JUPITER trial poll result

The NEJM Clinical Directions set up a poll and invited readers to respond to questions raised by the results of the JUPITER trial published on its website on 9 November 2008. The poll was closed on 26 November 2008 with 2553 responses.

Poll questions :

Do you believe, on the basis of the JUPITER trial results, that the approach to laboratory screening of apparently healthy adults should be changed?

49% - Yes, the trial results indicate that the approach to laboratory screening should be changed.
51% - No, the trial results do not provide a basis for a change in the approach to laboratory screening.

Do you believe, on the basis of the JUPITER trial results, that the therapeutic use of statins in apparently healthy adults should be changed?

48% - Yes, the trial results indicate that the therapeutic use of statins should be changed.

52% - No, the trial results do not provide a basis for a change in the therapeutic use of statins.

See also post - JUPITER trial - will you change your practice?

Passing postgradute exams - don't be late

Are you preparing for your exams? Did you know that better-prepared doctors arriving on time were more likely to pass the exam?

In this article - "Disorganized junior doctors fail the MRCP (UK)". Medical Teacher. Feb 2006, 28(1):e40-e42(1) (abstract only) - researchers examined whether organization skills relate to exam outcome amongst junior doctors taking the RCP clinical Part ll exam.

The study was condudcted at 4 clinical courses that prepared the trainees for the exam. Arrival time at registration ( 8.00 am ) for the course was chosen for organisation skills. 81 doctors passed the exam and arrived 14 minutes earlier, 71 doctors failed the exam and arrived 6 minutes later than those who passed.

The study has shown that good time-keeping skills are positively associated with exam outcome and the authors suggested that "arriving on time is a valid marker of organization skills and preparation" and advised prospective candidates that "lateness is a sign of failure: get organised".

The BMJ Careers has published a 4 part series to help doctors maximise their chance of passing postgraduate exams.

Exam technique 1

Exam technique 2: performing

Exam technique 3: revision

Exam technique 4: study

Conventional blood pressure test has no prognostic value

Researchers enrolled 556 people aged 65 on average who had high blood pressure despite having been treated with anti-hypertensive drugs and followed up for 4.8 years to determine which form of blood pressure monitoring was a better predictor of risk of cardiovascular disease in people with medication-resistant high blood pressure.

They found that conventional surgery-measured BP did not predict strokes or heart attacks, but readings taken over 24-hour period could. Critics say conventional blood pressure testing by a GP remains essential and is invaluable in detecting and monitoring high blood pressure that often has no symptoms and is difficult to detect.

Source: Salles GF, Cardoso CRL, Muxfeldt ES. Prognostic Influence of Office and Ambulatory Blood Pressures in Resistant Hypertension. Archive of Internal Medicine 2008; 168: 2340-2346
(f/t via Athens)

Incompetent boss increases employees' heart disease risk

Many studies have linked employee health to workplace conditions but a new Swedish study called WOLF, involving more than 3200 men aged 19 to 70 without pre-existing ischemic heart disease who were working in Stockholm, suggested a significant effect of concrete managerial skills on employee heart disease risk .

All the participants were asked to rate the leadership style of their senior managers on competencies, researchers found that the poorer the men rated their boss's leadership ability, the higher the risk of heart disease. The risk increased the longer the men worked in the same stressful environment.

The lead researcher said "Enhancing managers' skills -- regarding providing employees with information, support, power in relation to responsibilities, clarity in expectations, and feedback -- could have important stress-reducing effects on employees and enhance the health at workplaces".

Source: Nyberg A, et al "Managerial leadership and ischaemic heart disease among employees: the Swedish WOLF study" Occupational and Environmental Medicine 2008; DOI: 10.1136/oem.2008.039362. (See BBC link )

Counselling could cut breast cancer

227 women aged between 20 and 85 years who had undergone surgery for breast cancer were enrolled in a study and were randomly assigned into two groups, one group received a psychological intervention, while the other did not.

The psychological intervention aimed to reduce distress, improve quality of life and mood, improve heath related behaviours and to improve the women’s adherence to their cancer treatment and follow-up programme.

After 11 years follow-up and comparison, researchers found that the psychological intervention roughly halved the chances of cancer returning and affected the length of time it took for the disease to reoccur. Critics say the study highlights the importance of appropriate support for women with breast cancer.

Source: Andersen BL, Yang HC, Farrar WB. Psychologic intervention improves survival for breast cancer patients. Cancer 2008; Published Online: 17 Nov 2008

Pepermint oil is effective in treating IBS

A new study of randomised controlled trials comparing fibre, antispasmodics, and peppermint oil with placebo or no treatment in adults with irritable bowel syndrome found that all three were more effective than placebo in the treatment of irritable bowel syndrome (IBS).

However, critics say the treatment effect might have been overestimated by the lack of concealment in the allocation of the treatments. Adverse effects were not reported across studies. The trials have only compared each treatment to placebo, so it cannot be assumed that any one treatment is more effective than the others.

Ford AC, Talley NJ, Spiegel BMR, et al. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. BMJ 2008; 337:a2313 ( f/t via Athens)

Large waist doubled death risk

A large scale study involving about 360,000 participants, conducted by research institutions across Europe has found that those with a large waist had twice the risk of premature death even if they were not overweight.

The study ran for 9.7 years and researchers found that BMI, waist circumference and waist-to-hip ratio were all strongly associated with the risk of death. They said the findings suggested that "general adiposity (fat) and abdominal adiposity are associated with the risk of death and support the use of waist circumference or waist-to-hip ratio in addition to BMI in assessing the risk of death".

The European co-ordinator of the study said people with large waist should exercise every day, avoid alcohol and improve their diet.

Source: "General and Abdominal Adiposity and Risk of Death in Europe" NEJM 359(20):2105-2120 (November 13, 2008) free f/t

JUPITER trial - will you change your practice?

The findings of a large statins trial presented at the Am Heart Association meeting on 9 November 2008 dominated the news and stirred up debates.

The study, called JUPITER trial, funded by AstraZeneca (maker of rosuvastatin, marketed as Crestor, the drug in the trial) is a large international, double-blinded, placebo controlled randomised clinical trial including 17,802 "healthy" men and women with normal LDL cholesterol but elevated CRP (C-reactive protein) assigned to receive either 20mg of daily dose of rosuvastatin or placebo.

The researchers found the rosuvastatin reduced their risk of heart attack ( 54% ), stroke (48% ), in need of angioplasty or bypass surgery (46% ) and death from any cause ( 20% ). The trial leader, Dr Paul Ridker, who receives grant from the drug company, said expanding the use of statin could prevent 250,000 heart attacks, strokes, vascular procedures or death over 5 years. The JUPITER trial was designed a 4-year study but stopped after 1.9 years because of the benefits found.

Opinions on the findings are mixed and many questions raised. Some said that clinical practice on CRP testing and statin therapy would be affected by this important landmark study while some questioned the short follow-up and long-term safety of low LDL levels achieved in this trial. Dr Mark Hlatky wrote in the NEJM's editorial "the evidence should be examined critically" before drug treatment is expanded and "Long-term safety is clearly important in considering committing low-risk subjects without clinical disease to 20 years or more of drug treatment."

NEJM published this article and the accompanying editorial ( free f/t ) on its website on 9 November 2008 and invited doctors to contirbute their thoughts on the JUPITER results.


Source: "Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein" Published at www.nejm.org November 9, 2008 (10.1056/NEJMoa0807646)

Poor sleep links to heart disease

In a study of 1,255 Japanese adults with high blood pressure aged 70.4 in average, researchers recorded each participant's blood pressure changes over 24-hour period and followed them for about 50 months.

During the follow-up, there were 99 cardiovascular disease events, they also found that participants who slept less than 7.5 hours a night had 68% high risk of one of these complications than those who had longer sleep.

They also found that the risk was higher among participants who also had an increase in overnight blood pressure than those who did not have an increase in blood pressure. Researchers concluded that "shorter duration of sleep is a predictor of incident cardiovascular disease in elderly individuals with hypertension, .......Physicians should inquire about sleep duration in the risk assessment of patients with hypertension."

Source: "Short Sleep Duration as an Independent Predictor of Cardiovascular Events in Japanese Patients With Hypertension" Arch Intern Med. 2008;168(20):2225-2231 (f/t via Athens)

Calcium and vitamin D do not prevent breast cancer

Previous studies have reported vitamin D supplements may reduce breast cancer risk but a new study, published online in the Journal of the National Cancer Institute, found that calcium and vitamin-D supplements do not reduce breast cancer incidence in postmenopausal women.

