BlogtoShare - Little Library Blog

Resources for GP AKT exams

2011-12-05T09:55:00.009Z

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

2011-11-01T11:30:00.003Z

"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

2011-10-27T14:52:00.003Z

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?

2011-07-25T09:27:00.004Z

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

2011-07-13T14:33:00.007Z

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

2011-07-07T11:16:00.005Z

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

2011-07-07T10:05:00.006Z

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

2011-07-06T11:12:00.006Z

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

2011-07-05T14:53:00.005Z

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

2011-06-22T12:55:00.005Z

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?

2011-06-15T10:07:00.005Z

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

2011-06-06T08:41:00.006Z

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

2011-06-01T11:14:00.001Z

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

2011-04-08T10:17:00.015Z

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.....

2011-03-18T14:51:00.009Z

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

2011-03-16T10:18:00.006Z

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

2011-03-15T14:12:00.007Z

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

2011-03-14T15:08:00.004Z

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

2011-03-09T15:07:00.006Z

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

2011-03-09T08:58:00.010Z

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?

2011-02-03T11:44:00.006Z

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

2011-01-20T15:36:00.006Z

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

2011-01-12T14:09:00.005Z

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

2011-01-12T13:16:00.006Z

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

UK cancer survival rate lags behind other countries

2010-12-22T14:21:00.004Z

According to a new study, published in The Lancet today, cancer patients in England, Wales and Northern Ireland have lower survival rates than those in Australia, Canada, Sweden and Norway.

This is the first study in a programme to investigate international survival disparities, with the aim of informing health policy to raise standards and reduce inequalities in survival.

The scientists analysed data on 2.4 million cancer patients in the UK (not including Scotland), Australia, Canada, Denmark, Norway and Sweden focusing on cancers of breast, bowel, lung and ovarian. They examined the survival rate at 1 and 5 years between 1995 and 2007 and found that in some cases survival rates in the UK are more than 10% lower than Europe, Australia and Canada particularly in the first year after diagnosis. In the 5-year survival rate, UK was the worst in bowel, lung and breast cancer. Denmark also lags behind, though generally its outcomes were not as bad as the UK's.

The authors said, "Differences in individual, health-system and clinical factors - such as public awareness of cancer, diagnostic delay, stage, comorbidity and access to optimum treatment - are all potential explanations for the overall differences in relative survival. The patterns are consistent with late diagnosis or differences in treatment, particularly in Denmark and the UK, and in patients aged 65 years and older".

Cancer Research UK urges the government to focus on early diagnosis and on improving equitable access to treatment. It also urges collecting reliable and good quality information nationally in order to understand the extent of the problem and identify the causes of the survival gap within the UK and other countries.

Source: Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995—2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. The Lancet, Early Online Publication, 22 December 2010

Should healthy middle-aged people take daily aspirin ?

2010-12-09T12:59:00.007Z

Studies have shown that aspirin, a commonly used painkiller, is linked to reductions in heart attacks and strokes, but it can irirtate the stomach and cause serious internal bleeding particularly in elderly people.

According to a new Oxford Univeristy study, published in The Lancet last week, taking a daily low dose of aspirin for reduced cancer deaths during and after the trials and the benefit increased with duration of treatment.

The researchers examined the data of 8 trials that looked at the effects of daily dose of aspirin on preventing heart attacks involving over 25,000 people. They found that aspirin reduced cancer deaths by 20% during the trial, but after 5 years, death rates were 34% lower for all cancer deaths. They also found the risk of all cancer deaths over a period of 20 years remained 20% lower for those who had taken aspirin, about 40% for bowel cancer, 30% for lung cancer, 10% for prostate cancer and 60% for oesophageal cancer. But there were not enough women participants to determine if daily aspirin could reduce breast, ovarian or endometrial cancer deaths.

The lead researcher said this study confirms the results of the previous study that found aspirin has preventive effect against cancer and has demonstrated a major new benefit of the drug. He believes that the findings have implications for guidelines on use of aspirin and the most benefit would be seen for those start taking aspirin between the age of 40 - 50 and continue for 25 years.

The previous study by the same authors, also published in The Lancet in October 2010, showed that a low dose of aspirin, 75mg per day taken for several years, reduced deaths due to colorectal cancer. However, opinions were divided on the result of the study.

Some said that the study did not give a balanced view of the effect of the treatment because it did not report the potential harms. The protective effects against cardiovascular disease were thought to be small for healthy adults. Some advised that aspirin should not be used to prevent heart attacks and strokes in "healthy" people as the risks outweigh potential benefits. Others said more research is needed before recommending taking aspirin to reduce cancer deaths.

Source: Rothwell PM, Fowkes FGR, Belch JFF, et al. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. The Lancet. 2010 Jan 7. [Epub ahead of print] Online publication 7 December 2010 ( f/t via Athens)

Previous studies :

Rothwell PM, Wilson M, Elwin C-E et al. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. The Lancet 2010, Early Online Publication, October 22 (f/t via Athens)

Benamouzig R, Uz B. Aspirin to prevent colorectal cancer: time to act? The Lancet 20110, Early Online Publication, 22 October (f/t via Athens)

Have you washed your hands - another study on patient safety

2010-12-09T11:42:00.009Z

Since the report by the Institute of Medicine in 2000 that found high rates of medical mistakes in the US, most US hospitals had made efforts to improve patient safety. A new study, published in the NEJM found that patient harm in hospitals has not decreased over time!

Harvard researchers reviewed 2341 admission records obtained from 10 randomly selected hospitals in North Carolina between 2002 and 2007, they found 588 incidents of patient harm, ie 25.1 harms per 100 admissions, resulting from medical procedures, medications, or other causes.
The study found that infections was one of the most common complications, 42.7% required longer hospital stay for treatment, eg infected surgical incision. The types of patient harm varied widely and included falls, injury during surgery, low blood pressure and low blood sugar. Most of the complications were temporary and treatable, but 3% were permanent, eg brain damage from a stroke ( could have been prevented after an operation), 8.5% were life-threatening and 2.4% "caused or contributed to a patient's death."

