Resources for GP AKT exams

The following resources may be of interest to GP trainees preparing for the AKT exam.


RCGP AKT sample questions - November 2011

GPST Society - run by the GP trainees in South-East Scotland to support other trainees in the area. The resources include guides and tips on passing the AKT exam, suggestions of useful resources etc, would be useful to GP trainees in other parts of UK.

gpst.info - run by Dr Mahibur Rahman, a GP who works in Birmingham, also the director of a commercial website, Emedica. The gpst.info website has some free MCQ questions for MRCP and tips for assessment, also advertisements about Emedica.

Books via Athens - click on books@ovid
Oxford Handbook series including : Oxford Handbook of General Practice. 3rd ed. and Oxford Textbook of Primary Medical Care. 1st ed.
BMJ Learning - GP trainee ( access via Athens )

Useful journal via PubMed Central (UK) - free open access
British Journal of General Practitionrs - 12 months after publication

BMJ Careers free articles : written by GP trainees
MRCGP applied knowledge test
MRCGP examination: applied knowledge test and clinical skills assessment
GP exam to change - July 2010

See also post on MRCP, MRCS free exam questions

Living Books About Life - free ebooks

"Living Books About Life" is a collaboration between Open Humanities Press and 3 academic institutions: Coventry University, Goldsmiths, University of London, and University of Kent.

Funded by the Joint Information Systems Committee (JISC), 21 living books are created and published by Open Humanities Press (OHP), the unifying theme is life: e.g., air, agriculture, bioethics, cosmetic surgery, electronic waste, energy, neurology and pharmacology.

The editors said that the series represents an exciting new model for publishing, in a sustainable and low-cost manner in the future. These books can be freely shared with other academic and non-academic institutions and individuals. They constitute an engaging resource for researching and teaching relevant science issues across the humanities, a resource that is capable of enhancing the intellectual and pedagogic experience of working with open access materials.

All the books in the series are open to ongoing collaborative processes of writing, editing, updating, remixing and commenting by readers, thus engaged in rethinking ‘the book’ itself as living.

The attributions/bibliography of each book often links to free full-text, some have video clips added. You may be able to download these books to e-book readers such as Kindle and the iPad!

Breast cancer screening review

Yesterday, the media reported that following an open letter by Susan Bewley, professor of complex obstetrics at King's College London, to the government's cancer chief, an independent investigation into breast cancer screening has been set up to try to settle the growing controversy around its benefits and potential harms.

The NHS Breast Cancer Screening Programme began in 1988 and claimed that the scientific evidence demonstrates clearly that regular mammographic screening between the ages of 50 and 70 reduces mortality from the malignancy.

The 1st systematic review of breast cancer screening came from the Nordic Cochrane Centre, part of the Cochrane Collaboration, published in The Lancet in 2000. The review was based of 8 large RCTs with more than 182,000 women in the Nordic countries. The authors found that the quality of the trials were low and the data showed that for every 1000 women screened biennially throughout 12 years, only 1 breast-cancer death was avoided whereas the total number of deaths was increased by 6. The authors concluded that "Screening for breast cancer with mammography is unjustified".

The most recent update of this review was published on 19 January 2011. The authors said that it is not clear whether screening does more good than harm and women invited to screening should be fully informed of both the benefits and harms.

Source: Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2011, Issue 1

Do we need to drink 8 glasses of water a day?

A Scottish GP, Margaret McCarthney, wrote a feature article in the BMJ last week that the common recommendation to drink 6 to 8 glasses of water a day is "debunked nonsense", as a result, hundreds of comments, some agreeing, many disagreeing, were sent to the BMJ and other media.

The GP argued that there is no high quality evidence to support the recommendation and that too much water can lead to hyponatremia and other problems. She said that the "Hydration for Health" initiative, sponsored by Danone, maker of bottled water Volvic and Evian, has vested interests to re-inforce the myth. Dr McCarthney argued that reports that drinking more water can improve concentration and mental performance in kids have lacked evidence and that Hydration for Health has oversold the benefits of drinking more water without clear evidence to support it. "We should just say no", she said.

An expert noted that there is well established literature on the negative effects of dehydration on mental skills in adults and children. Another said that the author failed to mention an important US report(2004) that reviewed all studies.

