of an obesity epidemic, but does the evidence stack up? Researchers in this week‟s BMJ debate the issue. Claims about an obesity epidemic often exceed the scientific evidence and mistakenly suggest an unjustified degree of certainty, argue Patrick Basham and John Luik. For example, the average population weight gain in the United States in the past 42 years is 10.9kg or 0.26kg a year. Yet, between 19999-2000 and 2001-2002, there were no significant changes in the prevalence of overweight or obesity among US adults or in the prevalence of overweight among children. Furthermore, they say, the categories of normal, overweight, and obese is entirely arbitrary and at odds with the underlying evidence about the association between body mass index and mortality. For example, the study on which the bands for overweight and obesity in the US are based found that the death risks for men with a body mass index of 19-21 were the same as those for men who were overweight and obese (29-31). Other studies have shown negligible differences between body mass index and death rates. The association of overweight and obesity with higher risks of disease is equally unclear, they write. And, despite supposedly abnormal levels of overweight and obesity, life expectancy continues to increase. They suggest that some public health professionals may have deliberately exaggerated the risks of overweight and obesity, and our capacity to prevent or treat them on a population wide basis, in the interests of health. They warn that this has unwelcome implications for science policy and for evidence based medicine. But Robert Jeffery and Nancy Sherwood argue that a large body of scientific evidence shows that obesity is a major global health problem. In the US, the prevalence of obesity in 1976-80 was 6.5% among 6-11 year olds and 5% among 12-17 year olds. In 2003-4 it was 19% and 17% respectively. Europe can also expect to see the numbers of overweight and obese children rising by around 1.3 million a year by 2010. The risks of obesity on many serious health conditions including high blood pressure, diabetes, heart disease and some forms of cancer, are also serious and well established, they write. Most health economists and epidemiologists agree that the contribution of obesity to current healthcare costs is high and that it is likely to get much higher. Some have argued that we may even see real falls in life expectancy within a few decades, they add. In summary, a large body of evidence documents that over-nutrition and obesity are a major global health problem, say the authors. With the continuing rise in obesity and limited treatment efficacy, options for averting a poor public health outcome seem to rest either on the hope that scientists are wrong in their projections or speedy investment in the development of more effective public health measures to deal with it. They think the second option a more prudent scientific and policy choice.
1 February 2008 Parenting programme does not prevent toddler behaviour problems Universal parenting programme to prevent early childhood behaviour problems: cluster randomised trial BMJ Online First A study of the first universal parenting programme, designed to prevent early child behaviour problems, shows that it has little impact on toddler behaviour. The study, conducted at the Centre for Community Child Health (CCCH) in Melbourne, Australia, is published on bmj.com today. Behaviour problems affect up to 20 per cent of children and have major personal, societal and economic ramifications. Left untreated, up to half of behaviour problems in preschool children develop into later mental health problems. Prevention targeted to high-risk families can be effective, but has limited reach and may stigmatise. Universal programmes offered to all families could address these concerns, but their effectiveness is uncertain. Researchers from the CCCH and the Parenting Research Centre, with input from maternal and child health nurses, designed a programme suitable for all parents to be delivered by trained health professionals in primary care. The programme aimed to prevent child behaviour problems, such as defiance and aggression, and improve parenting and maternal mental health. Over 700 mothers of 8 month-old infants participated in the study and were randomised to either the programme (three sessions at age 8-15 months) or usual care from their local Maternal and Child Health centre. Mothers were surveyed throughout the study and their mental health was assessed when their children reached 18 and 24 months. At 18 months, child behaviour and parenting scores were similar between the two groups. By age 24 months, parents on the programme were less likely to report harsh or abusive parenting and unreasonable expectations of child development, but there was no improvement in maternal distress or toddler behaviour. This was the first trial to evaluate a universal parenting programme involving families from all social backgrounds, say the authors. They conclude that the outcomes are insufficient to support widespread introduction of this programme to prevent toddler behaviour problems. 1 February 2008 European regulatory agencies should employ full time statisticians Open letter: European regulatory agencies should employ full time statisticians BMJ Volume 336 p 250 European regulatory agencies should employ full time statisticians to enable competent licensing and labelling decisions to be made, argue leading statisticians in an open letter to this week‟s BMJ. Sara Hughes, Chair of PSI, the professional UK body of statisticians in the pharmaceutical industry, and director of statistics at GlaxoSmithKline, together with 34 colleagues set out what
they believe is a “major deficiency” in European regulatory agencies that are responsible for reviewing applications to market new medicines across the whole of the European Union. Only agencies in the UK, Germany, Sweden, and Austria employ several full time statisticians, and a few others employ a single statistician, they write. Some do not employ any full time statisticians – instead they rely on external consultants. Yet, statistics is central to the design of clinical trials and to the interpretation of their results. Unless the design and statistical analysis of a trial are appropriate, results cannot be considered reliable and no confidence can be placed in the subsequent clinical interpretation, they warn. Another important role of regulatory agencies is to provide scientific advice and general guidance on statistical issues, they add. But, without permanent statisticians, agencies are at risk of giving incomplete advice. In particular, they point out that innovation may be stifled if novel methods that are presented are methodologically sound but are disregarded because they are poorly understood by regulatory advisers. They argue that statistical review should be conducted by those who are professionally expert in the area, not by medical assessors with some knowledge of statistics. “We believe the current situation is unacceptable,” they say. “We call on the heads of the regulatory agencies in the EU that do not have full time statisticians in their organisations to rectify this as a matter of urgency.” 8 February 2008 Acupuncture can improve IVF success rates Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis BMJ Online First Preliminary results published on bmj.com today suggest that acupuncture given with embryo transfer can improve rates of pregnancy and live birth among women undergoing in vitro fertilisation. Some 10 to 15% of couples have difficulty conceiving at some point in their reproductive lives and seek specialist fertility treatment. A commonly used option is in vitro fertilisation, which involves retrieving a woman‟s egg, fertilising the egg in the laboratory, and then transferring the embryo back into the woman‟s womb. In 2000, approximately 200,000 babies worldwide were conceived through in vitro fertilisation. Because each cycle is expensive, lengthy, and stressful, new drugs and technologies have been developed to improve success rates, but progress has been limited. However, acupuncture has been used in China for centuries to regulate the female reproductive system. So researchers at the University of Maryland School of Medicine and the VU University Amsterdam set out to determine whether acupuncture given with embryo transfer improves the rates of pregnancy and live birth among women undergoing in vitro fertilisation.