The study's lead author, Dr. Christopher Landrigan, said "these harms are still very common, and there's no evidence that they're improving". Many of the problems were caused by the hospitals' failure to use protective measures that have been proven to improve care including computerizing patient records and drug prescription orders, using checklists for surgical procedures and other methods. He noted that the frequency of medical errors and injuries has been underestimated and there is a need for a mandatory monitoring system.

Some experts on hospital safety said heathcare providers should have a culture of strong communication and teamwork and it is essential that hospitals be more open about reporting problems. Some suggest that patients need cultural change too in ensuring their own safety, eg discussing about drug interactions with the doctor or asking if the doctor has washed his/her hands!

In the US, 27 state laws require public reporting of hospital-acquired infection rates. In 2005, all hospitals in New York were required by legislation to report hospital-acquired infections to the NY State Department of Health. In 2009, the NY Department of Health issued a state-wide report on hospital-by-hospital infection rates. They said that the information will help patients make more informed choices and allow hospitals to compare with other providers.

In the UK, despite promoting hand hygiene among staff, patients and visitors in NHS Trusts in England and Wales to reduce hospital acquired infections, infection rates and resulting harm are still very high.

In June 2010, the Health Secretary, Andrew Lansley, announced that as part of the new government's information revolution, infection figures for all hospitals in England will be published on a weekly basis from July on the government website . By making the data available to patients as well as hospital managers, he said people can make comparisons between different hospitals and healthcare organisations.

Have you washed your hands? Would you be offended if a patient or a colleague asks if you have washed your hands? What's your veiw?

Source : Temporal Trends in Rates of Patient Harm Resulting from Medical Care. N Engl J Med 2010; 363:2124-2134 ( full text via Athens )

Antibiotics for pediatric ear infections - benefits and risks

2010-11-18T13:06:00.006Z

Middle ear infections, known as acute otitis media (AOM), are the most common childhood illness in the US where antibiotics are routinely prescribed. According to a new study published in JAMA, using antibiotics to treat newly diagnosed acute ear infections among children is modestly more effective than no treatment, but causes adverse effects.

US researchers, requested by the American Academy of Pediatrics, to update practice guidelines for treating children's ear infections, reviewed 125 published previous on the effect of antibiotics and found that 80% of children with ear infections would recover within about 3 days without antibiotics. If all of the children were treated with antibiotics, an additional 12 would improve in 3 days, but 5 to 10% of the children would develop diarrhea.

They found no evidence that higher- priced antibiotics work better in general than generic ones and there is a wide variation in diagnosis and management of AOM, they suggested that using an otoscope may help improve the accuracy of diagnosis.

The authors concluded that doctors need to weigh the risks and benefits "before prescribing immediate antibiotics for uncomplicated AOM" and further research is needed.

Source: Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children - A Systematic Review. JAMA. 2010;304(19):2161-2169. (f/t via Athens)

Do you need to find information for patients?

2010-11-17T13:31:00.002Z

According to NHS Evidence, a recent research shows that 53% of professionals are most likely to be looking for patient information specifically when conducting a search for health and social care information.

NHS Evidence provides access to more than 8,000 pieces of accredited patient and public information including fact sheets, patient health questionnaires and guidance on conditions, treatment choices and support to help patints and carers make informed choices.

You can browse the leaflets by subject, alphabet or publisher and you can print them.

Using pre-surgery checklists can reduce medical errors

2010-11-16T11:37:00.017Z

At the end of a long day, Dr David Ring, a hand surgeon at Massachusetts General Hospital, walked into the operating room and performed the last operation - he did a carpal-tunnel release on his trigger finger patient!

In an extraordinary open admssion of performing wrong surgery in this week's NEJM, Dr Ring said leading up to the wrong surgery were a series of events and mistakes that occurred during the course of the day, such as poor scheduling and staffing, the patient's left arm was marked at the wrist, not at the finger, and the marking was washed away etc.

Dr. Ring realized his error while dictating the report, and immediately notified both the hospital and the patient of the error. He performed the correct procedure that day without complication. However, the patient lost faith in him and sought treatment elsewhere. The hospital waived all her charges and paid a financial settlement shortly after the event.

Dr. Ring asked the case be presented at the departmental conference and published in the Case Records of the Massachusetts General Hospital because he wanted to encourage others to follow procedures that would prevent similar errors in the future. He said "I hope that none of you ever have to go through what my patient and I went through. I no longer see these protocols as a burden. That is the lesson." Dr Ring was praised for his courage by patient safety advocates and his counterparts.

In the same issue of the NEJM, a team of Dutch researchers published a study showing the dramatic effect of implementing surgical safety checklists in reducing surgical errors. Comparing hospitals that use pre-surgery checklists with those that do not, the researchers found that surgical complications fell dramatically from a level of 27% to just 17%. In- hospital mortality decreased from 1.5 to 0.8%, but the outcomes in the 5 control hospitals did not change.

In an accompanying editorial, the author said studies have shown the use of surgical checklists can have dramatic effect in reducing both complications and mortality and believed that they have "crossed the threshold from good idea to standard of care".

Studies have found that serious errors such as wrong-site surgery or wrong patient did occur, often due to simple mistakes or surgical team failing to perform pre-operation checks. Wrong-site surgery occurs in all surgical specialties, 68% of claims in the US related to orthopedic surgery. The American Academy of Orthopaedic Surgeons (AAOS) developed the "Sign Your Site" initiative in 1998 advising surgeons to mark the surgical site with their initials in order to avoid errors.

In the UK, more than 129,000 surgical incidents were reported to the National Patient Safety Agency (NPSA) in 2007. Over 1,000 resulted in severe harm and 271 death. The NPSA issued a patient safety alert in January 2009, requiring NHS organisations to implement the WHO Surgical Safety Checklist for every patient undergoing a surgical procedure. All hospitals in England and Wales must implement use of the Surgical Checklist by February 2010.

The checklist focuses on basic good practice before anaesthesia is administered, before a patient is cut open, and before a patient is removed from the operating theatre, and is designed to promote effective teamwork and prevent infection and unnecessary blood loss. NHS organisations can adapt it for their own use.