Dr McCartheny argued that her article was to examine the evidence of the benefits that Danone claimed via "Hydration for Health" and was not a systematic review on the subject and she did not imply that it is dangerous for children to drink 6-8 glasses of water a day.

Source: Waterlogged? BMJ 2011; 343:d4280 doi: 10.1136/bmj.d4280 (Published 12 July 2011) , full text via Athens

Provenge therapy for advanced prostate cancer

Prostate cancer is one of the most common malignancy in North American males causing more than 30,000 deaths each year, up to 30% experience recurrence.

Chemotherapy and hormonal therapy are the usual treatment available to these patients, but many patients have progressed to castrate-resistant prostate cancer (CRPC) and chemotherapy has significant side effects.

A new study was published online in the journal Maturitas in May about a novel therapeutic cancer vaccine, Sipuleucel-T, or Provenge, produced by Dendreon Ltd, for the treatment of CRPC after randomized trials showed significant survival advantage compared to controls.

In April 2010, the US FDA approved the vaccine therapy for advanced prostate cancer that has failed to respond to hormone therapy. The therapy involves taking the patient's own immune cells, externally activated against prostate cancer antigen PAP and infuse back into the patient. The patient's own immune system will then create T-cells to attack these cells.


Provenge does not cure prostate cancer but trials show that it extends survival by 4 months or years for some patients. Phase I and Phase II trials show that the vaccine is safe but some patients suffer side effects such as fatigue, headache, back pain, joint pain etc. It is advised that patients should discuss the risks and benefits with their physicians.

Source: "Vaccine therapy with sipuleucel-T (Provenge) for prostate cancer". Maturitas 2011 Aug;69(4):296-303. Epub 2011 May 31

sitting for long periods doubles risk of blood clots in the lungs

According to a new study published by the BMJ, women who sit for long period of time everyday are 2 to 3 times more likely to develop blood clot in their lungs than more active women. The study is the first to prove that a sedentary lifestyle increases the risk of developing a pulmonary embolism.

US researchers followed almost 70,000 female nurses for 18 years and collected information about their lifestyle through biennial questionnaires. They found that the risk of pulmonary embolism was more than twice higher in women who spent more than 41 hrs a week (outside work) sitting comapred with those who spent less than 10 hrs a week. The study also showed that physical inactivity correlated with heart disease and hypertension.

The authors concluded that physical inactivity is associated with pulmonary embolism in women and suggest that the incidence of pulmonary embolism could be redudced by discouraging physical inactivity among the general public.

Source: Physical inactivity and idiopathic pulmonary embolism in women: prospective study. BMJ 2011; 343:d3867 (Published 4 July 2011) Open access

Risk of irregular heart rhythm from NSAIDs is low

The use of NSAIDs, commonly known as painkillers, including ibuprofen are already known to be associated with cardiovascular risk but a new study, published in the BMJ, showed for the first time a link between the drugs and atrial fibrillation or flutter (AF) also known as irregular heart rhythm.

Danish researchers examined the records of more than 32,000 patients who had a first diagnosis of AF between 1999 and 2009 and compared each to 10 randomly selected control patients.They found that patients starting treatment with non-aspirin NSAIDs had 40-70% increased risk of AF compared to non-users. New users of cox-2 inhibitors, the newer forms of the drugs, were associated with a 70% increased risk.

The lead author concluded that the overall increased risk was still low and patients taking these medicine should not stop them but should discuss the potential risks with doctor. One-off doses or short courses of over-the-counter-strength ibuprofen are still considered safe.

In an accompanying editorial, the author said doctors should be cautious when precribing NSAIDs to older people because of the higher risk of AF.

Critics say that this was a population-based case control study with many strengths, but the lack of data on the amount of NSAIDs taken by the patients, confounders, lifestyle factors etc. could have affected the results.

Source: Schmidt M, Christiansen CF, Mehnert F, et al. Non-steroidal anti-inflammatory drug use and risk of atrial fibrillation or flutter: population based case-control study. BMJ 2011; 343:d3450 ( open access)

Editorial : Gurwitz JH. NSAIDs and atrial fibrillation. BMJ 2011, 343: d2495 (open access)

Anticholinergic medication may put elderly at risk

According to a new study, a group of researchers in the UK and US re-analysed data collected between 1991 and 1993 as part of a large ongoing MRC study into the decline of mental functioning in people over 65 to determine whether the use of anticholinergic drugs increases the cognitive impairment risk and death in older people.