They reviewed seven trials involving 1,366 women undergoing in vitro fertilisation. The trials compared acupuncture, administered within one day of the embryo transfer procedure, with sham acupuncture or no additional treatment. The overall quality of the trials was good and included a broad selection of women at various ages and with different causes and durations of infertility. Complementing the embryo transfer process with acupuncture increased the odds of pregnancy by 65% compared to sham acupuncture or no additional treatment. In absolute terms, this means that 10 women would need to be treated with acupuncture to bring about one additional pregnancy. In trials where the baseline pregnancy rates were already high, the benefit of acupuncture was smaller and non-significant. Although still somewhat preliminary, this review suggests that acupuncture given with embryo transfer can improve rates of pregnancy and live birth among women undergoing in vitro fertilisation, say the authors. In vitro fertilisation is an expensive procedure, costing an average of $12,400 per cycle in the United States, they add. So, even if the increased likelihood of success with acupuncture was small, it may still be cost-effective. They call for further studies to confirm these preliminary findings and to investigate the relation between baseline rate of pregnancy and the effectiveness of additional acupuncture. 8 February 2008 Depression among trainee doctors linked to medication errors Rates of medication errors among depressed and burned out residents: a prospective cohort study BMJ Online First Editorial: Medication errors caused by junior doctors BMJ Online First Doctors in training who are depressed are more than six times as likely to make medication errors as their non-depressed colleagues, finds a US study published on bmj.com today. Depression and burnout are highly prevalent among doctors in training in the US. Studies have found rates of burnout to be between 41 and 76%, while rates of depression range from 7 to 56%. Medication errors are also very common. In the US, up to 98,000 patients die each year due to medication errors, while in the UK, adverse events occur in more than 10% of hospital admissions, half of which may be preventable. The stress of resident training, including sleep deprivation and lack of leisure time, are the most commonly cited explanations, yet few studies have sought to quantify the relationship with patient safety. So researchers set out to determine the prevalence of depression and burnout among 123 paediatric residents at three children‟s hospitals in the United States and to establish if a relationship exists between these disorders and medication errors. One in five (20%) of the participating residents were depressed and almost three quarters (74%) were burned out, according to recognised criteria.
During the survey period, a total of 45 medication errors were made by participants. Those who were depressed made 6.2 times as many medication errors as their non-depressed colleagues. However, burnout did not appear to be associated with higher rates of medication errors. These findings indicate that mental health may be a more important contributor to patient safety than previously suspected, say the authors. The high burnout rate in this study, which is consistent with other studies, also raises questions about whether current methods of doctors‟ training generate avoidable stress that is detrimental to the health of residents, they add. The authors acknowledge several study limitations, including the fact that they collected their data before the implementation of work hour limits for residents in the US. However, recent studies suggest that work hour changes significantly decreased burnout scores but did not alter rates for depression. Our results highlight the need for better research on the mental health of doctors, write the authors. Further efforts to study and improve the working conditions and mental health of doctors should be a priority, they conclude. Although the suggestion that medication errors may be linked to depression and burnout seems reasonable, these results are far from conclusive, warn researchers from the University of Aberdeen in an accompanying editorial. Large, prospective, and appropriately designed studies are needed to clarify the roles of individual factors involved in error generation, they say. 8 February 2008 One in five hospital patients are malnourished Editorial: Malnutrition in hospitals BMJ Volume 336, pp 290 About 20% of patients in general hospitals are malnourished, or thin and losing weight, or both, warn experts in this week‟s BMJ. And up to 80% of these patients enter and leave hospital without any action being taken to treat their malnutrition because screening tools are underused and poorly enforced, they add. Malnutrition is a common cause and consequence of illness particularly in older people, write Professors Mike Lean and Martin Wiseman. The number of malnourished people leaving NHS hospitals in England has risen by 85% over the past 10 years and is still rising. Malnutrition affects the function and recovery of every organ system, increases the risk of infection, extends hospital stay, and makes readmission more likely. So clinicians need to be able to identify patients who have malnutrition or are at risk of malnutrition. So how can this be achieved, they ask? Several scoring systems that allow health professionals to identify and refer adults at risk of malnutrition exist, but they need to be validated before use in the community and hospital settings. In 2006, the National Institute for Health and Clinical Excellence (NICE) recommended that all patients in hospital should be screened and monitored regularly for malnutrition, but these standards are weakly policed and are probably insufficient to stop many elderly people becoming malnourished if the quality of food is poor and there is a lack of staff to feed people.