Source:
"Case 34-2010 — A 65-Year-Old Woman with an Incorrect Operation on the Left Hand". NEJM 2010; vol 11, 363:1950-1957 ( full text via Athens )

"Effect of a Comprehensive Surgical Safety System on Patient Outcomes". NEJM 2010; vol 11, 363:1928-1937 ( Netherlands trial, full text via Athens)

Editorial : "Strategies for Improving Surgical Quality — Checklists and Beyond". NEJM 2010; vol 11, 363:1963-1965 ( full text via Athens)

Could stronger statins save lives?

2010-11-09T14:51:00.007Z

Statin is one of the world's biggest selling drug for lowering LDL cholesterol, a new research suggests using more potent doses of statin could prevent thousands more heart attacks and strokes.

40,000 high-risk patients were assessed for major vascular events after one year of randomisation to either regular or intensive treatment statin. The results, published in The Lancet, found that stronger treatments reduced major heart attacks and strokes by 15%. This included a 13% cut in heart-related death or non-fatal heart attacks, a 19% drop in bypass and other coronary treatments, and a 16% drop in strokes.

However, the study warned that simply raising the dose of simvastain might lead to health problem as muscle weakness and muscle damage are some of the known side effects.

Source: "Intensive lowering of LDL cholesterol with 80 mg versus 20 mg simvastatin daily in 12 064 survivors of myocardial infarction: a double-blind randomised trial". The Lancet, Early Online Publication, 9 November 2010 (full text via Athens)

Does vitamin E increase stroke risk?

2010-11-08T14:56:00.003Z

Previous studies suggested taking vitamin E can protect the heart from coronary heart disease, but a BMJ study found that taking vitamin E could slightly increase the risk of haemorrhagic stroke - bleeding in the brain. Stroke is the third biggest cause of death in the UK

Researchers identified 9 studies with about 119,000 people randomised either to vitamin E or placebo on the outcome of stroke. They found that vitamin E increased the risk of haemorrhagic stroke by 22%, also found that vitamin E reduced the risk of ischaemic stroke by 10%. Given the small reduction in the risk of ischaemic stroke is exceeded by the incraese in the risk of haemorrhagic stroke, the researchers concluded that the widespread use of vitamin E should be avoided.

Critics say the findings are of small statistical significance, more research is needed to determine the level of Vitamin E that can become harmful. They "urge people to maintain a lifestyle of a balanced diet, regular exercise and monitoring their blood pressure to reduce their risk of a stroke."

Source: "Effects of vitamin E on stroke subtypes: meta-analysis of randomised controlled trials". BMJ 2010; 341:c5702 (Published 4 November 2010) free f/t.

Alcohol is more harmful than heroin or crack cocaine

2010-11-08T13:27:00.004Z

A new study, published in the Lancet, found that alcohol is the most harmful drug above heroin and crack cocaine based on harm caused to the user and others.

The investigation was led by David Nutt, former government drugs adviser sacked after criticising government policies on cannabis. The team reviewed a range of drug harms using the multicriteria decision analysis modelling, drugs were scored with 100 being the most harmful and 0 being no harm at all. They found that overall alcohol scored 72, heroin 55 and crack cocaine 54. The authors said "the present drug classification systems have little relation to the evidence of harm" and that the findings showed that ‘aggressively targeting alcohol harms is a valid and necessary public health strategy."

Some newspapers reported the DH said it is determined to prevent alcohol abuse without disadvantaging those who drink sensibly.

In an accompanying commentary, "Ranking of drugs: a more balanced risk-assessment" The Lancet, 376(9752): 1524-25, the Dutch experts said "the new data provide a valuable contribution for the re-evaluation of current drug classification in the UK", but the study did not address the polydrug use which can make some drugs much more dangerous. However this was outside the scope of the study.

Source: Drug harms in the UK: a multicriteria decision analysis. The Lancet 376(9752):1558-1565 ( full text va Athens)

Tips on MRCP, PACES, MRCGP exams

2010-10-14T14:31:00.009Z

The following "The way I see it" articles published in BMJ Careers may be of interest to those who are preparing for the MRCP, FACES, MRCGP exams.

"When should I sit the MRCP?" - a consultant nephrologist suggested that taking the exams early has competitive advantage.

"Taking the MRCP early on" - a founadtion doctor thought that taking the exam early will help stand out from the crowd and has many advantages.

"Passing the MRCP written papers" - a SpR gave useful tips on passing the exam.

"The new MRCP PACES station 5" - 2 SpRs wrote about the changes and format of the new station 5 and offered advice on how to prepare for the exam - "the key is timing and maintaing professional behaviour throughout."

"Passing PACES" - a SpR offered Dos and Don'ts to help you "don't fall at the final hurdle - the PACES exam".

"MRCGP applied knowledge test" - a GP trainee offered advice on preparing for the new MRCGP AKT.

See also previous post on Passing postgraduate exam techniques

Share your views and experience to help others better prepare for the exams! If you like to add more information on this topic, click on "comment" and "send."

Is light drinking during pregnancy safe?

2010-10-08T10:13:00.007Z

The finding from a UCL study suggesting that a glass of wine a week during pregnancy will not harm your child's development has caused controversy but the lead author said that the more the social factors were taken into account, the weaker the association became.

The study involved over 11,000 women who were asked about their drinking habits and their child's development until they were 5 years old. They found that children born to light drinkers were 30% less likely to have behavioural problems and achieve higher scores on cognitive tests than those whose mothers did not drink during pregnancy.

Some experts said that the study was flawed because it only looked at children up to the age of 5. The Dep of Health said "After assessing the available evidence, we cannot say with confidence that drinking during pregnancy is safe and will not harm your baby...... Our advice to pregnant women and women trying to conceive is to avoid alcohol", reported in the Telegraph.

An US alcohol epidemiologist said that alcohol is the leading fetal neurotoxin in the world, there is no safe amount of alcohol a pregnant woman can drink based on the evidence that alcohol kills brain cells in the developing fetus, reported in White Coat Note.

So the debate goes on.