More than 36,000 postmenopaused women were randomly assigned to take 1000 mg of calcium plus 400 IU of vitamin D daily or placebo. Researchers found that the incidence of breast cancer was similar in the supplement ( 528) and placebo ( 546) groups. The authors concluded that " the main findings do not support a causal realtionship between calcium and vitamin D supplement use and reduced breast cancer incidence".

In an accompanying editorial "Breast Cancer Prevention Using Calcium and Vitamin D: A Bright Future?" ( free f/t), the authors say that the study results may have been affected by multiple "important confounders" and that vitamin D and calcium may still have a "bright future" in breast cancer prevention and further studies will be needed.

Source: "Calcium Plus Vitamin D Supplementation and the Risk of Breast Cancer" Journal of the National Cancer Institute. Advance Access published online on November 11, 2008 JNCI, doi:10.1093/jnci/djn360

Folic acid and B vitamins do not affect cancer risk

Folic acid and B vitamins are thought to have an important role in cancer prevention, but a study published in JAMA found that these supplements had no significant effects on overall cancer risk.

More than 5000 women health professionals, aged 42 or older, enrolled in a RCT designed to evaluate the effects of folic acid and B vitamins on cancer risk in women with high risk cardiovascular disease. They were randomly assigned to receive a daily combination of folic acid and B vitamin or a placebo for 7.3 years.

Researchers found that the supplement group had similar risk of developing cancer or death and there was a significant reduced risk of cancer in women aged 65 or older at study entry. The authors said "if the findings is real and substantiated, the results may have public health signficance because the incidence rates of cancer are high in elderly perosns...."

Source: Effect of Combined Folic Acid, Vitamin B6, and Vitamin B12 on Cancer Risk in Women. JAMA, 2008; 300 (17): 2012-2021 ( f/t via Athens)

Statins lower prostate cancer risk?

Rising blood levels of PSA (prostate-specific antigen) is used to diagnose prostate cancer, but there is conflicting evidence that statins ( cholesterol-lowering drug) may be associated with a reduced risk of prostate cancer.


Researchers at Duke University studied changes in PSA levels in 1,214 men who were prescribed statins and found PSA level drops slightly in men who lower their cholestrol with statin drugs. They said that the reduction could mean that statins may affect prostate biology or statins may lower their PSA levels without lowering the risk of prostate cancer, making the disease more difficult to diagnose.


Critics said further research is needed and men who currently take Statins should not be worried by these findings. In the UK, PSA testing is not rountinely carried out.


Source: Hamilton RJ, Goldberg KC, Platz EA, Freedland SJ. The Influence of Statin Medications on Prostate-specific Antigen Levels. Journal of the National Cancer Institute 2008; Advance Access published online on October 28, 2008

HRT can increase joint problems

A study funded by Cancer Research UK, the NHS Breast Screening Program and the Medical Research Council followed 1.3 million women for an average of 6.1 years and collected information on reproductive history, use of hormonal therapies, other medical history and lifestyle.


Researchers found that women using HRT are more likely to need a knee replacement due to arthritis than women who have never used HRT. There is also increased risk of hip replacement. The researchers conclude that ‘hormonal and reproductive factors increase the risk of hip and knee replacement, more so for the knee than for the hip. The reasons for this are unclear.’


Critics say that there are limitations of its data collection method and the findings conflict with those of previous studies.


Source: Liu B, Balkwill A, Cooper C et al. Reproductive history, hormonal factors and the incidence of hip and knee replacement for osteoarthritis in middle-aged women. Annals of Rheumatic Diseases 2008; Oct 28 ( via press release)

New diet pill doubles weight loss

A phase II trial ( funded by Neurosearch, a pharmaceutical company in Denmark and other sources) in which 203 obese patients were randomised to receive three different daily doses of tesofensine ( a new diet drug) or placebo pills found that those who received tesofensine lost more weight than those received placebo.

Dieting patients on the highest doses lost up to 12.8kg (28.2lbs) in six months, roughly twice the level achieved by best weight loss drugs already used in Europe. However, side effects have been experienced by these patients.

Critics said more trials are needed and the efficacy and safety of the drug need confirmation in larger phrase III trials. ( Note: The maker of tesofensine, Neurosearch, is seeking approval for the drug in the US and Europe).

Source: Astrup A, Madsbad S, Breum L, et al. Effect of tesofensine on bodyweight loss, body composition, and quality of life in obese patients: a randomised, double-blind, placebo-controlled trial. The Lancet. Early Online Publication, 23 October

Leukaemia drug halts MS

Researchers compared alemtuzumab (a drug to treat leukaemias or blood cell cancers) in treating MS with interferon beta-1a (a drug that is already used to treat the condition) and found that it halted and reversed the effects of the disease. However, there were some serious side effects in a few patients.

334 patients with early symptoms of MS were recruited from 49 centres across Europe and the US between December 2002 and July 2004 and randomised to receive interferon beta-1a or alemtuzumab at a dose of either 12mg or 24mg. Researchers found that those who took alemtuzumab had a reduction in disability (71%) and reduction in the risk of relapse (74%) compared with beta-interferon.

Critics said that it is not known if the drug would be beneficial for more advanced MS and the result of restoration of brain tissue will need confirmation in larger phase 3 trials.

Source: The CAMMS223 Trial Investigators. Alemtuzumab vs. Interferon Beta-1a in Early Multiple Sclerosis. NEJM 2008; 359: 1786-1801

Doctors often prescribe placebo treatments

The use of placebos is controversial, researchers at the NIH ( National Institute of Health) surveyed 1200 internists and rheumatologists to examine the doctors' attitudes towards and the use of placebo treatments in the US.


679 physicians returned the survey questionnaires, half said they prescribed placebo treatments on a regular basis, 62% believed the practice ethically acceptable and were happy to recommend or prescribe placebo treatments. 68% of those prescribe placebo drugs said that they describe the placebo treatments to patients as "a potentially beneficial medicine or treatment not typically used for their condidtion", only a small number of physicians inform patients of the placebo treatment.


The most commonly prescribed placebo treatments were painkillers (41%) or vitamins (38%), some prescribed antibiotics (13%) and sedatives (13%), a few using sugar pills.


The authors concluded that precribing painkillers or vitamins to promote positive expections may not raise serious concerns but prescribing antibiotics and sedatives when they are not clearly indicated could have adverse effects for patients and public health.


Some doctors said the survey is misleading and the conclusions need disputed.


Source: "Prescribing "placebo treatments": results of national survey of US internists and rheumatologists" BMJ 2008;337:a1938 ( f/t via Athens)

JAMA editoral argues against preemption

JAMA published an editorial in the October issue in urging the US Supreme Court not to endorse preemption and argues for patients' right to sue drugmakers in state court for harms caused by defective drugs that were approved by FDA.

The editorial states that " ......if the court rules in favors of Wyeth, endorsing preemption, patients will lose an irreplaceable method for seeking remedies for injuries resulting from pharmaceutical agents that were approved by FDA."

American legislation states that federal regulation preempts state law - this means that patients have no legal right to sue drugmakers in state court for injuries caused by FDA-approved drugs.

Source: Catherine D. DeAngelis, Phil B. Fontanarosa Prescription Drugs, Products Liability, and Preemption of Tort Litigation JAMA 2008;300(16) :1939-1941 ( f/t via Athens)

Top tips for good surgical sign-out practice

In America, 80-hour workweek was recently adopted to reform medical care and resident education with the benefits of reducing fatigue among physicians and reducing medical errors. The change of work hours also brings new challenge of the continuity of care as residents have to depend more on colleagues to assume the care of patients at different times.

Surveys show that there is no standardised sign-out process and transitions of care among residents as policies and procedures for sign-out practices vary widely among institutions, services and individuals.

The surgical interns at The Johns' Hopkins Hospital carried out a review of current literature on this topic and develop a list for safe and effective sign-outs based on their personal experiences.

Source: "The Top 10 List for a Safe and Effective Sign-out" Archives of Surgery. 2008;143(10):1008-1010

Doubts over aspirin use in diabetes

UK guidelines recommend a daily dose of aspirin as a "preventive" treatment in the diabetics as they are at a much higher risk of cardiovascular disease. However, a study published in the BMJ found no benefit from either aspirin or antioxodants in preventing heart attacks. It also increases the risk of internal bleeding.

The study invloved 1,276 adult patients with diabetes mellitus from 16 diabetic clinics in Scotland between November 1997 and July 2001. Participants were randomly assigned in four groups to receive the aspirin tablet + antioxidant capsule, or aspirin tablet + placebo capsule, or placebo tablet + antioxidant capsule or both a placebo tablet and a placebo capsule.