Nutritional support is an important part of medical treatment, say the authors, yet hospital food is still provided by caterers who lack validated training in nutrition. Malnutrition is also often overlooked in residential care homes. They believe the final solution to malnutrition in hospitals probably lies in recognising human nutrition as a discrete discipline, in which all medical graduates should reach a minimum level of competence, and some will specialise. As such, they call for a basic understanding of human nutrition to be part of medical training and formal course in nutrition to be a requirement for higher training in medical specialties such as cardiology, diabetes, and public health. 8 February 2008 Changing parental behaviour key to tackling cot deaths Does cot death still exist? BMJ Volume 336 pp 302-4 Getting parents to stop smoking during pregnancy and to follow safe sleeping advice is key to tackling sudden unexplained infant deaths, according to an article in this week‟s BMJ. The term sudden infant death syndrome (SIDS) was introduced in 1969 as a recognised category of natural death that carried no implication of blame for bereaved parents. Since then, however, a lot has been learnt about risk factors, such as smoking and the role of parenting in cot death, undermining the popular myth that cot death is a bolt from the blue that can strike any child from any family. So, in a special report, freelance journalist Jonathan Gornall asks whether it is time to stop classifying unexplained infant deaths as SIDS and instead focus on reducing the risks that we now know account for most sudden infant deaths. In October, Britain‟s leading SIDS research team concluded that maternal smoking during pregnancy – already a recognised factor in 90% of cot death cases – was directly responsible for 60% of such deaths. The Foundation for the Study of Infant Death endorsed this, saying: “If no women smoked in pregnancy, about 60% of cot deaths could be avoided, reducing the number of deaths in the UK from around 300 to 120 a year.” Heeding advice on sleeping position has also had an impact. Since the 1991 Back to Sleep campaign, the number of cases in the UK has fallen by 75%. However, a 2006 study found that the proportion of SIDS babies who died while co-sleeping with their parents had risen from 12% in 1984 to 50% in 2003. However many SIDS cases there are, the fact that by the foundation‟s own estimation most are now attributable to modifiable parental behaviour suggests the need for a fundamental rethink, writes Gornall. Can the foundation continue to justify funding the hunt for the elusive “cause” of SIDS when even scientists can‟t agree on where to look for an answer, he asks? Attitudes must change, he says. Efforts must focus on educating women who smoke throughout their pregnancies and those parents who continue to endanger their infants with other unsafe parenting practices, whether through ignorance or carelessness.
SIDS campaigners, many of them cot death parents whose children died before key risk factors were as well understood as they are today, have worked hard to ensure that parents do not suffer the additional burdens of suspicion and stigma, he writes. Yet the flip side of this coin is the need to confront the hard truths about cot death if the “reduce the risk” message is to be brought home to those parents who remain the hardest to reach and whose children are most at risk. 8 February 2008 Government targets to cut smoking in pregnancy “unrealistic” Personal View: We need better data on smoking in pregnancy BMJ Volume 336 p 330 National targets to reduce smoking in pregnancy are unreliable and unrealistic because they are based on incomplete data, argues a midwife in this week‟s BMJ. The initial national target was to reduce smoking in pregnancy from 23% in 1995 to 18% by 2005 and now to 15% by 2010. An additional requirement is to reduce the rate of mothers who are smoking at delivery by 1% year on year, specifically focusing on disadvantaged women to tackle inequalities in infant mortality. Yet, according to Department of Health figures published in June, only a quarter of Primary Care Trusts achieved this target in 2005-7. Carmel O‟Gorman, a midwife specialising in smoking cessation at the Good Hope Hospital in Birmingham, is concerned by how realistic this target is and whether it is achievable within the required timescale. The quality of current smoking data makes it difficult to set local targets and baselines and to monitor progress, she warns. The latest infant feeding survey shows marked variations in smoking in pregnancy by mother‟s social class and age. But this survey is only undertaken every five years and cannot provide local information. To provide a more timely and regional breakdown of the number of mothers smoking at delivery, she believes that all hospital trusts with maternity services should collect data on smoking, though she acknowledges there are problems with data recording. Another weakness is that the data are based on self-reporting and should be interpreted with caution, she warns. She suggests measuring cotinine levels (a by-product of nicotine) during pregnancy and at delivery to help increase the trustworthiness of data and clarify the true scale of the problem. Given these problems, her view is that the resultant targets are unreliable and unrealistic, which can be demotivating and cause needless stress for those involved. Collecting quality data isn‟t just about meeting targets, she says, it is key to knowing whether our interventions are improving health. She describes successfully working with women and their partners to prevent postnatal relapse back to smoking, but points out that not all of these may be measurable in the target driven NHS.