Source: Light drinking during pregnancy: still no increased risk for socioemotional difficulties or cognitive deficits at 5 years of age? Journal of Epidemiology and Community Health 2010, October

Mild Alzheimer's patients to get treatment on NHS

2010-10-08T08:58:00.005Z

BBC News reported that following a U-turn by the health watchdog, patients in the early stages of Alzheimer's disease could get drug treatments that were previously only available to patients with more advanced cases.

NICE has now given new draft guidance for the treatment of Alzheimer's disease that people with mild symptoms should also get the drugs and recommends a 4th drug, Ebixa, for patients with severe Alzheimer's. The final decision will be made later this year.

Latest data shows that about 380,000 people in England and Wales have Alzheimer's and more than 50% are estimated to have mild to moderately severe disease.

Hands-only CPR saves more lives

2010-10-06T14:40:00.006Z

According to a study published in JAMA this week, hands-only CPR saves more lives in cardiac arrests.

Out of hospital cardiac arrest is a major public health problem in the US, in 2005, Arizona launched a programme to encourage the public to use compression-only CPR (COCPR) to improve survival.

The study included 2900 patients who received no bystander CPR, 666 conventional CPR and 849 COCPR. The researchers found that "among patients who received bystander CPR, the proportion with COCPR increased significantly over time, from 19.6% in 2005 to 75.9% in 2009", COPR was associated with a 60% improved odds of survival comapred with no bystander CPR or conventional CPR. The authors said that COPR has the advantage of minimizing interruptions in chest compressions during CPR.

In an accompanying editorial, the author said that the findings should encourage continuing investigations into the compressio-only CPR method. "Healthcare professionals involved in resuscitation should look to new Guidelines 2010 dodcuments for the international consensus on the science of compression-only CPR ........ to encourage the general public to learn this simple and potentially lifesaving skills".

However, a Lancet article published in April 2010 (17;375(9723):1347-54. Epub 2010 Mar 2. )states that "for children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compression-only CPR is similarly effective".

The 2010 Resuscitation guidelines will be available at Resuscitation Council (UK) website on 18 October 2010.

Source : Chest Compression–Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest. JAMA. 2010;304(13):1447-1454. doi:10.1001/jama.2010.1392 (f/t via Athens)

Editorial : Compression-Only CPR . JAMA. 2010;304(13):1493-1495. doi:10.1001/jama.2010.1420 (f/t via Athens)

Want to be happy?

2010-10-06T13:16:00.006Z

A popular theroy of happiness states that happiness is 50% genetic but a new study finds that the choices you make in life can equally affect long-term happiness.

The findings are based on the data collected from a 25-year study on 60,000 Germans from 1984 to 2008. The researchers found that choices relating to partner, balance between work and leisure, participation in social activities and healthy lifestyle are key factors in determining satisfaction in life. For example, the findings show that having neurotic partners significantly reduce life happiness. People who prioritise altruistic and family goals are happier than those who prioritise career and material success. Church attendance, getting involved in social and community events and regular exercises are equally important in affecting happiness.

The authors says the study is the most extensive of its kind and a breakthrough in psychological research. They concluded that life happiness is chosen not predetermined, it has a lot to do with life choices and people can change their life goals. Although the study was based on Germans, the findings can also be applied in other parts of the world. The study is published in Proceedings of the National Academy of Sciences (PNAS).

Source: Long-running German panel survey shows that personal and economic choices, not just genes, matter for happiness. PNAS. doi: 10.1073/pnas.1008612107 . Published online before print October 4, 2010, free open access article

Look AHEAD trial - lifestyle intervention for diabetes

2010-10-05T08:53:00.005Z

Following the Avandia scandal in July 2010, the European Medicines Agency (EMA) on 23 Sept recommended the suspension of the rosiglitazone-containing anti-diabetes medicines Avandia, Avandamet and Avaglim, they will be banned in Europe within the next few months. At the same time, the US government put toughened resrictions on the use of the drug. Critics say these "decisions will virtually eliminate use of the drug around the world".

According to a new study published in the Archives of Internal Medicine, 27 September, lifestyle interventions are recommended to improve glycemic control and risk factors in type 2 diabetes to prevent long-term complications, but the evidence of their efficacy is limited to short-term studies.

The authors said that the Look AHEAD study, a 4-year non-drug approach using intensive lifestyle interventions helped reduce cardiovascular risk factors in type 2 diabetics. The trial randomized 5145 patients with type 2 diabetes to following an intensive lifestyle- intervention program or to receive standard diabetes support and education. The intensive program including a combination of diet modification and physical exercises, with training and group support, was designed to achieve 7% weight loss in the first year and to maintain the weight in subsequent years.

After 4 years, the intensive intervention group maintained a weight loss of 6.15% of their weight compared with 0.88 % in the standard support group. They also experienced greater improvements in fitness, blood sugar, blood pressure, triglycerides and good cholesterol. The standard group had lower levels of bad cholesterol.

The authors said that the result indicated that the intensive intervention group had been exposed to lower cardiovascular disease risk factors during the trial, although it would be too early to say that intensive intervention can prevent heart attacks, there may be long-term benefits from the 4-year period. The study is continuing for several more years.

Should we look beyond Avandia and other drugs for diabetes treatment and invest in more preventive efforts?

Source: Long-term Effects of a Lifestyle Intervention on Weight and Cardiovascular Risk Factors in Individuals With Type 2 Diabetes Mellitus - Four-Year Results of the Look AHEAD Trial. The Look AHEAD Research Group. Arch Intern Med. 2010;170(17):1566-1575. (f/t via Athens)

Less invasive cancer surgery is safe and effective

2010-09-22T15:11:00.006Z

In most cancer patients, axillary-lymph-node dissection (ALND) involves the removal of most of the lymph nodes in the underarm region to improve the chances of survuval, but sometimes it causes damages to the patients' arm and shoulder.

American scientists found that sentinel-lymph-node surgery (SLN), a less invasive technique that only removes the sentinel nodes, the ones closest to the breast, is safe and effective.