Anticholinergic drugs block the chemical acetylcholine which is vital in the transmission of electrical impulses between nerve cells, also have an effect on concentration, memory and causes confusion. Drugs with anticholinergic effects are commonly used in many areas of medicine, eg, eye drops Timolol Maleate, warfarin for blood thinning, the painkiller Codeine, allergy tablets Piriton, incontinence drug Ditropan, the antidepressant Seroxat and the sleeping pill Nytol.


Researchers examined more than 80 drugs having anticholinergic effects and classified them with score into 3 groups : severe, moderate and mild based on potential harm. Drugs with a severe risk include Piriton, Nytol and Ditropan.


Researchers found that nearly half of the elderly patients in the study took 1 or more of these drugs, 4% were taking drugs with definite anticholinergic properties. The results showed that 20% of those taking drugs with a total score of 4 or more died by the end of the two-year study, compared with only 7% of those taking no anticholinergic drugs. Those taking several of the drugs had a 4% worse score in key tests to check the function of their brain. They concluded that the use of anticholinergic drugs increases the risk of cognitive impairment and mortality.


Critics say that the data were collected 20 years ago and may not reflect the current prescribing practice. Although the use of anticholinergic drugs was associated with increased death, it may have been influenced by some underlying conditions. It is important that people should not stop taking prescribed anticholinergic medication before speaking to their GP.


Source: Anticholinergic Medication Use and Cognitive Impairment in the Older Population: The Medical Research Council Cognitive Function and Ageing Study. Journal of the American Geriatrics Society. Article first published online: 24 JUN 2011 (full text via Athens)

More calcium does not reduce fracture risk

It is already known that calcium along with vitamin D are important in keeping bones healthy. In the US, the guideline for calcium intake was 1000 mg a day for women under the age of 50, 1200 mg for older women with the upper intake level of 2000 mg because of kidney stones and other risks caused by high calcium intake. In the UK, the recommended Ca intake for adults is 700 mg a day.

Several recent studies linked calcium supplements to increased risk for cardiovascular events and kidney stones in women. A new study published in the BMJ looked at the relationship between calcium and risk for fractures and overall bone health involving more than 61,000 Swedish women, followed up for 19 years.

The study found that women with the lowest Ca intake, below 750 mg, had a higher risk of fractures or develoing osteoporosis, but increasing intake of Ca did not reduce the risk of fracture further. Women who had the highest Ca, 1100+ mg seemed more at risk of broken hip. It concluded that moderate levels of calcium intake were best for bone health and more was not better.

The large size of the study with better precision is regarded a strength of the study, but critics say researchers used a questionnaire covering diet and lifestyle to find out how much calcium women were getting from food may result in recall bias. Experts suggest women should get enough calcium from a balanced diet, eg half pint of milk, green vegetables and nuts.


Source: "Dietary calcium intake and risk of fracture and osteoporosis: prospective longitudinal cohort study". BMJ 2011; 342:d1473 (Published 24 May 2011) Open access

Google Chromebooks

Google launched Chromebooks on 15 June 2011. What are Chromebooks? These are laptops with the Chrome OS, an operating system based on the web browser. In fact the browser is all you have - "Nothing but the web"! Chrome promises effortless computing, easier, faster and better without the need for expensive IT support.


According to reviewers, Chromebook users can do most of the things they do with their PCs and laptops in the Chrome browser without storing any data on their machines, but you can't run Microsoft office or play games on an iPad. Everytime you boot up a Chromebook, it will give the latest version of its software and security patches, filter out the spam and check viruses, so it eases the burden of spam, software updates, security and hardware failure. In the event of computer breakdown or lost, your data will be safe becuase they are stored in Google's cloud.


The cloud is simply a place for storing data instead of keeping it, you merely have access to them through servers operated by the cloud providers. Google claims that Chromebooks come with an encrypted file system by default, so they are very safe. Many computing security experts have expressed reservations about the security of the cloud, however supporters say that while there are drawbacks, most cloud services are adequate and safe.

Avoiding hospital admissions: what does the research evidence say?

Emergency admissions represent around 65% of hospital bed days in England. It is a major concern for the NHS, despite considerable efforts to reduce emergency admissions, only a few PCTs succeeded between 2007 and 2009.