15 February 2008 Suicide rates in young men at lowest levels since 1970s Suicide rates in young men in England and Wales in the 21st century: time trend study BMJ Online First The population impact on incidence of suicide and non-fatal self harm of regulatory action against the use of selective serotonin reuptake inhibitors in under 18s in the United Kingdom: ecological study BMJ Online First Editorial: Antidepressants and suicide BMJ Online First The reasons for the steady decline in suicides among young people in the UK are explored in two studies by researchers from the University of Bristol published on bmj.com today. The studies were carried out in collaboration with the Office for National Statistics and IMS Health. The first shows that fewer young men in England and Wales are dying by suicide than at any time in the last 30 years. Contributory factors probably include less unemployment and laws that have reduced the risks from car exhaust fumes. The researchers carried out a time trend analysis among men and women aged 15-24 and 25-34 between 1968 and 2005 using data on suicide mortality, population statistics and surveys, prescribing information and data on unemployment and divorce. They found that for 15-24 year-old men, the overall suicide rate dropped from 16.6 per 100,000 people in 1990 to 8.5 per 100,000 in 2005. Amongst 25-34 year old men, overall suicide rates declined from 22.2 per 100,000 in 1990 to 15.7 per 100,000 in 2005. Various factors have played a part in this reduction to the suicide rate. Car exhaust emission legislation in 1993 has contributed to falling suicide rates, say the authors, because it has led to a marked reduction in car exhaust gas poisoning due to the increased number of cars with catalytic converters. This, however, is one of several factors at play including the impact of the suicide prevention policy initiatives in England and Wales. For women, suicide rates in the 21st century are at their lowest levels since 1968, but the proportion of women aged 15-34 committing suicide by hanging has increased massively from 5.7 per cent of all suicides to 47.3 per cent by 2005. Professor David Gunnell, co-author of the papers, said: “Favourable changes in several different factors – levels of employment, substance misuse and antidepressant prescribing as well as policy focus on suicide and vehicle exhaust gas legislation – may have contributed to the recent reductions.” The second study finds no effect on suicide of the recent restrictions on antidepressant prescribing to children and adolescents in the UK. They analysed three separate sets of data between 1993 and 2006 (SSRI antidepressant prescriptions to 12-19 year olds in the UK, annual deaths from suicide in 12-17 year olds in England and Wales, and hospital admissions for self-harm in 12-17 year olds in England).
But they found no evidence of a temporal association between trends in antidepressant prescribing and deaths from suicide or hospital admissions for self harm despite a halving in levels of prescribing following regulatory action in 2003. The authors say: “These findings are important because they suggest that reduced access to antidepressants in young people appears not to have had an adverse impact on suicide deaths.” An accompanying editorial suggests that sustained use of antidepressants is probably too rare to have much overall effect on risk of suicide in people living with depression.
15 February 2008 Should doctors advocate alternative sources of nicotine? Head to Head: Should doctors advocate snus and other nicotine replacements? BMJ Volume 336 pp 358-9 Should doctors suggest alternative sources of nicotine to people who are unable to give up cigarettes, asks this week's BMJ? Smoking currently kills over 100,000 UK citizens each year, predominantly from lung cancer, heart disease, and chronic obstructive pulmonary disease, writes John Britton, Professor of Epidemiology at City Hospital, Nottingham. Currently 77% of UK smokers want to quit, and 78% have tried and failed, mainly because of nicotine addiction. He argues that health professionals should strongly advise smokers to quit all nicotine use, and do all they can to support this. However, for those who try repeatedly and fail, or for those who are not ready to stop using nicotine, switching to a medicinal nicotine product is the logical best option. By far the safest alternative is the current range of nicotine replacement products, he says. But, if all else fails, there is a case for individual smokers trying smokeless tobacco, or snus, which is substantially less hazardous than smoking. Recent data from Sweden, where snus has been available for years, suggests that smokeless tobacco is an acceptable smoking substitute for some smokers. Yet, in the UK, it is illegal for a doctor or anyone else to supply snus. Britton believes that, as a measure of last resort in smokers who have tried all other cessation and substitution options, doctors would be justified in suggesting an individual trial of snus. Whether this approach will prove effective remains to be seen and desperately needs to be tested in clinical trials, he concludes. But Alexander Macara, President of the National Heart Forum, argues that this could result in increased use of tobacco. He points to evidence that smokeless tobacco is carcinogenic to humans. Studies have also shown increases in the risk of oral and pancreatic cancers and heart attacks related to the use of various smokeless tobacco products. He acknowledges that smokeless tobacco is less addictive than smoked tobacco, but warns that at least 60% of people who use snus to quit smoking become chronic snus users.