The findings show that in adults with diabetes and no symptoms of cardiovascular disease, there was no evidence that aspirin or antioxidants use prevented heart attacks, strokes, amputations or death. However, the drug was beneficial in people who already have a history of heart attack or stroke.

Experts said the study was "extremely important" because it confirms the concerns of aspirin use by the general population and it is worth revisiting the guidelines.

Source: Belch J, MacCuish A, Campbell I, et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ 2008; Published 16 October ( f/t via Athens)

Vitamin B supplement does not slow Alzheimer's disease

Reserachers thought that vitamin B may slow Alzheimer's disease because it can lower the levels of homocysteine, an amino acid linked to brain cell damage. A new research published in JAMA has demonstrated that vitamin B supplements made very little difference to the decline of mental functions, contrary to what previous studies have suggested

340 patients with mild to moderate Alzheimer's disease were randomised to receive either a combination of vitamin B supplements or a placebo for 18 months. Researchers found no significant difference in reduction of cognitive ability between the groups and concluded that this is not a useful treatment of Alzheimer's disease.

Source: Aisen PS, Schneider LS, Sano M et al. High-Dose B Vitamin Supplementation and Cognitive Decline in Alzheimer Disease: A Randomized Controlled Trial. JAMA 2008; 300(15): 1774-1783 ( f/t via Athens)

Lancet study confirms Vioxx risk

Vioxx, a pain killer, was withdrawn from the market in 2004 after the APPROVe trial showed that it doubled the risk of heart attacks.


In a new study published in The Lancet, researchers contacted 84% of the people who took part in the original trial and confirmed the findings of previous study. They also found that a year after stopping the treatment, participants still had increased risk of heart attack, stroke or death comapred with those in the placebo group. The researchers raised the concern that long term use of of all non-aspirin NSAIDs may have a similar effect and suggested doctors to weigh up the benefits of these drugs in individual patients.


The drugmaker, Merck, issued a statement :"....this post-hoc analysis using limited data from a prematurely terminated study needs to be interpreted very cautiously......".



Source: Baron JA, Sandler RS, Bresalier RS et al. Cardiovascular events associated with rofecoxib: final analysis of the APPROVe trial. The Lancet 2008; Oct 14 [Early online publication]

Counselling to hospitalised smokers

Researchers analysed the results of 33 trials of smoking cessation interventions in 9 countries from 1999 to 2007 to see what kind of hospital- based smoking cessation programmes works.


They found that smoking counselling that began during hospitalization and included supportive contacts for more than 1 month after discharge increased smoking cessation rates at 6 to 12 months, no benefit was found for interventions with less postdischarge contact.

The lead author concluded that "offering smoking cessation counseling to all hospitalized smokers is effective as long as supportive contacts continue for more than 1 month after discharge".


Source: "Smoking Cessation Interventions for Hospitalized Smokers - A Systematic Review" Archives of Internal Medicine. 2008;168(18):1950-1960 (f/t via Athens)

Is honey better at healing wounds than standard treatments used in the NHS ?

The Cochrane Library publishes a systematic review that aimed to determine whether honey increases the rate of healing in acute wounds and chronic wounds.

Researchers identified 19 RCTs or quasi randomised trials involving more than 2,500 patients with various wounds and found that in the trials of partial thickness burns, honey reduced healing time to healing by 4.68 days compared with some conventional dressings. However the researchers said this finding should be treated with caution.

In chronic wounds, they found that honey dressings used under compression bandaging did not increase healing in venous leg ulcers significantly, but researchers said there is insufficient evidence to guide clinical practice in other areas.

Source: Jull AB, Rodgers A, Walker N. "Honey as a topical treatment for wounds (Review)." Cochrane Database Systematic Review 2008; Issue 4 ( f/t via Athens)

Painkillers reduces breast cancer risk

Researchers carried out a meta-analysis of 38 relevant studies carried out in 5 different countries and involving 2.7 million women to examine the association between NSAID use and breast cancer.


The combining results from all 38 studies show that the use of NSAIDs was associated with a 12% reduction in risk of breast cancer. Analysis of all studies examining aspirin use only found a 13% reduction in the risk while the ibuprofen analysis found a 21% reduction in the risk of breast cancer. The authors conclude that there was an overall decreased risk of breast cancer with NSAID use.


Critics say that the use of aspirin and ibuprofen is not without risk in themselves and warn that long-term use of these painkillers would have serious side effects.


Source: Takkouche B, Regueira-Méndez C, Etminan M. Breast Cancer and Use of Nonsteroidal Anti-inflammatory Drugs: A Meta-analysis. Journal of the National Cancer Institute 2008; Oct 7 [Epub ahead of print]

Absence from work links to death

UCL researchers studied the sickness records of 6500 employees in 20 Whitehall departments between 1985 and 1988 and comapred with mortality up until 2004.


Researchers found that employees who had extended periods of sick leave had 66% higher risk of early death. They were surprised to find that those who had long absence from work due to psychiatric reasons were twice as likely to die from cancer as the healthy colleagues. The study leader said " it would be useful for this information to be collected because we could identify groups with high risk of serious health problems".


Critics say the recorded reasons of sickness mat not cover the actual causes.


Source: Head J, Ferrie JE, , Alexanderson K, et al. "Diagnosis-specific sickness absence as a predictor of mortality: the Whitehall II prospective cohort study." BMJ 2008; Oct 3 [Epub ahead of print]

Free drug samples to children

Researchers analysed the data on more than 10,000 US children under 18 years old from a 2004 national survey that included questions on receipt of free drug samples.


They found that 1 in 10 children who take prescription medications received free samples and 1 in 20 children overall got free samples. The study showed that wealthy and insured American children who had access to medical care and saw doctors in private offices rather than in hospitals or clinics were more likely to get free drug samples although drug companies argue that free samples help uninsured and low-income people get the medications they need.


The author said that most free samples were new and expensive drugs, in her previous study on free samples for adults, Vioxx topped the list but was later withdrawn from the market due to dangerous side effects. She concluded that "Poor and uninsured children are not the main recipients of free drug samples. Free samples do not target the neediest children selectively and they have significant safety considerations."


Source: "Free Drug Samples in the United States: Characteristics of Pediatric Recipients and Safety Concerns" ( Published online October 1, 2008) Pediatrics Vol. 122 No. 4 October 2008, pp. 736-742

Does common cold cause asthma?

US researchers studied more than 250 newborns at high risk for asthma and followed them from birth to 6 years old to investigate the relationship between specific childhood illnesses and early development of asthma. Samples of mucus from their nose and throat were taken and analysed and they were tested for specific viruses during wheezing illnesses.

Researchers found that nearly 90% of the children wheezing with common cold virus, rhinovirus (RV) at age 3 subsequently developed asthma at age 6. The lead author wrote in the Americam Journal of Respiratory and Critical Care Medicine that rhinovirus which causes wheezing in childhood was the most significant predictor of the subsequent development of asthma at age six.

Critics say that athough the study demontrated an association between wheezing during childhood colds and later asthma, it does not mean that cold is the casue of asthma. Asthma is a very difficult condition to diagnose but asthma at age six does not necessarily mean that the it will persist into later childhood.

Source: "Jackson DJ, Gangnon RE, Evans MD, et al. Wheezing Rhinovirus Illnesses in Early Life Predict Asthma Development in High-Risk Children." Am J Respir Crit Care Med 2008: 178; 667–672 ( abstract only)

The blind can see after gene therapy

Multiple newspapers have reported a small trial of a revolutionary new gene therapy that has cured a form of inherited blindness within days.

Three young adult volunteers who had LCA, a particular form of blindness, and had severe vision loss since childhood were recruited. The researchers used a technique whereby the DNA of the virus AAV was removed and then replaced with DNA containing the desired gene (RPE65 in this case). The virus carrying the RPE65 gene was then injected into the retina of one eye in each of the volunteers.

The researchers found that all three volunteers had an improvement in their vision 30 days after the injection, with two volunteers reporting improvements as early as 7 - 10 days after the treatment.

Critics say it is important to note that this particular gene therapy would only work for this type of LCA, more "studies are needed to fully understand the process and its longer-term effects and safety before it can be used more widely".

Source: "Human gene therapy for RPE65 isomerase deficiency activates the retinoid cycle of vision but with slow rod kinetics". PNAS USA 2008; Sep 22 [Epub ahead of print]

Does regular use of paracetamol cause asthma?

The findings of a multi-centre study involving 1,028 participants across Europe suggested that using paracetamol at least once a week increases the risk of asthma.