The King's Fund has published a paper which considers the research evidence for a range of interventions to avoid emergecy or unplanned hospital admissions addressing the following key questions:
- What interventions work to reducing avoidable admissions?
- Who is at risk and how do we identify them?
- Which admissions are potentially avoidable?
- Which interventions work in primary, secondary and emergency care as well as discharge from hospital?

Some of the findings on interventions in A&E :
- A recent systematic review of the evidence for the effectiveness of GPs working in EDs found that this intervention may result in fewer referrals for admissionn but the evidence is weak.
- A study of a GP service aimed at patients who are referred for urgent medical admission by a GP in the ommunity showed a small reduction in admissions to the medical assessment unit.
- Making a senior emergency medicine clinician available to review patients in the ED has been shown to reduce inpatient admissions by 12 % and specifically reduced admissions to the acute medical assessments unit by 21%.

The paper finds that there is insufficient evidence to support many of the interventions currently being implemented and concludes that policy-makers, providers and commissioners can introduce a number of changes that have proved to be effective in reducing admissions and includes recommendations for all of these groups, emphasising the importance of using evidence-based interventions.

Source: "Avoiding hospital admissions: what does the research evidence say?" King's Fund , Dec 2010

Free access to research articles on E. coli bacteria

During the past few weeks, a significant increase in the number of patients as a result of eating salad infected with E.Coli has been reported in Europe, especially in Germany.

The Executive Vice President Corporate Communications of Springer Science+Business Media, said, "As a global scientific, technical and medical publisher, Springer plays a major role in the distribution of scientific information and access to knowledge and research. Therefore we are making all studies, published up to now on the E. coli bacteria, freely available online on SpringerLink. By doing this, we hope to play a small part in helping researchers and medical professionals solve, or at the very least alleviate, this crisis."

Springer Science+Business Media is offering all journal articles and book chapters which deal with the E. coli bacteria free of charge at SpringerLink. The articles can be found by using the search terms "Enterohaemorrhagic and Escherichia and coli".


A total of over 400 scientific articles are available to print out or download from now until 1 September 2011. The articles which are available free of charge concern the better-known and less aggressive strain E. coli 0157:H7.

Springer Science+Business Media is a leading global scientific publisher, in the science, technology and medicine (STM) sector, the group publishes around 2,000 journals and more than 7,000 new books a year, as well as the largest STM eBook Collection worldwide.

UCLP library project

In March 2009, 5 academic health science centres (AHSC) were officically formed and recognised by the Government, these are partnerships between a university and NHS Trust with the aim to improve the quality of health services by bringing research, educaton and patient care closer together. AHSCs include :

Cambridge University Health Partners
Imperial College AHSC
King's Health Partners
Manchester AHSC
UCL Partners

JISC Collections, the UK academic community e-content procurement service, major STM publishers and database suppliers have agreed on a 1-year pilot programme that will allow the univeristies at the AHSCs to extend access to their subscribed content to their partner NHS organisations. Publishers include Elsevier, Nature, Springer, Thomson Reuters and Wolters Kluwer Health have granted extended access at no additional cost for 2011.

Works are underway to link the resources to Athens, once activated, they will be available through MyAthens. The project will end on 31 December 2011.

Foundation doctors as teachers

The GMC documents Tomorrow’s Doctors and Good Medical Practice and the Foundation Programme Curriculum all outline the need for junior doctors to develop their teaching skills because doctors have a professional obligation to contribute to the training of other doctors, medical students and non-medical healthcare professionals.

According to an article in the BMJ Careers written by a F1 doctor together with a foundation school director, most foundation trainees have little formal training in teaching when they leave medical school. Many foundation trainees teach medical students at the bedside in their job and develop their own teaching style through trial and error. The authors said that these skills are not innate but can be learnt and developed.

The article discusses the teaching role of foundation trainees, the skills required to be bedside teachers including : practical and theoretical understanding of the topics to be taught, assessing each student's needs, develop good learning relationship, how to give feedback, planning the session and different styles of teaching. Ways foundation trainees can improve their teaching skills are also suggested.

It is advised that junior doctors who want to involve in teaching medical students should discuss their teaching activities with their firm lead and education supervisor to ensure support and workload planning can be arranged.