Both Action on Smoking and Health and the Royal College of Physicians of London have considered providing safer sources of nicotine as a harm reduction option, but Macara fears that, if legalised, snus might be taken up by people, especially the young, who might never have smoked tobacco but who may then progress to doing so. The tobacco industry‟s constant defence is that tobacco is a legal product, he says. But if we had known before tobacco was ever used, how disastrous it would prove to be, would it not have been banned in all its forms?
15 February 2008 One in four stroke patients die within a month Editorial: Functional status and long term outcome of stroke BMJ Volume 336 pp 337-8 Despite advances in prevention, acute care, and rehabilitation, 20-30% of stroke patients in the UK die within a month and 13% of survivors are discharged to institutional care, according to experts in this week‟s BMJ. Their views follow a study published on bmj.com last month which found the more independent patients are six months after a stroke, the better their chances of long term survival. Despite undoubted progress, we still have much to do, argue Richard Thomson and Helen Rodgers from Newcastle University‟s Medical Faculty. For example, most acute trusts in the UK now have a stroke unit, but in 2006 only 62% of patients in the UK were admitted to a stroke unit and only 54% spent more than half of their inpatient stay on one, they say. Thrombolysis (giving anti-clotting drugs within three hours of an acute stroke) reduces death and disability, yet in 2006 only 30 trusts in the UK provide this service, and even fewer provide it at all hours of the day, they add. And, although up to 20% of stroke patients may be eligible for thrombolytic treatment, in 2006 only 218 patients – less than 0.5% of patients with acute ischaemic stroke in England, Wales, and Northern Ireland – received it. Early supported discharge by a specialist stroke team can also improve outcome, yet provision of this service is limited. Research has largely focused on prevention and care soon after stroke, and less upon interventions to improve care for survivors and on how to minimise the long term effects of stroke. Patients and their carers often report feeling abandoned after discharge and that they are badly informed and supported, both practically and emotionally. The national stroke strategy, published in December 2007, emphasises the importance of service development and implementing evidence based practice as well as involving patients, carers, health professionals, social services, and charities in shaping local stroke services. Let us hope that these admirable aims will become the template for both commissioners and providers of care to seize the opportunity to enhance the health and wellbeing of a substantial and, to date, underserved group of patients, they conclude.
15 February 2008 Infertility will become more common in generations to come, say experts Editorial: Interpreting trends in fecundity over time BMJ Volume 336 pp 339-40 Infertility will become more prevalent in generations to come, but interpreting these trends is complicated, say researchers in this week‟s BMJ. Infertility is a common problem in affluent societies, write experts from Aarhus University Hospital Denmark and the University of California in an editorial. It affects around 15% of couples trying to conceive, although not all seek medical help. In some countries, up to 6% of children are conceived through assisted reproductive techniques. But examining changes in fecundity over time is difficult, say the authors, because fertility is determined by social, behavioural, and biological factors that cannot be reliably ascertained in studies based on retrospectively collected data. These cultural and social norms may mask more subtle biological changes in the population. More direct markers of fecundity are urgently needed, they say, and the time has probably come to include fecundity in ongoing representative health surveys. They predict that fecundity is expected to decline over time, even if no environmental causes are identified. This is because, with the advent of assisted conception, subfertile couples may have as many children as fertile couples, so genetic factors linked to infertility will become more prevalent in the generations to come. The best way to counteract infertility and help couples to have children naturally is to deal with the avoidable causes of subfecundity, say the authors, and there are good grounds for promoting further research and for trying to make up for the many years during which research into infertility has been neglected. The endocrine disruption hypothesis – which states that environmental chemicals may cause adverse development of sexual organs by interference with hormonal regulation – is just one of many hypotheses that deserve attention from funding agencies, they conclude.
15 February 2008 Group education for diabetes patients can change behaviour and improve health Effectiveness of the diabetes education for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial BMJ Online First Editorial: Structured education in people with type 2 diabetes BMJ Online First A structured group education programme for people with newly diagnosed type 2 diabetes can successfully change patients‟ attitudes and behaviour towards their condition and improve their health, according to a study published on bmj.com today.