Half of the participants were recruited as cases of self-reported diagnosis of asthma and half were healthy volunteers with no diagnosis of asthma as control. They found that cases were about 2.5 - 2.9 times more likely to have taken paracetamol regularly than controls but they did not find any association between use of other painkillers and asthma. The researchers said "there is now a need to carry out suitable intervention studies to determine whether the link is causal".

Critics say there are problems with this study - eg a case-control study cannot prove causation and cannot rule out that asthma causes people to take more painkillers. It was suggested that a randomised controlled study of healthy participants to paracetamol or not will produce more conclusive results.

Source: "The relation between paracetamol use and asthma: a GA2LEN European case-control study". European Respiratory Journal 2008; Published online before print June 25

Colonoscopy vs CT scan

In a study of 2600 asymptomatic adults at 15 study centres, CT colonographic screening identified 90% of medium and large of adenomas detected by colonoscopy. The findings published in NEJM suggest that people who do not want a colonscopy could opt for a CT scan, reported The Wall Street Journal.

CT colonography is a noninvasive option in screening for colorectal cancer, it can show other problems that may need followed. Critics say there is a third test called fecal occult blood testing (FOBT) that has been shown to reduce death from colon cancer, but there is insufficient evidence to say which is the best.

Source: "Accuracy of CT Colonography for Detection of Large Adenomas and Cancers" NEJM 2008 Volume 359(12):1207-1217 (abstract only)

Improving your chances of getting the dream job

Want that job? Follow these tips published by the BMJ Careers.


The author writes " it’s not all about luck , there are concrete ways to improve your chances" of getting your dream job.

1). Medical CV writing skills
Tips on how to stand out from the crowd by focusing on the evidence with examples showing full range of skills that the prospective employers are looking for etc

2). Interview skills
Tips on knowing the questions, preparing your answers and questions to strengthen your interview and impress the interviewing panel etc

3). Presentation skills: 4 P's - plan, prepare, phrase, and project
Tips on how to deal with common difficult situations - interruptions, audience looks bored, audience not listening and talking, questions you can’t answer etc

4). Networking skills - more than just self promotion
Benefits of networking and how to approach it.

Food packaging chemical links to diabetes and heart disease

Multiple newspapers reported a study published in JAMA that found higher level of bisphenol A (BPA), a chemical widely used in food and drink packaging, in adults' urine increased the risk of heart disease and diabetes.

Researchers looked at the data of a survey that assessed the health and diet of the general US population invloving 1455 adults aged 18 - 74 to investigate associations between BPA concentrations in urine and adult health status.

Critics say that this is the first cross-sectional study on this subject, it can only show the relationships between exposure and risk but it cannot prove BPA cause these chronic diseases. Further research will be needed to confirm these findings.

Source: Lang IA, Galloway TS, Scarlett A, et al. Association of Urinary Bisphenol A Concentration With Medical Disorders and Laboratory Abnormalities in Adults. JAMA 2008; 300(11):1303-1310

Fewer surgical mistakes after shorter hours for residents

Concern has been raised about the effects of restricted work hours on patient care and surgical training among the medical community in the US. A study published in the Archives of Surgery this week found that surgical compliactions have fallen after the restrictions on work hours introduced in a large teaching hospital in California.

Researchers studied the medical records of 2470 patients who had laparoscopic gallbladder surgery. Half of the operation were performed before the 80-hour restriction on the surgical residents and the other half were after the change in hours. They found that after the shorter weeks, fewer patients had bile duct injuries, a common problem frequenetly caused by technical error. The author said the study is "the first that has shown there is improvement in outcomes in this new era" although it is unclear why the complication rates decreased.

Source: "Decreased Bile Duct Injury Rate During Laparoscopic Cholecystectomy in the Era of the 80-Hour Resident Workweek" Arch Surg. 2008;143(9):847-851.

Mediterranian diet protects against all major diseases

The BMJ published a large scale systematic review and meta-analysis which statistically combined the results of 12 separate studies with over 1.5 million people. The results show that those who follow strictly this style of diet are more likely to live longer, and less likely to die from major diseases such as heart disease, stroke or cancer etc.

The researchers said the results seem “clinically relevant for public health, in particular for encouraging a Mediterranean-like dietary pattern for primary prevention of major chronic diseases.” However they point out that it is important to estimate the effects of the dietary pattern as a whole rather than the individual components of the diet.

Source: "Adherence to Mediterranean diet and health status: meta-analysis." BMJ 2008; 337:a1344 ( published online)

Knee surgery had no benefit for osteoarthritis

Two studies raising doubts about the effectiveness of knee surgery were published in the New England Journal of Medicine (NEJM).


About 200 patients with moderate-to-severe osteoarthritis of the knee were randomly assigned to receive either surgery, drugs and physical therapy ( as treatment group with arthoscopic surgery ) or drugs and physical therapy alone ( as control group ). (1)


At the end of the study, researchers found that patients in the treatment group had slightly less pain than those in the control group after 3 months, but no significant differences between the two groups after 2 years. Researchers concluded that “arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy”. A previous study published in 2003 had similar results.

Another study in the same journal found that MRI scan of middle-age and older people show that meniscal tears in the knee are more common in this age group than previously thought and often without pain or stiffness. The author said "Clinicians who order MRI of the knee should take into account the high prevalence of incidental tears when interpreting the results and planning therapy". (2)


Source 1 :"A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee." NEJM 2008; 359(11):1097-1107 ( abstract only)


Source 2: "Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons Volume" NEJM 2008. 359(11) :1108-1115 ( abstract only)

Less US medical students choose to work in primary care

The Wall Street Journal published an interesting article about more and more US medical graduates choose their careers in specialties over primary care. It has attracted a large number of comments.

The article is based on two studies published in this week's JAMA. A research letter in the journal suggests that higher pay in specialties is a reason for the career choose.

A survey, published in the same journal, involving 1177 fourth-year medical students at 11 US medical schools in 2007, found that only 2% planned to work in primary care internal medicine. A similar survey in 1990 found 9%. The decline has raised worries about shortage of primary care physicians in the US.

Paper work, increasing demands of the chronically ill, the elderly and people with complex diseases and students' concerns about the primary care system, insurance pays, lawsuits, debts, the need to see large number of patients daily to break even also contibute to the primary care gap. Some primary care physicians feel that specialty doctors get more respect and chance of practice medicine.

Source: Research letter - "Future Salary and US Residency Fill Rate Revisited" JAMA. 2008;300(10):1131-1132 ( f/t via Athens )

Source: "Factors Associated With Medical Students' Career Choices Regarding Internal Medicine" . JAMA. 2008;300(10):1154-1164 ( f/t via Athens )

Vitamin B12 may prevent brain shrinkage

A study, led by scientists at Oxford University, involving 107 healthy elderly found that those with lower vitamin B12 levels in their blood were six times more likely to experience brain shrinkage compared with those who had higher levels of the vitamin.


Particpants were given annual scans of their brain volume, blood tests to assess the vitamin B12 levels as well as physical examinations for up to five years. The researcher said "this study suggests that simply adjusting our diets to consume more vitamin B12 through eating meat, fish, fortified cereals or milk may be something we can easily adjust to prevent brain shrinkage and so perhaps save our memory."


However, "more information is needed before recommending that people take vitamin B12 supplements to guard against the loss of brain volume and possibly prevent declines in thinking and memory", the author concluded.



Source: "Vitamin B12 status and rate of brain volume loss in community-dwelling elderly". Neurology 2008; 71:826–832

Fresh research rule out MMR-autism link

Despite a growing amount of evidence that MMR vaccine is safe, many parents are still concerned that MMR causes autism. A few newspapers reported a new study that replicates the methods of the original study conducted in 1998 by Dr Andrew Wakefield that sparked the controversy of a link between autism and the MMR vaccine.

The new study compared children with gastrointestinal disturbances who also had autism with a control group without autism to see if there was evidence of meales virus RNA in the bowel of children with autism who also have gastrointestinal disturbances. The reserachers said their results did not support the association of autism with persistent measles in the bowel or with MMR vaccination.

Critics say that although this is a stronger study than the Wakefield's with a control group and more cases, it is still small and the findings may still be due to chance. However, this study provides evidence that disproves the MMR-autism link.

Source: " Lack of Association between Measles Virus Vaccine and Autism with Enteropathy: A Case-Control Study." PLoS ONE 2008; 3(9):e3140

Hospital doctors' memory sticks threaten data security

Two doctors surveyed their colleagues at a teaching hospital in London and found that 92 out of 105 held unsecured memory sticks, 79 held confidential patient information but only 5 were password protected. The authors said this is a clear breach of data security, reported the BBC.