5,611 American women whose breast cancer did not appear to have spread to their lymph nodes were recruited to assess their differences in survival rates between the 2 types of surgery. Half of the patients had ALND surgery to remove all of the lymph nodes in the underarm area, while the other half had SLN surgery to remove the sentinel lymph nodes only. Patients were tracked over the next eight years.

The researchers found no significant differences in the patients' survival rates between the two groups. Patients who underwent the SLN procedure were less likely to experience arm problems or lymphoedema (chronic swelling of the arm). The authors concluded that "SLN surgery alone with no further ALND is an appropriate, safe, and effective therapy for breast cancer patients with clinically negative lymph nodes" and that SLN surgery "represents the next major step in reducing the extent of surgical procedures to treat breast cancer".

An accompanying comment said that the paper "vindicates contemporary practice of SLN biopsy and provides support for a reduction in extent of axillary surgery for most patients with breast cancer".

Source: Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncology, 11(10):927 - 933. Published Online: 21 September 2010 (f/t via Athens)

Is glucosamine effective in reducing OA joint pain?

2010-09-20T12:10:00.016Z

A BMJ study found that 2 popular supplements, glucosamine, chondroitin and their combination are no better than placebo at reducing joint pain.

The study, funded by the Swiss National Science Foundation, was a meta-analysis based on 10 randomised controlled trials with more than 3800 patients with hip or knee osteoarthritis treated with either glucosamine, chondroitin or both, followed up for 1 to 36 months. The outcome measures were pain intensity and joint structure. The analysis of data was by network meta-analysis, a relatively new statistical technique.

The researchers found that all these 2 supplements have been prescribed by GPs and rheumatologists and used widely by patients for treating osteoarthritis (OA), their study showed that glucosamine, chondroitin and their combination do not have a useful clinical effect in treating osteoarthritis. They wrote "we believe it unlikely that future trials will show a clinically relevant benefit of any of the evaluated preparations".

Critics say that the study results may be biased by the heterogeneity of the varying studies included and the network meta-analysis it used to do the calculation. Furthermore, the small size of the trials could also have large effect on the overall results.

Some patients, based on their own experience, are convinced that these supplemnets are beneficial and have written to the BMJ in response to the findings, some doctors pointed out that glucosamine has 2 different formulation, the favourable response of glucosamine to knee OA involves glucosamine sulphate not hydrochloride and that many of the recommendations of use of glucosamine are on knee OA not hip, but the study included both knee and hip OA in the analysis.

It was also noted that the conclusion of the study on the efficacy of glucosamine on knee OA is questionable because it does not include the data of the LEGS trial which investigates glucosamine sulphate in knee OA, the study is yet to be completed.

Source:

1). Wandel S, Jüni P, Tendal B et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. BMJ 2010; 341:c4675 ( f/t via Athens)

2). The Long-term Evaluation of Glucosamine Sulphate Study (LEGS) - study to be completed in October 2011

Revised UK guidelines for melanoma 2010

2010-09-20T12:09:00.004Z

According to Cancer Research UK, the latest statistics show that 5,697 cases of malignant melanoma were diagnosed in women and 4,975 in men in the UK in 2007. If melanoma is diagnosed early, the survival statistics are very good.

Many guidelines have been drawn up by various groups and professional bodies to promote good standards of care. Last month, the British Journal of Dermatology published revised consensus guidelines for treatment and a brief overview of epidemiology, diagnosis, investigation and follow up.

The guidelines were drawn up by a multidisciplinary working party with representatives from various groups or organisations in the UK. Levels of evidence to support the guidelines are given, but the authors said that care should be individualized wherever appropriate. Where no level of evidence is quoted, it is regarded as a consensus statement, represented level IV.

Summary of the guidelines:

Melanoma patients who must be referred from the local skin cancer multidisciplinary team to specialist skin cancer multidisciplinary team
Recommendations for local skin cancer team record keeping of clinical features
Recommendations for sscreening and surveillance of high-risk individuals
Requirements for microscopy of melanoma
Surgical wider excision margins for primary melanoma
Staging investigations for melanoma
Recommendations for the management of clinically node-negative patients
Recommendations for locoregional recurrent melanoma
Recommendations for metastatic disease
Pregnancy, oral contraceptives and HRT
Follow up of melanoma patients

Source:
"Revised U.K. guidelines for the management of cutaneous melanoma 2010". Published in the British Journal of Dermatology, August 2010 Vol. 163, PP.238-256. Free full text

Low-carb diet rich in meat may may cause higher health risks

2010-09-16T10:00:00.005Z

Studies show that a low-carbohydrate diet produces weight loss and improves some cardiovascular risk factors, but there has been concern about the Atkin-type low-carb diet that is based on animal fat and animal protein.

Harvard reserachers examined 2 types of low-carb diets in relation to long-term health impact. They examined the data of 2 prospective cohort studies involving 85,168 women for 26 years and 44,548 men 20 yaers on a low-carbohydrate diet, either an animal-based or a vegetable-based low-carbohydrate diet. Diet was assessed via a questionnaire.

The researchers found that animal-based low-carb diets were associated with higher all-cause mortality in both men and women. A vegetable-based low-carbohydrate diet was associated with lower all-cause and cardiovascular disease mortality rates. They said the results suggest that the health effects of a low-carb diet may depend on the type of protein and fat. The mixed effects on lipid profiles may have been due to the varying amount of plant or animal fat consumed in low-carb diets.

An accompanying editorial cautioned the interpretation of this study saying that it "addresses a critical, unresolved public health question of diet but cannot satisfy us with a definitive answer", a large- scale randomised clinical trial with meaningful clinical endpoints is needed.

Source: Low-Carbohydrate Diets and All-Cause and Cause-Specific Mortality - Two Cohort Studies. Annals of Internal Medicine. September 7, 2010 vol. 153 no. 5 289-298 (f/t via Athens)

Should I take vitamin B supplements for mild memory problems?

2010-09-09T13:36:00.004Z

Oxford scientists investigated the effects of vitamin B on brain atropy ( the loss of neurones and their connections) in people with mild memory problems. Studies have found that high levels of homocysteine (tHcy), an amino acid in the blood, affect the rate of brain atropy and that raised levels of tHcy increase the risk of Alzheimer's disease.