Type 2 diabetes affects around 4-5% of European populations and consumes a disproportionate amount of health service resource. In the long-term, it can lead to serious complications such as blindness, kidney failure, and amputation. It is also associated with increased illness and premature death from heart disease. Although the Diabetes National Service Framework in the UK promotes group structured education, until now, there has been no scientific evaluation and no programmes meeting all the quality criteria identified by the National Institute for Health and Clinical Excellence. So researchers set out to test whether the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) structured education programme could fill this evidence gap. Their study involved 824 patients with newly diagnosed type 2 diabetes at 207 general practices in England and Scotland. The average age of participants was 59.5 years. Participants were divided into two groups. The intervention group received a six-hour structured group education programme delivered in the community by two trained health care professional educators. The control group received usual care. All patients were monitored over 12 months. The intervention group showed a modest but significant weight loss (1.1kg) at 12 months. The proportion giving up smoking was also significantly higher in the intervention group. However, there was no difference in blood glucose levels (HbA1c) between the groups. Self-reported physical activity was greater in the intervention group at 4 months, but this difference was not present at 8 and 12 months. But there was a greater improvement in risk for coronary heart disease at 12 months. The intervention group showed greater understanding of their illness and its seriousness. They showed a better perception of the duration of their diabetes and of their ability to affect the course of their diabetes through lifestyle changes. They also experienced less depression, which is often linked to poor blood sugar control and increased mortality in patients with diabetes. In summary, this programme encapsulates a patient centred approach to diabetes care, say the authors. This trial has filled an existing gap in the evidence base and has shown that group structured education focused on behaviour change can successfully engage patients in starting additional effective lifestyle changes sustainable over 12 months from diagnosis, they conclude. 22 February 2008 No good evidence that private treatment centres are value for money Independent sector treatment centres: the evidence so far BMJ Volume 336, pp 421-4 There is no good evidence that independent sector treatment centres have provided additional capacity, value for money, or high quality care, argue researchers in this week‟s BMJ. Despite this, the government is continuing with the programme. But Professor Allyson Pollock and Sylvia Godden from the University of Edinburgh warn that this will contribute to NHS deficits, NHS service closure and staff redundancies.
The policy of the Department of Health in England is to use NHS funds to contract with for-profit multinational healthcare corporations to deliver clinical services, they explain. Part of this policy is the £5bn independent sector treatment centre programme, which over the course of two phases (waves) aims to provide extra capacity to the NHS and reduce waiting times for elective surgery. Yet, four years into the programme, the Department of Health has not gathered adequate data to justify the policy, say the authors. They reviewed the available data and evidence in terms of the programme‟s objectives and found a worrying failure to collect and publish data on performance. For example, data on the number of available and occupied beds are collected annually from NHS Trusts, but no such data are collected from independent sector treatment centres. Without these data, it is impossible to assess the contribution that these centres make to capacity, productivity, or efficiency. A recent report by the Healthcare Commission found that incomplete and poor quality admissions and outpatient data from independent sector treatment centres limited their ability to assess quality of care. Furthermore, the first research on the quality of work undertaken by private centres, published in October 2005, stated that data were so variable in quality and so incomplete as to render “any attempt at commenting on trends and comparisons between schemes and with any external benchmarks, futile.” The Royal College of Surgeons of England also reported “increasing evidence” that these centres were unable to manage complications and patients were being readmitted to the NHS. The failure on the part of the DoH to collect meaningful systematic data about quality of care heightens concerns about standards of care, write the authors. Data on workforce, contract performance and finances are also lacking. The government‟s assurance that staff employed by the private sector in treatment centres would be „additional‟ rather than parasitic upon the NHS has not been honoured. It has reneged upon its original guarantees, so that more than a quarter of the staff employed by the private sector are NHS staff. Furthermore there is growing evidence that NHS funds are being diverted to the private sector for services they have failed to provide under the contract, they warn. The government‟s failure to collect and publish meaningful relevant data on the productivity, performance, staffing and quality of private independent treatment centres, and its refusal to provide any data on their value for money is worrying, they say. Professor Pollock cautions: “The policy of diverting scarce NHS funds into independent sector treatment centres is leading to fragmentation and financial instability and NHS beds and services are being closed to make way for the for-profit private sector. Despite assurances by the secretary of state for health, Alan Johnson, the available evidence suggests that the private sector is profiting at the expense of patients, the public, and the NHS.”
22 February 2008 Antioxidants do not help children with Down’s syndrome develop Supplementation with antioxidants and folinic acid for children with Down’s syndrome: randomised controlled trial BMJ Online First Editorial: Giving antioxidants to infants with Down’s syndrome BMJ Online First Giving children with Down‟s syndrome antioxidants and nutrients does not help their condition improve at all, according to a study published today on bmj.com. UK researchers studied the effect of giving such supplements to 156 babies under 7 months old with Down‟s syndrome over an 18-month period. Down‟s syndrome is the most common genetic cause of learning disability in the UK affecting around 1 in 1,000 new born babies. Previous studies have investigated the possibility that giving folate, antioxidants, or both might improve the effects of Down‟s syndrome, particularly language and psychomotor development. Although none have reported any significant effect, use of vitamin and mineral supplements is widespread in children with Down‟s syndrome in Europe and the USA due to marketing of commercial preparations claiming substantial benefits. In this study, the babies, from several sites in England, were split into four groups. One group was given a daily dose of antioxidants, one folinic acid, one a combination of antioxidants and folinic acid, and one a placebo. All the supplements were given in a powder that could be mixed with food or drink. After 18 months, the children remaining in the study were assessed for their mental and cognitive development. The researchers found that giving the supplements made no difference to the biochemical outcomes in the children and did not improve their language or psychomotor development. This study provides no evidence to support the use of antioxidant or folinic acid supplements in children with Down‟s syndrome, conclude the authors. Parents who choose to give supplements to their children need to weigh their hope of unproved benefits against potential adverse effects from high dose, prolonged supplementation. These findings are supported in an accompanying editorial, which states that until evidence of any benefit of expensive vitamin supplements is available, they cannot be recommended. 22 February 2008 Investigation reveals “invisible influence” of sponsors in medical education The invisible influence BMJ Volume 336, pp 416-7 Amid global calls to end drug companies‟ direct sponsorship of doctors‟ education, this week‟s BMJ reports on an investigation in Australia which reveals sponsor involvement in the education of thousands of general practitioners.