They claim that the findings reflect the lack of security across UK hospitals and beyond.

Although hospitals issue doctors with chip-and-pin cards to access NHS databases and patient records, many doctors increasingly rely on their own memory sticks to store patients data tradidtionally written in doctors' notebooks.

The DH said "any breach of patient security is unacceptable…...The NHS locally has legal responsibility to comply with data protection rules." The survey is published in today's Health Service Journal.

Vytorin's cancer saga

The New England Journal of Medicine published an editorial yesterday on its website rising the doubts of the safety of the drug Vytorin and its cancer link. It concludes that “physicians and patients are unfortunately left for now with uncertainty about the efficacy and safety of the drug”.

Vytorin is a combination of 2 drugs : a statin called simvastatin and ezetimibe, a new drug for lowering cholesterol . Vytorin is one of the best-selling drugs in the world and heavily prescribed by doctors although there is little evidence that ezetimibe offers the same benefits as stains.


The SEAS trials of Vytorin, conducted by reserachers in Norway found that Vytorin lowered the average levels of “bad” LDL cholesterol but not the aortic valve disease. It also found unexpectedly more cancer cases among patients taking Vytorin than the placebo.


This has prompted the analysis of the ezetimibe trials by Oxford researchers. When the results from all trials were combined, they did not find an increased incidence of cancer and they concluded that there is "no credible evidence of any side effect of ezetimibe on cancer risk". However, they suggest that “follow-up of longer duration will permit the balance of risks and benefits to be determined more reliably.”

Source: Both articles are published online on Sept 2 at the NEJM website ( will appear in Sept 25 issue of the journal)

NEJM meeting the needs of future physicians

New England Journal of Medicine is seeking 20 visionary medical students and trainees from North America and west Europen to join the editor in October to explore how NEJM should meet the information needs of the next generation physicians and trainees.

Free accommodation and airticket will be provided for selected participants who will be required to present their ideas at the conference. If you think you have a creative mind and should be selected for attending the conference, submit an application form.

Do certification examination scores reflect quality of care?

Researchers studied some 3600 physicians in US to determine the associations between their performance scores on the American Board of Internal Medicine MOC examination and the subsequent quality of care received by Medicare patients.

They found that physicians scoring in the top quartile were more likely to perform processes of care for diabetes and mammography screening than those in the lowest quartile, but no significant difference in lipid testing of patients with cardiovascular disease. They concluded that the findings suggest that physician's cognitive skills are associated with higher rates of processes of care for Medicare patients.

In the accompanying editorial, the author said that there are several mehtodological limitations in this study, what is needed is a method for measuring physician performance reflective of higher cognitive abilities and processes.


Source: "Association Between Maintenance of Certification Examination Scores and Quality of Care for Medicare Beneficiaries". Archives of Internal Medicine. 2008;168(13):1396-1403 ( full text via Athens )

Anxiety could double diabetes risk in men

A 10-year study of 5,000 middle-aged Swedish men and women, found that men who suffered stress and sleepless nights were twice as likely to develop type 2 diabetes, the BBC reported.

All participants were asked questions about their lifestyle and had their BMI measured. They also completed a questionnaire to report their ‘psychological distress’. The researchers concluded that self-reported psychological distress was associated with development of type 2 diabetes in men, not in women.

Critics say previous studies have found a link between stress and type 2 diabetes in both men and women. There are also many limitations in the study, further studies are needed.

Source: "Psychological distress and risk of pre-diabetes and type 2 diabetes in a prospective study of Swedish middle-aged men and women". Diabetic Medicine 2008; 25:834-842

45 minutes walk a day can help control diabetes

Newspapers reported a small study of 20 volunteers ( 10 with and 10 without type 2 diabetes)that found walking improved the bodies' ability to store sugar and burn fat, helping to control diabetes.

Each volunteer was given a pedometer and asked to walk an extra 45 minutes each day. After increasing physical activity for 8 weeks, the number of steps had increased to 12,322 a day in the diabetic group, and to 9,187 steps a day in the control group. Researchers found there were no changes in the enzyme ATP use, but lipid metabolism rates increased more in the people with diabetes than in the control group. They concluded that physical activity such as walking can improve cellular metabolism of the diabetes. Further studies would be needed.

Source : "Increased daily walking improves lipid oxidation without changes in mitochondrial function in Type 2 diabetes." Diabetes Care 2008; May 16 [Epub ahead of print]

Daily orange juice could increase diabetes risk

Newspapers reported a large study of 70,000 female nurses in the US to determine the links between diet and risk of various outcomes.

During the 18-year follow-up, 4529 new cases of diabetes were reported. Reserachers found that drinking one or more cups of orange juice per day increased the risk of diabetes by about 24% compared with drinking less than one cup a month, whereas the same increase in whole fruit consumption was associated with a lower risk of developing diabetes. Also found that an increase of 1 serving/day in green leafy vegetable consumption was associated with a modestly lower risk of diabetes.

Critics say the link between fruit juice consumption and risk of type 2 diabetes may be related to the high sugar content in the juice and the results warrent further study.

Source :"Intake of Fruit, Vegetables, and Fruit Juices and Risk of Diabetes in Women." Diabetes Care 2008; 31:1311-1317

Prostate cancer wonder pill trial

Multiple news sources reported a small phase 1 trial involving 21 men with aggressive and incurable form of prostate cancer. The participants were given daily dose of a new drug, abiraterone, in 28-day cycles. Researchers found that 12 of the 21 patients had a 50% decline in PSA ( prostate specific antigen) after one month and 6 had a 90% decline. They also found in some patients, tumor shrank, regression of some of the cancers and reduction of the dose of analgaesics required to ease the pain. Researchers said the results indicated the evidence of the safety of abiraterone.

Critics say the results are preliminary and no survival advantage has been proved in this very small trial. A 2nd larger study is already underway and will provide more information about the effectiveness of the drug in treating the disease to a wider group of people.

Source : "Phase I Clinical Trial of a Selective Inhibitor of CYP17, Abiraterone Acetate, Confirms That Castration-Resistant Prostate Cancer Commonly Remains Hormone Driven." Journal of Clinical Oncology 2008; Jul 21 [Epub ahead of print]

Wholegrain bread protects pregnant women against re-eclampsia

A newspaper reported a study that suggests eating slices of brown bread a day protects women against pre-eclampsia in pregnancy.

More than 1,500 women were given food frequency questionnaires at around 13.1 weeks of pregnancy to assess their diet before conception and during the first trimester. The researchers found that women with the highest fibre intake had about 70% reduction of pre-eclampsia risk compared with those in the lowest intake. They also found that women with the highest fibre intake had the lowest levels of blood triglycerides (excess fat) and higher levels of good cholesterol. They said more studies are needed to confirm the health benefits associated with increased fibre consumption before and during early pregnancy.

Source: "Dietary Fiber Intake in Early Pregnancy and Risk of Subsequent Preeclampsia." American Journal of Hypertension 2008; Jul 17 [Epub ahead of print] (Free full text)

Epilepsy drug may increase risk of birth defects

A newspaper reported that the epilepsy drug, topiramate, which is also used for people with migraines, increased risk of birth defects if it is taken during pregnancy.

The finding is based on a small study of 203 pregnant women who were exposed to topiramate during the first 12 weeks of pregnancy. 70 of the partcipants used topiramate only, and the rest were exposed to topiramate plus at least one other antiepileptic drug during pregnancy.

Critics say the findings reflect what is already known that a number of antiepileptic drugs including topiramate, carry a risk of harming the developing foetus. Care should be provided to women who become pregnant while taking the drugs.

Source: "Topiramate in pregnancy: Preliminary experience from the UK Epilepsy and Pregnancy Register". Neurology 2008; 71:272–276

Art class will make better doctors?

Art courses are now offered to medical students in medical schools in the US to help improve their observation and diagnostic skills, reported The Boston Globe.

Dr Joel Katz, an internist at an American hospital, runs art courses for medical students and wrote about a study that showed medical students' ability to make accurate observations increased after completing the art course while the control group who did not take the course did not change. He said that doctors' physical examination skills are declining and many rely on technology to do their work. He believes that art class will train students to look more carefully at patients for clues and do not make assumptions about what they see.

Source: "Formal Art Observation Training Improves Medical Students’ Visual Diagnostic Skills" Journal of General Internal Medicine 2008; 23(7) : 991-7

Doctors from all walks of life

This is an interesting perspective article on age as a factor in admissions decisions to medical schools and has attracted much online discussions from people all over the world.