Source: Foundation doctors and bedside teaching. BMJ Careers ( free article)

See also : Teaching and Learning ‘At the Bedside’ . London Deanery. ( free article)

What distinguishes top-performing hospitals.....

In recent years, public reporting of hospitals' performance is becoming increasingly common in America to improve patient outcomes and accountability. Many hospitals have made substantial efforts in quality improvement including investing in high-tech equipments and systems, but disparities still persist between the highest and lowest performing hospitals in patient mortality rates.

According to a new study, conducted by Yale Global Health Leadership Institute at Yale University, published in the Annals of Internal Medicine, between 2005 and 2007, the 30-day mortality rates for Medicare heart attack patients ranged from 11.4%-14% among the high performers and 17.9%- 20% among the low.

Earlier studies suggested that the high mortality rates in low-performing hospitals could have been caused by factors such as hospital location, bed size, for-profit status, nurse staffing ratio and patient population, eg black, elderly. However, the Yale researchers found that these factors accounted for a small percentage of the variation between the high and low peforming hospitals.

They compared the characteristics of 11 hospitals ranking the top or bottom 5% measured by the 30-day mortality rates for acute myocardial infarction (AMI). They interviewed 158 key staff who were involved with AMI care at the hospitals and found few differences in protocols and processes used in treating heart attacks, but what differentiated the high performers from the low was how they did things - a shared organisational culture that focused on communication and support to improve patient care.

They found that high-performing hospitals were characterised by the followings :
- staff shared organisational values and goals of providing high quality care
- senior management involvement and commitment to high quality care

- broad staff presence and expertise in clinical decision making
- strong communication and coordination across disciplines and departments resulting in seamless transitions in care
- used adverse events and feedback as opportunities for problem solving that focused on nonpunitive learning

The study concluded that protocols and processes are not sufficient for achieving high performace in AMI care but "long-term investment and concerted efforts to create an organisational culture that supports full engagement in quality, strong communication and coordination .... problem solving and learning across the organisation" may be required.

Source: What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates? A Qualitative Study. Annals of Internal Medicine. March 14, 2011 vol. 154 no. 6 384-390 ( f/t via Athens)

Metformin still best first-line type 2 diabetes drug

According to a new review published online in Annals of Internal Medicine, there are numerous regimes of diabetes medications to treat type 2 diabetes in the US. Many of these patients need to take multiple medications to control their blood sugar levels, but they have side effects - hypoglycemia ( low blood sugar levels) is the the most common serious side effect, others include nausea or diarrhea.

Researchers at Johns Hopkins reviewed 166 studies that examined the efficacy of 6 classes of diabetes drugs. They found that most of the medications lowered blood sugar levels by a similar amount and that combination of 2 drugs improved blood sugar control, but no combination was shown to have significant benefits over another. The study found that metformin, an older drug approved in 1995 in the US, was consistently associated with fewer side effects and is cheaper than most newer drugs. Reserachers suggested metformin is probably the best first-line therapy for type 2 diabetes.

The study noted that 95 of the 166 studies reported drug company support, many of them were not long enough to study the side effects. The study leader said longer-term reserach into their impact on long-term outcome is needed .

Siurce: Comparative Effectiveness and Safety of Medications for Type 2 Diabetes: An Update Including New Drugs and 2-Drug Combinations. Annals of Internal Medicine, First published online on March 14, 2011 ( free f/t article)

Tamoxifen saves lives and costs

Research has shown that tamoxifen (Nolvadex) can protect against breast cancer but can have side effects including hot flashes, weight gain, abnormal menstrual periods and nausea.


To investigate those women who can most benefit from tamoxifen as a cancer preventive drug, US researchers analysed 4 randomised, placebo-controlled trials and assessed the effects that tamoxifen would have on breast cancer risk 10 years after the treatment.


Investigators used a mathematical model and found that in post-menopausal women under 55 who have an increased risk of developing breast cancer, the benefits of using tamoxifen to prevent cancer are sufficiently outweigh its side effects, it also saves costs.


Source: Cost-effectiveness of chemoprevention of breast cancer using tamoxifen in a postmenopausal US population. Cancer, 2011; published online 14 March 2011

Mediterranean diet reduces metabolic syndrome

Many studies have found that the Mediterranean diet reduces heart disease, but a new review, published in the Journal of the American College of Cardiology, examined the effects of the Mediterrean diet on the risk factors of cardiovascular diseases.