This weekend, a programme by the Australian Broadcasting Corporation will show that it is not uncommon for drug company sponsors to suggest speakers at sessions that are assumed by the thousands of general practitioners who attend them to be totally independent. Drug industry representatives have confirmed that similar practices take place in the United Kingdom, where roughly half of all education for doctors is sponsored by drug companies, writes Ray Moynihan, honorary lecturer at the University of Newcastle in Australia. He describes how leaked documents and emails from a range of sources show drug company sponsors having input into the selection of some speakers at seminars held in recent years, despite the fact that these have been aggressively sold to general practitioners in brochures claiming that “all content is independent of industry influence.” The drug industry‟s representative body Medicines Australia has confirmed that the practice of inviting input from sponsors into the selection of speakers is by no means uncommon, while the view from the drug industry is that allowing sponsors to suggest speakers does not compromise the independence of medical education, as the educational providers have ultimate control over who speaks. However, research for the investigation in Australia reveals several examples where sponsors‟ suggestions were embraced by the company providing supposedly independent education, writes Moynihan. Industry representatives in Australia and the UK strongly argue that, in the interests of transparency, doctors attending educational sessions should be fully and explicitly informed if sponsors have suggested speakers for these sessions. Such a degree of disclosure could radically change perceptions of the content of accredited education, says Moynihan, which many doctors believe to be independent of sponsor influence. The evidence, such as it is, tentatively indicates that the prescribing habits of doctors may be affected by attending sponsored educational events, albeit only in the short term. A recent paper by Harvard Professor David Blumenthal, an internationally recognised authority on relationships between doctors and drug companies, and colleagues called on US academic medical centres to end the direct drug company sponsorship of continuing medical education events. They suggested the creation of a blind trust to fund education at an institution level. Others have called for medical education to be funded by the taxpayer through competitive grants. Oversight of these educational events is currently a self-regulatory affair, and institutions seem uninterested in guaranteeing independence, argues Moynihan. Perhaps the recent revelations from Australia, and confirmation from the industry itself that it is “not unusual” for sponsors to suggest speakers, will sharpen the lines of debate about how to achieve more independent education or at least greater transparency, he concludes.
29 February 2008 Many children still susceptible to measles, mumps and rubella infection Factors associated with uptake of measles, mumps, and rubella vaccine (MMR) in the UK and use of single antigen vaccines in a contemporary UK cohort: prospective cohort study BMJ Online First Editorial: Improving uptake of MMR vaccine BMJ Online First Not enough children are being immunised against measles, mumps and rubella to ensure adequate control of the diseases, finds a large study of children born 2000-2002 in the UK. Researchers at the UCL Institute of Child Health and Great Ormond Street Hospital for Children found that 88.6% of children had been immunised with MMR by the age of three. 5.2% had received at least one of the single vaccines, and 6.1% were unimmunised. Of the 634 children who had received at least one single vaccine, just over half (52%) had received all three. The study published on bmj.com today emphasises that this is well below the level needed to prevent outbreaks of the diseases. Although the uptake of MMR vaccine has increased recently, there have been more cases of measles in 2007 than in any year for the past decade so further improvement is essential, say the authors. The combined measles, mumps and rubella vaccine (MMR) was introduced in 1988 in the UK. Following the publication of research in 1998, which was interpreted as suggesting a link between the vaccine and autism and bowel disease, uptake fell from a high of 92% in 1995 to a low of 79% in 2003. The UCL researchers explored social, economic and cultural factors associated with uptake as well as parents‟ reasons for not having MMR vaccine for the 14,578 children in the study. They only looked at uptake of the first dose of MMR vaccine. Uptake of the second dose is much lower, say the authors, but is necessary to ensure all children are adequately protected. Children who had not received any MMR vaccine were more likely to come from a large family, their mother was more likely to smoke, and was either younger (under 20) or older (over 34) than average when she gave birth. In contrast they found that parents who chose single vaccines were significantly more likely to be white, well educated, affluent, older, and have just one child compared with parents who fully immunised their child. The authors stress that single antigen vaccines are not licensed for use in this country and are not a good substitute for the combined MMR vaccine. They are only available on a private basis. Of the parents who chose not to have their child immunised with the MMR vaccine, nearly three quarters (74.4%) said it was due to a “conscious decision.” Common reasons given were being too scared, thinking the vaccine was too dangerous, links with autism, and negative media attention. Although MMR uptake in this study is high, say the authors, a substantial proportion of children remain susceptible to avoidable infection, largely because parents consciously decide not to immunise. They conclude, as does an accompanying editorial, that to achieve the best possible control of vaccine preventable diseases, a variety of measures may be required to target the different groups where uptake of the vaccine is low.