The author, a Ph D in condensed-matter physics, entered medical school at 26, now assistant professor of medicine in NY, writes in The New England Journal of Medicine about nontraditional medical students who enter medicine at a later age and without the traditional pre-med background. He said that these nontraditional students are often a challenge to medical educators but the class is definitely enhanced by their presence.

Medical schools now routinely admit older students who already have families or another career. The author writes ".... perhaps they believe that medicine needs new voices…"

Source: "From All Walks of Life — Nontraditional Medical Students and the Future of Medicine" NEJM 2008, 359(3) : 224-227 ( free full text)

Medical and social disabilities of preterm birth

Advances in perinatal care have increased the survival of very premature infants, however this has led to concerns about the ability of these children to cope as adults.


A new study published in the NEJM reported a cohort of nearly 1 millions infants in Norway, researchers used data from national registries to examine adult outcomes of these infants who were born without anomalies between 1967 and 1983. They found that the risks of medical and social disabilities in adulthood increased with decreasing gestational age at birth.


Source: "Long-Term Medical and Social Consequences of Preterm Birth" New England Journal of Medicine 2008, 359(3):262-273 ( abstract only)

Low-carbohydrate diet more effetcive for weight loss

322 moderately obese employees of a research centre were assigned randomly to 3 different diets : low-carbohydrate, Mediterranean and low-fat diets over a 2-year period with support from the workplace. Researchers found that those on low-carbohydrate and Mediterranean diets lost about 10 pounds while those on low-fat diet an average of 6.4 pounds.

They also found that participants who followed low-carbohydrate and Mediterranean diets had better cardiovascular health than those in the low-fat group. For people with cholestero, low-carbohydrate diet seemed best, for those with diabetes, the Mediterranean diet. Critics say it is not clear whether individuals would have the same results without workplace support.

Source: "Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet." New England Journal of Medicine 2008; 359:229-241

Is background TV bad for young children?

A newspaper reported a randomised controlled trial that looked at the effects of background TV on young children’s play behaviour. Researchers observed 50 children of 12 - 36 months old play with toys for 1 hour. A TV was on with commercials in the background for half an hour, then turned off for half an hour.

The researchers found that “very young children’s toy play was disrupted by background television” and said this may have a cumulative effect if the child has long periods of TV exposure at home. However, critics say it is not clear from this study whether this has any effect on development but this is an area of topical interest that will benefit from further research.

Source: "The Effects of Background Television on the Toy Play Behavior of Very Young Children." Child Development 2008; 79:1137–1151

Breast self-examinations questioned?

According to a new Cochrane review, breast self-examination by itself does not increase survival. The finding is based on 2 studies of 120,000 Russian women and 266,000 Chinese women in 2003 and 2002 respectively.

Both suggest that self-examination actually increase benign biopsies but does not get the patient into earlier treatment. However, the study does not say women should not do self-examinations, but researchers wrote "screening by self-examination or physical examination cannot be recommended".

Source: "Regular self-examination or clinical examination for early detection of breast cancer." The Cochrane Database of Systematic Reviews 2008 Issue 3 ( full text via Athens from Cochrane Library)

Eating too many nuts could increase childhood asthma risk

Newspapers reported that eating too many nuts in pregnancy could put babies at risk of asthma.
More than 4,000 expectant mothers and their children were followed over 8 years, researchers found that children who developed asthma-like symptoms were significantly more likely to be born to mothers who ate nut products daily dudring their pregnancy, than women who ate nuts rarely.


Critics say that the headline is inaccurate because there were no significant links found between nut consumption and child asthma. The increased asthma symptoms in the child were only found when comparing daily consumption with rare nut product consumption, but not with regular vs rare consumption. It is recommended that pregnant women should have a healthy balanced diet and avoid excessive consumption of one particular food.


Source: "Maternal Food Consumption during Pregnancy and the Longitudinal Development of Childhood Asthma". Am J Respiratory Critical Care Medicine 2008; 178:124-131

Fish oil supplements may reduce asthma risk

A newspaper reported a trial that gave women fish oil supplements during their third trimester and compared the effects on their child’s health with olive oil capsules or no supplements.

Researchers found that the children of those mothers taking fish oil supplements were about 60% less likely to have asthma 16 years after the study began and concluded that their results suggest that fish oils intake in the third trimester may protect the offspring against asthma, however they said there is a need for large randomised controlled trials to examine this further.

Source: "Fish oil intake compared with olive oil intake in late pregnancy and asthma in the offspring: 16 y of registry-based follow-up from a randomized controlled trial." Am J Clin Nutr 2008; 88:167-175

Pregnant women have increased risk of heart attack

According to a new study, pregnant women have the risk of having a heart attack 3 to 4 times the normal risk. Since many women today delay having children until later in life, they could potentially increase the risk of suffering heart problems.

The review is based on a systematic review of 103 cases of pregnancy-related acute myocardial infarction (AMI) in the last 10 years and compared them to 125 cases diagnosed prior to that time. Critics say the review did not look at whether the increasing age is affecting pregnant women's risk of heart attack. Women should not worry as the risk of pregnancy-related heart attack is very low if they are healthy and they can reduce their risk of heart attack by not smoking and by reducing the intake of saturated fat at all times.

Source: "Acute Myocardial Infarction Associated With Pregnancy." J of Am College Cardiology 2008; 52:171–180

Heavier babies may have higher risk of arthritis later in life

According to a study published in the Annals of Rheumatic Diseases, a birthrate of over 4.54 kg or 10 pounds doubled the risk of developing rheumatic arthritis (RA) when they are adults compared with individuals with average birthweight.


The finding is based on a review of the data on 87,077 participants in the Nurses' Health Study. Although the mechanism for the association was not clear to the investigators, researchers said that foetal growth is influenced by nutrition and enviroment independent of genetics, if nutrition has an impact on rheumatoid arthritis, it is a potentially modifiable factor.

Source: "Is birthweight associated with risk of arthritis? Data from a large cohort study." Annals of Rheumatic Diseases 2008; Jul 1 [Epub ahead of print]"

Can eating chocolate reduce cancer risk?

News sources reported that eating chocolate can help fight cancer. This is based on a laboratory study that investigated the chemical GECGC, a man-made antioxidants called procyanidins, which naturally occur in cocoa beans. The scientists added GECGC to 16 different types of cancer cells and found that it inhibited the growth of some cells, with the greatest effect in two types of bowel cancer cells.

Critics say this study cannot be taken as evidence that eating chocolate will reduce any type of cancer. Exercises and healthy balanced diet are the best ways to maintain good health.

Source: "Selective cytotoxicity of synthesized procyanidin 3-O-Galloylepicatechin-4b,8-3-O-galloylcatechin to human cancer cells." Cell cycle 2008; 7: 1648 – 1657

Is coffee bad for health?

Researchers analysed data from two cohort studies, one included 41,736 male health professionals and the other 86,214 female nurses and found that regular coffee consumption was not associated with increased death rate in men or women.

In the female cohort, coffee consumption ( including decaffeinated coffee) were associated with significantly lower risk of death compared with no coffee. The reductions ranged from 7% among nurses drinking 5 to 7 cups a week, to 26% among nurses drinking 4 or 5 cups a day.

According to the findings, coffee seemed to protect both men and women against cardiovascular death but not death from cancer. However, critics said that recent studies have offered a mixed picture on the health benefit of coffee consumption.

Source : "The Relationship of Coffee Consumption with Mortality." Annals of Internal Medicine 17 June 2008:148(12); 904-914 (full text via Athens)

Electronic interference with hospital tracking chips

According to a study published in JAMA, radio frequency identification tags (RFID) used in critical care units in hospitals such as syringe staplers and blood bags, can interfere with life-saving equipment and machines.

Dutch researchers conducted 123 tests of 2 types of RFID tags on 41 medical devices in an unused room at a university medical centre intensive care unit not involving patients and found 34 cases of electromagnetic interferences, 22 of which would have been life-threatening.

An accompanying editorial said the study will need to be conducted with patients present in order to get a true understanding of the problem. However, the co-author of the study argued that these tests could endanger the patients.

Source: "Electromagnetic Interference From Radio Frequency Identification Inducing Potentially Hazardous Incidents in Critical Care Medical Equipment" JAMA. 2008;299(24):2884-2890. (Full text via Athens)

Anaesthetics may enhance pain

According to a newspaper, scientists carried out a laboratory study in mice and discovered that although general anaesthetics suppress the central nervous system and make people unaware of pain during surgery, some general anaesthetics can cause inflammation in other parts of the body causing some patients high levels of pain when they wake up.