168 elderly people with mild cognitive impairment but not taking anti-dementia drugs were recruited in the Oxford area. Both the volunteers and researchers were unaware of the treatment received, either high dose of vitamin B tablets ( a combination of folic acid, B12 and B6) or placebo pills for a 2 year period.

The researchers found that taking B vitamins for 24 months led to brain shrinkage and the rate of shrinkage in the treatment group was 30% less than the placebo group. They concluded that a simple and safe treatment can slow down the rate of brain atropy in people with mild cognitive impairment. The study was published in PLoS One, a peer-reviewed journal. A study published in 2008 in JAMA showed conflicting results.

Critics say that this is well-conducted randomised controlled trial with promising results. However the evidence did not show brain shinkage may lead to improvement in symptoms or that the B vitamins can prevent Alzheimer's disease, but warrant more research.

Source: David Smith A, Smith SM, de Jager CA et al. Homocysteine-Lowering by B Vitamins Slows the Rate of Accelerated Brain Atrophy in Mild Cognitive Impairment: A Randomized Controlled Trial. PLoS One 5(9): e12244

The Avandia scandal

2010-09-09T10:52:00.011Z

An investigation by the BMJ published this week calls for the withdrawal of the daibetes drug, Avandia, immediately from the market because of the concerns that it may increase the risk of myocardial infarction and the paucity of good evidence to support its use.

Rosiglitazone, also known as Avandia, was GSK's second biggest selling drug, introduced in 1999 and is widely used to lower blood glucose levels in patients with type 2 diabetes. It was approved by the EMA in 2000 despite concerns over its safety.

In 2007, several studies found Avandia having harmful effects and issued serious health warnings. The researchers questioned why Avandia is still available on the market and why physicians would prescribe it to diabetic patients when there are other drugs without these side effects. They called for Avandia to be withdrawn from the market. Since then, the sales of Avandia fell sharply.

The BMJ investigators found that in July, the UK Commission on Human Medicines advised the MHRA to withdraw Avandia as the risks of Rosiglitazone outweigh its benefits. This has raised a lot of questions about the quality of the data used in the studies and the lack of trial results made available to the public. The investigators also ask why the regulators accept such poor evidence on benefit and safety, why patients in the UK and Europe are not make aware of the concerns about this drug and whether the current regulatory body is doing its job properly. They said that doctors are advising that no new patients shoud use this drug, existing diabetic patients should review their options and those at high risk of heart disease should stop taking it.

In the accompanying editorial, the authors said that clinicians had focused on the wrong endpoint and lost sight of the main reason for treating this disease, "which is not to reduce glycaemia but to prevent complications". They went on to say that clinicians need to be "absolutely certain that the long term treatment for type 2 diabetes are not causing the harm they are meant to prevent" and should insist on robust evidence of benefits and harms.

Professor Freemantle noted in the accompanying commentary that the Avandia studies were hindered by inadequate data due to high levels of loss to follow-up. He wrote "In order to learn from our mistakes, we must improve the quality of safety data from clincal trials on all new healthcare interventions, not just antidiabetic drugs" and an overhall in the standards of regulatory trials is needed.

Sources : free f/t
Rosiglitazone: what went wrong? BMJ 2010; 341:c4848 (Published 6 September 2010) Editorial - Licensing drugs for diabetes BMJ 2010; 341:c4805 (Published 6 September 2010)
Commentary: What can we learn from the continuing regulatory focus on the thiazolidinediones?BMJ 2010; 341:c4812 (Published 6 September 2010)

Is chocolate good for the heart?

2010-08-20T14:01:00.005Z

Previous studies have shown that chocolate can reduce blood presure, a strong risk factor for heart failure. Harvard reserachers carried out a large prospective cohort study, including more than 39,000 Swedish women, investigating if chocolate intake is linked to the risk of heart failure.

The data were obtained from a questionnaire on health and lifestyle including details about diet and chocolate intake. After 9 years follow up, the researchers found that women who ate 1 - 2 servings a week or 1 -3 servings a month had lower risk of hear failure than those who ate 3 or more servings a week. They suggest that flavenoids in chocolate may have a beneficial effect on cardiovascular risk factor.

Critics said that the study relied on participants self-reporting of their chocolate intake, it is also unclear how much chocolate was consumed in one "serving". Although this was a large study, it is felt that the evidence was not strong enough to tell if chocolate reduces the risk of heart failure. Furthermore, flavenoids in chocolate can be found in fruit and vegetables.

Source: Mostofsky E, Levitan EB, Wolk A, et al. Chocolate Intake and Incidence of Heart Failure: A Population-Based, Prospective Study of Middle-Aged and Elderly Women. Circulation: Heart failure 2010; Published online before print August 16 ( f/t via Athens)

Diabetes drug linked to higher heart attack risk

2010-07-08T14:15:00.009Z

Avandia and competitor drug, Actos, are commonly used diabetes drugs. Avandia has been found having harmful effects since 2007 while Actos seems safer apparently.

2 studies published last week reported serious health warnings. One study, published in June 28 issue of JAMA, reviewed the data of 227,000 patients takng either Avandia or Actos, found that Avandia increased the risk of heart attack, stroke or death by 17%.

The second study, published in the Archive of Internal Medicine, analysed 56 clinical trials involving 35,000 patients confirmed these findings. The reserachers questioned why Avandia is still available on the market and why physicians would prescribe it to diabetics when there are other drugs without these side effects. They called for Avandia to be withdrawn from the market.

However, some doctors said that the evidence is inconclusive.

Source:
1). David Juurlink. "Rosiglitazone and the Case for Safety Over Certainty". JAMA. 2010;304(4):(doi:10.1001/jama.2010.954). free f/t

2). Steven Nissen; Kathy Wolski. "An Updated Meta-analysis of Risk for Myocardial Infarction and Cardiovascular Mortality". Arch Intern Med. 2010;170(14), free f/t

Does statin use reduce prostate cancer recurrence?