29 February 2008 Has the hunt for conflicts of interest gone too far? Head to Head: Has the hunt for conflicts of interest gone too far? BMJ Volume 336 pp 4789 Are restrictions on doctors‟ and academics‟ interaction with commercial companies damaging research, or is it a price worth paying to maintain public trust? Two experts debate the issue in this week‟s BMJ. Conflicts of interest occur in health care when clinicians or researchers have personal, professional, or financial interests that could interfere with their professional obligation to act in the best interests of patients or objectively conduct, present, review, or publish research. Professor Thomas Stossel of Harvard Medical School believes that detailed disclosure of conflicts of interest are damaging research. The most extreme rationale for conflict of interest management is that companies distort evidence and flout safety to promote products without substantive benefits and probable harms, he says. Yet these charges obscure the fact that only private companies bring new products to patients and that medical care has improved steadily and spectacularly because of them. He points out that no evidence supports that corporate detailing and gifting adversely affect patient care, while medical journals waste space on meaningless compilations of who receives what payments from companies and dubious “social science research” claims to prove that most doctors lack the intelligence or character to be wary of promotional claims. These attitudes and regulations are not only ill founded but also harmful to the public‟s interest in medical innovation, he argues. The measures exclude the best experts from providing education and advice, cost time and money, and are deeply disrespectful of physicians and researchers. The University of California System‟s Academic Senate recently rejected intrusive conflict of interest regulations as vague, overbroad, addressing perceived rather than real concerns, and in violation of academic freedom. This is a step in the right direction, says Stossel, and he calls on others to follow this enlightened lead. But Kirby Lee, Assistant Professor at the University of California, San Francisco argues that such requirements help to maintain public trust in science and medicine. Evidence is growing, he says, to demonstrate the negative consequences of certain marketing practices and other interactions with industry on clinician behaviour. For example, clinicians with ties to industry are more likely to prescribe the company‟s brand name product rather than cheaper generic drugs when there is no therapeutic advantage. Such influence is a serious concern because nearly all doctors have some type of relationship with industry, he writes. He acknowledges that the drug and medical device industry has made large contributions to improving public health through beneficial relationships with clinicians and researchers on product development. However, despite guidelines for appropriate relationships and gift giving between industry and healthcare professionals, problematic conflicts continue to arise. He points out that the US has recently proposed a law mandating disclosure of payments to clinicians by drug companies, and there are proposals to ban all gifts to clinicians and prohibit
healthcare professionals who have ties with drug companies from making certain medical decisions (such as drug formularies and clinical practice guidelines) and publishing articles that have been ghostwritten by industry. Such requirements may frustrate clinicians and researchers but, in doing so, will help to ensure the safety and welfare of the public, uphold scientific integrity, and preserve trust, he concludes. 29 February 2008 Could half bottles of wine help cut alcohol-related harm? Personal View: Half bottle or half cut? BMJ Volume 336, p 507 Reducing wine portions could help cut alcohol consumption and related harm, suggests a doctor in this week‟s BMJ. Banning supersize meal portions may help to cut obesity rates. But where‟s the debate on supersize portions of wine, asks Dr Trish Groves, Deputy Editor at the BMJ? Why does wine have to come in 75cl bottles? I like a glass of good wine with my supper, she says. But, once two of us have had a glass each, it‟s all too tempting to finish the bottle there and then. Coupled with the news that wine is getting stronger, it‟s no wonder Britain‟s middle aged middle classes are getting wasted. A recent report from Liverpool John Moores University showed that wealthy towns top the league table for hazardous drinking in the UK. The BMA‟s new report Alcohol misuse: tackling the UK epidemic also confirms that men and women who are higher earners are more likely than the lower paid to have drunk alcohol at all, and to have drunk on five or more days a week. And, while beer remains Britain‟s favourite drink, wine consumption rose from 10% of all alcohol in 1970 to 28.8 % in 2005. Wouldn‟t reducing wine portions reduce some of this consumption and harm, asks Groves? Easier said than done. She points out that her local upmarket supermarket offers only three wines in half bottles and bumps up the prices prohibitively. Online UK retailers are no better, and it‟s no easier to find a decent half bottle in a UK restaurant. Maybe this is a peculiarly British problem, she suggests. For example, restaurants and cafes in France offer drinkable wines by the carafe, pichet (small jug), and half bottle, and mini markets have a good range at 37.5cl at fair prices. Most French wine websites also have a tab for searching by bottle size, and plenty of half bottles to choose from. There are some technical and economic downsides to producing wine in half bottles, she says, but some of the best French Grand Cru houses produce half bottles. And none of the disadvantages should rule out the production and sale of youngish, drinkable, everyday wines in half bottles. She concludes: Banning supersize meals won‟t stop people from buying two regular burgers, and selling half bottles won‟t stop some drinkers from simply having two. But there must be at least one supermarket chain willing to give the half bottle market a proper go with a decent range and fair pricing, and to trump their competitors‟ hands for responsible, healthy retailing.
An editorial, also published in this week‟s journal, supports higher alcohol taxes and restricting availability, while a clinical review discusses the diagnosis and management of alcohol use disorders.