The study has identified one protein that is associated with the activation of pain pathways by some general anaesthetics and this knowledge may be helpful to develop better general anaesthetics in the long term.

Source: "General anesthetics activate a nociceptive ion channel to enhance pain and inflammation". Proc Natl Acad Sci USA 2008; Jun 23 [Epub ahead of print]

A new technique offers new hope to patients with small malignant lung tumours

A newspaper reported that a new technique called radiofrequency ablation has given hope to patients with small malignant lung tumours that could not be treated with sugery, radiotherapy or chemotherapy.

Researchers said it has produced good response rates and is safe to warrant further study after they recruited 106 patients for the study and found that the new technique successfully treated 88% of tumours and about 50% of patients who had primary lung cancer were alive after two years. The study was funded by Angiodynamics which made the radiofrequency ablation device.


Source: "Response to radiofrequency ablation of pulmonary tumours: a prospective, intention-to-treat, multicentre clinical trial (the RAPTURE study)." Lancet Oncology 2008; Jun 18 [Epub ahead of print]

Lifestyle changes may slow prostate cancer

Newspapers reported a small pilot study of 31 men with very low risk prostate cancer that looked at the effects of lifestyle changes on the activity of different genes in prostate tissue.

The participants did not want immediate surgery, hormone therapy, or radiotherapy but agreed to change comprehensive lifestyle including good diet and exercise. By the end of the study, they had reduced BMI, blood pressure, waist size and blood lipids. 48 genes were found more active and 453 genes less active after the intervention. Some of them are related to tumour formation.

Researchers concluded that intensive nutritional and lifestyle changes may change gene activity in the prostate and suggest larger studies to confirm their findings.

Source : "Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention." Proc Natl Acad Sci 2008; [Published online June 16]

4 cups of tea a day cuts heart disease risk

Newspapers reported a review of several studies on tea consumption and its effects that found drinking more than three cups of tea a day cuts the risk of heart attack due to the natural plant antioxidants, polyphenols, in tea. The researcher also found that adding milk to tea made no difference to the effect of tea. The study was funded by the Tea Advisory Panel and the Tea Council.

Although the evidence indicates a positive role for tea in human health, critics say that there are many risk factors that contribute to the development of heart disease, people should not rely on drinking tea for protection from heart attacks.

Source: "Black tea and health." Nutrition Bulletin 2008; 33 91-101

Higher heart attack risk in men with vitamin D deficiency

News source reported that researchers at Harvard analyzed medical records and blood samples from 454 men who had a heart attack or disease and compared them to 900 men who had no history of cardiovascular disease.

They found that men with a vitamin D deficiency (15 nanograms or less per ml of blood) had a higher risk of heart attack than those with a sufficient amount of vitamin D (30 nanograms per ml of blood or more). They concluded "the results further support an important role for vitamin D in myocardial infarction risk"

Source :"25-Hydroxyvitamin D and Risk of Myocardial Infarction in Men - A Prospective Study"
Archieve of Internal Medicine. 2008;168(11):1174-1180.

Red yeast rice extract may be good for the heart

Newspapers reported that a large randomised placebo-controlled trial of 5000 patients showed that the extract of Chinese red yeast rice, XZK, that gives Peking duck its red colour, reduces bad cholesterol that subsequently lowers cardiovascular events in Chinese people who have already experienced a heart attack.

Critics say that although the study provides good evidence of the beneficial effect of the extract, the finding is not surprising because one of the cholesterol-lowering drugs, lovastatin, was originally extracted from yeast rice. They also say that people who are concerned about their risk of heart attack or their cholesterol levels should talk to their GP, who may prescribe them a statin.

Source: "Effect of Xuezhikang, an Extract From Red Yeast Chinese Rice, on Coronary Events in a Chinese Population With Previous Myocardial Infarction." American J of Cardiology 2008; Apr 11 [Epub ahead of print]

Regular use of painkillers could cut Alzheimer's risk

A few newspapers reported a study that has found regular use of ibuprofen, aspirin and other painkillers known as NSAIDs reduces the risk of developing the Alzheimer's disease. Doctors warn that people should not take over-the-counter pain remedies to ward off dementia as there are side effects. The finding is based on a review of six studies involved almost 14,000 people.

Researchers concluded that NSAID use reduced the risk of Alzheimer’s disease. However, they did not find that a sub-group of NSAIDs, known as the SALAs, more effective than other non-SALAs in preventing the disease. This suggests that all conventional NSAIDs have a similar protective effect in humans.

Critics say this was a review of selected studies and that the risk from bleeding need to be considered against any benefits.

Source: "No advantage of A 42-lowering NSAIDs for prevention of Alzheimer dementia in six pooled cohort studies." Neurology 2008; May 28 [Epub ahead of print]

Anti-hypertension drug types do not influence outcome

Previous studies suggest that the effects of anti-hypertensive drugs might be smaller among elderly people and some guidelines recommend specific types of blood pressure lowering treatment for particular age groups.

According to the BMJ, a new meta-analyses of 31 trials with more than 190,000 participants "showed no clear difference between age groups in the effects of lowering blood pressure or any difference between the effects of the drug classes on major cardiovascular events, .... also showed no difference in effects between the two age groups for the outcome of major cardiovascular events".

Source: "Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials -Blood Pressure Lowering Treatment Trialists’ Collaboration" BMJ 2008;336:1121-1123 ( free f/t)

Regular exercises reduce cancer death risk in men

Newspapers reported on a prospective cohort study of more than 40,000 Swedish men that found those who exercised moderately for at least 60 minutes a day reduced their risk of cancer, also in men who have cancer, 30 minutes a day of moderate exercise improved their chances of survival by 33%.

The researchers said the findings ‘may have major public health implications in the prevention and treatment of malignancies’ but the results require confirmation.

Critics say the study did not take into account the effect of diet that can influence their risk of cancer and it is possible that the men who exercised more also had healthier diets.

Source: "Association of physical activity with cancer incidence, mortality, and survival: a population-based study of men" British Journal of Cancer (2008) 98, 1864-1869.

Gum disease link to cancer risk

The BBC reports - Men with a history of periodontal (gum) disease were 14% more likely to develop cancer than those without. This is based on a prospective cohort study that analysed data for more than 48,000 male health professionals who had not had cancer prior to 1986 and who responded to questionnaires about periodontal disease.


Researchers concluded that "periodontal disease is associated with a small, but significant, increase in overall cancer risk" and that this increase in risk exists in men who had never smoked, but they said that "any recommendations for prevention of cancer based on these findings are premature" and further studies are needed to clarify whether periodontal disease itself causes the increase in cancer or whether it indicates some other factors.


Critics say the study included only male professionals, the results may not apply to other groups of people.


Source: "Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort study." Lancet Oncology 2008; May 6 [Epub ahead of print]

Music's healing and sedative effects in ICU patients

An interesting article from the New York Times.

Dr C Conrad, a senior surgical resident at Harvard with a doctorate in music philosophy, and colleagues carried out a simple study involving 10 ICU patients. Just after the sedation was lifted, 5 were given gentle piano music for 1 hour while 5 heard nothing.

They found that those patients listening to music showed reduced BP and heart rate, less need for pain medication and 20% drop in epinephrine and interleukin-6 ( 2 important stress hormones). They also had a 50% increase in pituitary growth hormone.

Previous research has shown growth hormone generally rises with stress and falls with relaxation, Dr Conrad argued that the growth hormone may reduce the levels of stress hormones that produce inflammation that in turn causes pain and raises BP and heart rate.

Experts said the study suggests a rise in growth hormone may dampen inflammation and stress responses although they did not buy in the proposed mechanism.

Source: "Overture for growth hormone: requiem for interleukin-6?" Critical Care Medicine. 2007 Dec;35(12):2709-13 ( f/t via Athens)

Flavanol-containing cocoa improves diabetics blood flow

A small study funded by Mars Inc. (who also provided the cocoa drinks used in the study) found that three mugs of specially formulated cocoa (containing high levels of flavanols, a type of antioxidant ) a day for a month improved blood flow through the arteries by 30% in diabetics.

They used FMD ( flow-mediated dilation) in the brachial artery (artery in the upper arm) to measure cardiovascular risk - lower FMD has been linked to a greater risk of cardiovascular enents. Researchers concluded that "diets rich in flavanols reverse vascular dysfunction in diabetes" and that cocoa could be used as a treatment to reduce the risk of cardiovascular disease.

Critics warn diabetics should not start eating chocolate to try to reduce their cardiovascular risk because of the high levels of fat and sugar involved, they should eat more fruit and vegetables that also have high levels of the antioxidants.