2010-07-07T13:30:00.007Z

Statins is a common treatment to lower cholesterol but a study, published online in June 28 in Cancer, found that men taking statins before their prostate surgery were less likely to show signs of the cancer recurring.

The study reviewed the data of 1319 men who had prostatectomy and took statins when they had their operation and showed that they had a 30% lower risk of PSA recurrence compared to those not taking statins. The greater the dose of statins taken, the less likely the cancer was to reappear.

The researchers said if other studies support their findings, a RCT of statins is warranted. However, critics say that the statin users differed significantly from non-users at presentation, eg they were older and had higher BMI that might affect the association between the statin use and risk for biochemical recurrence, also previous studies had mixed findings.

Another study, published in the Journal of Clinical Oncology, with 691 men underwent radiotherapy, showed a significant association between statin use and decreased biochemical recurrence.

Source:
1). Hamilton RJ, Banez LL, Aronson WJ et al. "Results from the Shared Equal Access Regional Cancer Hospital (SEARCH) Database". Cancer, [Early online publication] June 28 2010

2). "Statin Use and Risk of Prostate Cancer Recurrence in Men Treated With Radiation Therapy". Journal of Clinical Oncology, Vol 28, No 16 (June 1), 2010: pp. 2653-2659
Early Release 10.1200/JCO.2009.27.3003 on April 26 2010

Do B vitamins reduce lung cancer risk?

2010-06-23T10:32:00.007Z

Smoking is the major risk factor for lung cancer, according to a new study published in JAMA, higher levels of vitamin B6 and methionine in the blood was associated with lower risk of lung cancer.

This was a large scale IARC study with 520,000 volunteers across Europe, part of the EPIC cohort. Blood samples were taken from both the case group and the control group and the amount of B6 and methionine measured.

The researchers found that there was a lower risk of lung cancer with a higher level of B6 and methionine whether they were smokers or non-smokers. Overall, people with above average levels of B6 and methionine had 50% reduction in the risk of developing lung cancer than those with below average levels.

Critics say that the blood samples were taken on only one occasion and a cohort study cannot prove a cause and effect for a reduced risk of lung cancer for B6. Furthermore, B6 and methionine are found in meat and potatoes, but it was unknown whether eating more of this food would make a difference to the risk of developing lung cancer because a lower level of these substances in the blood may be due to poor absorption.

Source: Johansson M, Relton C, Magne Ueland P, et al. "Serum B Vitamin Levels and Risk of Lung Cancer". JAMA 2010; 303: 2377-2385

Racial gaps in lung cancer surgery

2010-06-22T14:06:00.004Z

A new study published in JAMA found that black patients newly diagnosed with lung cancer were less inclined to have surgery than whites because they did not connect well with their doctors.

Researchers analysed data from 386 lung cancer patients in Carolina and found that only 55% of black patients had surgery compared to 66% of white patients. They found that many black patients misunderstood their prognosis or did not feel comfortable enough to discuss with their doctors treatment options and outcomes. Black patients were also less likely to have other sources of support.

The authors said that there are many barriers to improving the disparities but doctors and hospitals can work on the negative perceptions of patient-physician communications and spend more time with patients about their treatment options.

Source: "Factors Associated With Decisions to Undergo Surgery Among Patients With Newly Diagnosed Early-Stage Lung Cancer". JAMA, 2010; 303 (23): 2368-2376

Are HRT patches safer than pills?

2010-06-22T09:58:00.008Z

A large study including 75,000 women suggests that low-dose HRT patches may be safer than tablets in terms of stroke risk, but the risk increases significantly with high dose patches.

The findings are based on a nested case-control study drawing data from the General Practice Research Database in the UK. Researchers compare a group of women who have stroke ( case group) to a group who do not ( control group) and found that women using low-dose HRT patches had no increased risk of stroke compared with those who had not used HRT patches, however, using high-dose patches had an increased risk of 89% compared with non-use.

Researchers concluded that low-dose HRT patches may be a safer alternative to oral HRT, although these results alone cannot prove causation, "this study should encourage further research on the importance of the route of administration to define the role of transdermal oestrogens in the therapeutic arsenal for the treatment of menopausal symptoms."

Critics say that this study could affect prescribing practice but it only looked at stroke risk while HRT is assocaited with other risks such as breast cancer, venous thromboembolism and heart disease. The study was published in the BMJ.

Source: Renoux C, Dell’Aniello S, Garbe E and Suissa S. Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case-control study. BMJ 2010;340:c2519, (Published June 3 2010) full text via Athens

Brush your teeth twice a day could lower cardiovascular risk

2010-06-22T08:48:00.005Z

According to a new research by University College London, published in the BMJ, people who brushed their twice a day had a lower risk of heart disease compared with those with less frequent toothbrushing.

The researchers analysed data from more than 11,000 adults who took part in the Scottish Health Survey between 1995 and 2003. Each survey was linked to hospital admissions and deaths, followed up until 2007. They found that people who rarely brushed their teeth had a 70% greater risk of cardiovascular disease than those who brushed their teeth twice a day. However they said that the study did not prove a cause and effect association between oral health and cardiovascular disease.

Previous studies have established a link between gum disease and cardiovascular risk, but the researchers said this is the first study to show an association between self-reported toothbrushing and incident cardiovascular disease and suggest "a possible role of poor oral hygiene in the risk of cardiovascular disease via systemic inflammation." They noted that further studies are needed to confirm whether the observed association is causal or merely a risk marker.

Source: Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey. BMJ 2010;340:c2451

Statins side effects quantified

2010-05-25T08:25:00.007Z

A new study, published in the BMJ, to quantify the unintended effects of statins according to type, dose, and duration of use found that statin use was associated with increased risks of serious liver dysfunction, acute renal failure, moderate or serious myopathy ( muscle weakness) and cataracts.

Researchers examined the medical records of over 2 million patients who registered at GP practices in England and Wales, the patients were monitored over a period of 6 years. They found that Simvastatin was the most prescribed statin and the side effects are already known. Eestimates of the absolute risks were also provided : for 10,000 people, there would be 17 extra cases of kidney failure, 252 cataracts, 65 liver problems and 32 myopathy. The adverse effects were similar across the statin types for each outcome except liver dysfunction where fluvastatin was associated with the highest risks.