The researchers reviewed and analysed the results of 50 studies in the English language with more than 500,000 participants, they also evaluated the quality of each study. They found that eating the Mediterranean diet reduced the development of the metabolic syndrome as well as all the individual components such as high blood pressure, high blood sugar, high blood fat, low levels of good cholesterol and large waist circumference - these are the risk factors often precede the development of cardiovascular diseases.

They concluded that thier findings have considerable public health importance but noted several limitations in the study, eg the considerable heterogeneity among the studies which could affect the results - only 8 studies addressed the effects on all the metabolic syndrome risk factors, of which 2 were RCTs, 2 cohort studies and 4 cross-sectional studies.

Source: Kastorini CM, Milionis HJ, Esposito K et al. The Effect of Mediterranean Diet on Metabolic Syndrome and its Components: A Meta-Analysis of 50 Studies and 534,906 Individuals. Journal of the American College of Cardiology, 2011; 57:1299-1313

Current fever management in children is challenged

A new clinical report prepared by the American Academy of Pediatrics (AAP) and published in Pediatrics highlights the need to educate patients and families about fever in children.


It is not a new research but an expert commentary with the aim to challenge current practice on fever management in children, ie fever reduction.

They said that fever is a physiological mechanism in fighting infection, there is no evidence that fever causes long-term neurological complications. The report emphasizes improving the child’s overall comfort rather than concentrating in normalizing the body temperature.


Paracetamol and ibuprofen are the most commonly used antipyretics, but there are adverse effects and toxicity. The report said that it is critical to administer a safe dosage of these drugs and the correct dosage is based on the child's weight. However, many parents do not understand dosing instructions resulting in potential inaccurate or overdosing.


The authors call for better information for parents and concluded that in fever management, fever reduction should not be the primary aim but parents and healthcare professionals should be more vigilant for signs of serious illnesses.


Source: Sullivan JE, Farrar HC and the Section on Clinical Pharmacology and Clinical Report. Fever and Antipyretic Use in Children. Pediatrics 2011 , published online Feb 28

UK-trained doctors from ethnic minority groups underperform academically

A third of all UK medical students and junior doctors come from ethnic groups. In 2009, 36% of newly qualified doctors and 52% of all other NHS doctors were from these groups. A new study conducted by UCL researchers found that UK-trained medical students and doctors from ethnic minority groups underpeformed academically compared with their white counterparts. They systematically analysed 22 reports involving about 24,000 UK- trained medical students and doctors from different ethnic groups and found that the odds of failure in non-white candidates was 2.5 times higher than the white candidates. They said that ethnic differences in academic performance are widespread across different medical schools, different types of exams and in both undergraduate and postgraduate assessments. It was persistent for 30 years and "cannot be dismissed as atypical or local problems". They called for further research into the causes to ensure that all future doctors are assessed fairly. In an accompanying editorial, the author said that soultions will be found through critically appraising assessment methods, curricula and interactions with students.

What do you think may have caused the ethnic differences in attainment and how can they be resolved?

Source: Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ 2011; 342:d901 ( free access) Editorial - Ethnicity and academic performance in the UK. BMJ 2011; 342:d709 ( free access)

Should I take statins as a preventive measure?

A new Cochrane systematic review conducted by London School of Hygiene and Tropical Medicine and the University of Bristol questioned the benefits of prescribing statins to people without heart disease.

Researchers reviewed 14 trials involving more than 34,000 patients with low risk of heart attack and strokes. They found that overall statins reduced mortality, but the effect was very small - 1000 people have to be treated for 1 year to prevent 1 death. Previous studies have found that statins have been associated with a range of side effects including kidney failure and muscle weakness, therfore not worth the risk in people without history of cardiovascular disease.

They pointed out that the findings of the trials were biased due to several shortcomings: 1/3 of the trials outcomes were selectively reported, 8 trials did not report on the adverse effects, 2 large trials were stopped prematurely, only 1 trial has been funded publicly while 9 trials were sponsored by drug companies partially or fully. They concluded "widespread use of statins in people at low risk of cardiovascular events ..... is not supported by the existing evidence".

Oxford researchers noted that the Cochrane review did not include the recent meta-analysis conducted by the Oxford group which was more reliable than the Cochrane review.