Source: "Sustained Benefits in Vascular Function Through Flavanol-Containing Cocoa in Medicated Diabetic Patients - A Double-Masked, Randomized, Controlled Trial" J American College of Cardiology, 2008; 51:2141-2149

HRT pills double risk of blood clots

Researchers in France and Glasgow carried out a systematic review and meta-analysis on some studies looking at the risk of venous thromboembolism in women taking hormone replacement therapy HRT) - the BBC reported.


They concluded that "current use of oral oestrogen increases the risk of venous thromboembolism by twofold to threefold" and they said that HRT patch may be safer but further research is needed.


The critics say this new study provides valuable evidence about the size of the risks and gives some idea of the difference between patches and pills, but women should not assume that it is unsafe to take HRT pills or patches are safe.


Source: "Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis" BMJ, published 20 May 2008. Ahead of print ( f/t via Athens)

Biological washing powders do not cause skin irritation

News sources reported that British researchers examined 44 papers about whether enzymes added to detergent washing powders can cause skin reactions and concluded that "biological detergents do not cause skin irritation. They advised that doctors should look beyond laundry detergents for the true cause of eczema, rashes and itches.

Critics said this seems a good advice but the readers should be aware of some of the limitations of this study - the researchers have not described their searching methods, it is not clear if all relevant papers have been looked at, they may fail to detect some publications which could influence their conclusion. The researchers have declared their consultancy fees from Unilever.

Source: "Enzymes, detergents and skin: facts and fantasies" British Journal of Dermatology 158(6): 1177-1181, June 2008

Rosehip for osteoarthritis pain reduction

Researchers conducted a meta-analysis of randomised controlled trials into the use of Rosa canina hip powder treatment compared with placebo for osteoarthritis, reported a newspaper.


They combined and analysed the results from these studies and found that use of Rosa canina reduced pain to about a third compared to the placebo group. People taking the powder were also less likely to use "rescue" medication, ie painkillers.


Critics say the study provides good evidence that rosehip reduces pain associated with osteoarthritis, however it was not set up to determine whether rosehip was better than current treatments.


Source: "Does the hip powder of Rosa canina (rosehip) reduce pain in osteoarthritis patients? – a meta-analysis of randomized controlled trials" Osteoarthritis and Cartilage April 2008 Ahead of print

Unpublished data on herceptin

The Guardian reported a study carried out by New Zealand researchers that investigate whether it is better to use herceptin, a breast cancer drug, alongside the chemotherapy or after it, ie sequential use.

They found that the data of the sequential use of herceptin were not published while data from the women given herceptin alongside their chemotherapy and women in the control group have been fully published in a peer-review journal. When they combined all these results, they found that the effect of herceptin was a third less effective than previously thought.

They concluded that not including these data in the overall assessment of the sequential use of herceptin has led to the treatment recommendation of the drug - a case of publication bias in which drug companies publish only trial results that are favourable.

Source: "Trastuzumab: possible publication bias". Lancet 2008; 371:1646-1648 ( free f/t via Athens)

"Overconfidence as a cause of diagnostic error in medicine"

The May issue of the American Journal of Medicine is dedicated to the understanding and addressing the sensitive issue of diagnostic error. The authors of this particular article conducted an extensive literature review ( with more than 200 references) on the incidence and impact of diagnostic error and examined the possibility that overconfidence contributes to diagnostic error.

The authors noted that the rate of diagnostic error is as high as 15%, "when directly questioned, many clinicians acknowledge that diagnostic errors exist but believe the rate is very low and that any errors are made by others who are less skillful or less careful". The authrs said this reflects overconfidence and complacency that leads to the failure to recognise one's own error.

In the great majority of cases, most diagnosis are correct, but the authors said that very often diagnostic errors are cognitive in nature and arise from those cases that physicians perceive as routine and unchallenging. They failed to recognise the shortcomings that derive from heuristic thinking.

The authors found that many physicians underutilized diagnostic decision-making tools, eg guidelines, and that feedback regarding their errors is also lacking, together with the overconfidence, these have contributed to the high misdiagnosis rates.

Based on the belief that physicians overall are dedicated and well-intentioned, if they were more aware of these factors and their own predisposition to error, they would take steps to reduce their errors, the authors suggest that strategies to address the problem should focus on "improving the physician's calibration between their perception of the case and the actual case".

The authors suggest two approaches to reduce diagnostic error :
1). Improving physician's cognition needs and focusing on making them better thinkers, less subject to biases, and more aware of what they know and do not know.
2). Changing the healthcare environment so that the data on patients, potential diagnoses and any additional information are more accurate and accessible.

Source:"Overconfidence as a Cause of Diagnostic Error in Medicine" American Journal of Medicine 2008;121(5), supplement, S2-S23 (Free f/t)

Beta blockers cost more lives than they saved

For many years, beta blockers have been given routinely to patients undergoing surgery to reduce the risk of heart attcks after operations, but a new study, published in The Lancet, of more than 8000 patients in 23 countries who had surgery has found that those given the drugs double their risk of stroke and a third more likely to die within a month of surgery, the BBC reported.

The lead researcher said although beta blockers had benefits in lowering heart attacks, they were outweighed bythe increase of stroke and death. The study claimed that about 800,000 would have died as a result of doctors giving out the drugs without considering the side effects.

Source: "POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomized controlled trial". Lancet 2008. DOI: 10.1016/S0140-6736(08) 60601-7. Ahead of print.

Breastfeeding may protect women against arthritis

According to a new study in the Annals of the Rheumatic Diseases that compared 136 women with rheumatoid arthritis to 544 without the condition, women who had breastfed for 13 months or more were half as likely to develop the disease as those who had never breastfed. The study also found that taking oral contraceptives did not have the same effect.

Experts said previous studies showed that "breastfeeding was a risk factor for developing rheumatoid arthritis in a small group of women soon after giving birth to their first child."

Source: "Breast-feeding, but not oral contraceptives, is associated with a reduced risk of rheumatoid arthritis" Annals of Rheumatic Diseases. Published Online First: 13 May 2008. doi:10.1136/ard.2007.084707 (f/t via Athens)

Mind your manners

An assistant professor of psychiatry at Harvard Medical School said that medical education and postgraduate training should place more emphasis on teaching doctors good behavior that would enhance their relationship with patients. He said when dcotors deal with patients in a polite manner, patients have a satisfying experience.

Source:"Etiquette-Based Medicine" New England J of Medicine, 2008, 358(19):1988-1989 ( free f/t)

Obesity increases dementia risk

Multiple news sources reported a systematic review of 10 published studies in 5 different countries that found obesity increases the risk of dementia in general by 42% and Alzheimer's by 80%. Researchers also found that people who are underweight have an elevated risk of dementia and its subtype. The study also included a meta-analysis of 7 stuides with at least 5 years followed up.

The senior author said that preventing obesity at a younger age could reduce the number of dementia patients in the US.

Source: "Obesity and central obesity as risk factors for incident dementia and its subtypes: a systematic review and meta-analysis". Obesity Reviews 9(3):204-218, May 2008

breastfed babies are smarter

Several newspapers reported on a study that found prolonged and exclusive breastfeeding makes kids smarter.

This is a large randomised trial involving more than 17,000 babies to see if a breastfeeding programme of promoting the duration and exclusive breastfeeding has an effect on childhood intelligence. The babies were followed up to 6 years. The decision of breastfeeding was the women's own choice.

The study found that children from the breastfeeding promotion group scored significantly higher than the controls on scores of vocabulary, similarities and verbal IQ.

Source: "Breastfeeding and Child Cognitive Development :New Evidence From a Large Randomized Trial" Archives of General Psychiatry. 2008;65(5):578-584. (f/t via Athens)

Aspirin daily reduces breast cancer risk

News sources reported a new study that found women who took aspirin, known as non-steroidal anti-inflammatory drugs (NSAIDs) daily were 16% less likely to develop breast cancer.


Researchers studied the questionnaire responses from a previous study conducted in 2003 and used the answers to relate the use of NSAIDs to the chance of developing breast cancer. They concluded that "breast cancer risk was not significantly associated with NSAID use, but daily aspirin use was associated with a modest reduction in oestrogen-receptor (ER)-positive breast cancer." However they suggested further research is required as other studies have shown conflicting results.


Source: "Nonsteroidal anti-inflammatory drugs and breast cancer risk in the National Institutes of Health–AARP Diet and Health Study" Breast Cancer Research 2008, 10:R38doi:10.1186/bcr2089 ( free f/t)