In an accompanying editorial, the author said that the current evidence supports the NICE guidance that statins should be used for the primary prevention of CVD for people with more than 20% risk of developing the disease. Given the limitations of the study, he suggested an alternative approach to focus on population-wide prevention.

Source:

Taylor F, Ward K, Moore THM et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2011, Issue

Editorial :Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease. Cochrane Library 2011, (January 19, 2011).

http://www2.cochrane.org/reviews/en/ab004816.html

Behavioral therapy reduces postprostatectomy incontinence

According to a study published in JAMA, 65% of men experience urinary incontinence up to 5 years following radical prostatectomy.

American researchers conducted a randomized controlled trial involving 208 men aged 51 - 84 with incontinence persisting 1 to 17 years after radical prostatectomy, to evaluate the effectiveness of behavioral therapy for reducing post-prostatectomy incontinence and to determine whether biofeedback and electrical stimulation enhance its effectiveness. 24% of the men were black and 75 % white.

The researchers found that over the 8-week treatment period, those in the behavioral therapy group had an average reduction of incontinence episodes of 55 % (from 28 to 13 episodes per week), while the control group had an average reduction of only 24 % ( from 25 to 21 episodes per week). Those in the behavior-plus group experienced an average reduction of 51% (from 26 to 12 episodes per week), indicating that the addition of biofeedback and electrical stimulation did not improve the 8-week results compared with behavioral therapy alone.

Improvements were evident up to a year in the treatment groups, 50% reduction in the behavioral group and 59% in the behavior plus group. By the end of the treatment period, 15.7 % of men in the behavior therapy group, 17.1% in the behavior-plus group, and 5.9% in the control group achieved complete continence.

The researchers concluded that for men with incontinence following radical prostatectomy, behavioral therapy resulted in significant reduction in incontinence espisodes and that these findings have important implications for doctors and patients.

In an accompanying editorial, the author wrote that the optimal way to address postprostatectomy incontinence remains unanswered and that a better strategy would be primary prevention.

Source: Behavioral Therapy With or Without Biofeedback and Pelvic Floor Electrical Stimulation for Persistent Postprostatectomy Incontinence - A Randomized Controlled Trial. JAMA. 2011;305(2):151-159. (f/t via Athens)

General anesthesia is closer to coma than sleep

According to a review published in the NEJM, patients undergoing general anesthesia before surgery are not "going to sleep" as their doctors probably told them, they are placed in a “reversible coma".


Three US neuroscientists took 3 years to research studies in general anestheisa, sleep and coma to understand how anesthetic drugs induce and maintain the behavioral states of general anesthesia. They discussed the clinical and neurophysiological features of general anesthesia and their relationships to sleep and coma, focusing on the neural mechanisms of unconsciousness induced by selected anesthetic drugs.


They conclude that better understanding of the the different states of the process would lead to new approaches to general anesthesia and improved diagnosis and treatment for sleep problems and emergence from coma.



Source: "General Anesthesia, Sleep, and Coma". New England J of Medicine 2010; 363:2638-2650 ( f/t via Athens)

Good cholesterol may reduce Alzhemier's risk

A new study claims that high levels of high-density lipoprotein (HDL) or ‘good’ cholesterol could lower the risks of developing Alzheimer’s disease in older adults,


US researchers studied 1,130 randomly selected elderly people aged 65 and over and had no history of memory trouble or dementia. The participants were follwoed for an average of four years. Researchers found that those with the highest HDL counts, over 55 mg/dL, had about a 60% reduced risk of developing the disease compared to those whose levels were under 39 mg/dL. The study author said that the result suggested that higher level of good cholesterol decreases the risk of Alzheimer's disease, but the mechanism is unknown.


It was noted that a previous study published in Neurology in 2001 found that Japanese-American men with higher HDL cholesterol were more likely to have Alzheimer's-related plagues and tangles in their brains.


Alzheimer's Society (UK) said until now, studies have focused on the associations between 'good' cholesterol and vascular dementia....... More research is needed to fully understand the link between HDL cholesterol and the processes that lead to Alzheimer's Disease.


Source:'Association of Higher Levels of High-Density Lipoprotein Cholesterol in Elderly Individuals and Lower Risk of Late-Onset Alzheimer Disease'. Archives of Neurology. 2010;67(12):1491-1497. doi:10.1001/archneurol.2010.297