The accompanying editorial says that the benefits of statins seem to outweigh the risks. It is suggested that patients should not change their medication.

Source: Hippisley-Cox J, and C Coupland. Unintended effects of statins in men and women in England and Wales: population based cohort study using the QResearch database. BMJ 2010;340:c2197 ( f/t via Athens)

Processed meat increased heart disease risk

2010-05-19T12:53:00.011Z

A new systematic review and meta-analysis of 20 studies involving more than 1.2 millions people from 10 countries found that processed meat such as bacon, salami, sausages, hot dogs and processed deli, was linked to increased risk of heart disease and diabetes, but red meat was not.

Participants were followed up to 18 years and found that those who ate 50 gram a day of processed red meat had 42% higher risk of heart disease and 19% higher risk of type 2 diabetes than those who did not eat processed red meat.

Researchers said that the processed meat contain much higher salt and preservatives ( rather than fats) than unprocessed meat and this could explain the difference. They found the same even when lifestyle factors were taken into account and suggested that these types of meats should be studied separately in future research.

Source: "Red and Processed Meat Consumption and Risk of Incident Coronary Heart Disease, Stroke, and Diabetes Mellitus. A Systematic Review and Meta-Analysis". Circulation. 2010 Published online before print May 17, 2010 ( f/t via Athens)

Medical journals on Twitter

2010-05-18T13:16:00.008Z

Twitter started as social networking or microblogging that combines blogging and instant messaging. Users can create a short message of up to 140 characters ( called “tweets”), send and receive updates from any computer or mobile devices with Internet access.

Tweets are instantly available to the “followers”, so it is a quick way of communicating with a group of people. Twitter has become a major distributor of timely information, particularly in the area of breaking news. The 1st reports of the crash of a US jetliner into the Hudson River in January 2009 were sent by witnesses on Twitter.

Many medical journals and organisations have started to use Twitter to disseminate information quickly to large groups of people.

For example - "Are probiotic drinks good for children? Looking at research we agree they may have small benefit for some illnesses " - was a tweet by NHS Choices

BMJ, The Lancet, NEJM, JAMA and many others also use Twitter to provide Table of Contents (TOC) service with links to the most current articles.

If you use Twitter to share medical information and opinion, beware of the issues of confidentiality.

Eating nuts may reduce cholesterol

2010-05-18T12:20:00.005Z

Previous studies have shown that nut consumption reduces the risk of coronary heart disease, a new systematic review published in the May 10 issue of Archives of Internal Medicine found that diets rich in nuts were associated with reduced total cholesterol and bad cholesterol.

Researchers pooled data from 25 trials conducted in 7 countries that compared a control group to an experimental group assigned to consume nuts. An average of 67 grams of nuts per day were consumed over 3 to 8 weeks, they found that total cholesterol was reduced by 5.1% and bad cholesterol by 7.4%, but there was a lesser effect on reducing the cholesterol levels of people with higher BMIs.

Critics noted that the overall population of the studies was relatively small, the study results might have been affected by the different diets used in different studies. The experimental diet lasted only 3 to 8 weeks long, so it is not clear what effect it would have over the longer term. It is also unclear whether the reductions in cholesterol and LDL-cholesterol would be enough to lower the risk of coronary heart disease. Although nuts may reduce cholesterol, they are high in saturated fats and should be eaten in moderation.

Source: "Nut Consumption and Blood Lipid Levels - A Pooled Analysis of 25 Intervention Trials". Arch Intern Med. 2010;170(9):821-827. ( f/t via Athens)

Working overtime is bad for your heart

2010-05-17T14:40:00.007Z

According to a study of 6000 British civil servants published online in the European Heart Journal, people who regularly work overtime have higher risk of developing coronary heart disease than those who do not.

The study involved over 6000 men and women aged between 39 and 61 who did not have heart disease and worked full time at the start of the study. Researchers found those who worked 3 to 4 hours of overtime a day had 60% higher risk of developing heart disease, overtime work was also associated with lower HDL cholesterol ( good cholesterol).

Experts said the study highlights the importance of work-life balance but note that the link was only found in association with 3-4 hours oertime a day. The lead researcher said more research is needed.

Source: Overtime work and incident coronary heart disease: the Whitehall II prospective cohort study. Eur Heart J (2010). First published online: May 11, 2010 ( f/t via Athens)

Vitamin A does not reduce maternal mortality

2010-05-17T13:53:00.004Z

A new study, (Obaapa VitaA) in Ghana showed that vitamin A supplementation to women of child-bearing age in poor nations does not reduce maternal death rates. The Ghana findings contradicted previous results from a trial in Nepal which showed a 44% decrease in maternal death among women given vitamin A.

The researchers conducted a randomised and double-blind trial in 7 districts in the Brong Ahafo Region of Ghana. Participants were randomly assigned to vitamin A supplement or placebo capsule orally every week. They found that there was no statistically significant difference between the intervention and the control groups.

The author, Professor B Kirkwood at The London School of Hygiene and Tropical Medicine concluded that "the results of this trial in Ghana vindicate the decision not to change safe motherhood policy immediately after the Nepal trial."

Source: Betty R Kirkwood et al. Effect of vitamin A supplementation in women of reproductive age on maternal survival in Ghana (ObaapaVitA): a cluster-randomised, placebo-controlled trial. The Lancet, 2010; 375(9726):1640-1649 ( f/t via Athens)

Virgin olive oil changes gene activity

2010-04-27T15:04:00.005Z

Previous studies have shown a Mediterranean diet is associated with lower risks of all major diseases, but a small size study published in the open access journal BMC Genomics shed new light on how virgin olive oil influences certain genes that promote inflammation and can lead to heart disease.

Spanish researchers gave 20 volunteers with metabolic syndrome 2 breakfasts containing virgin olive oil with either high or low levels of phenols randomly on 2 separate days with a week apart. Both researchers and participants did not know who had received which breakfast. The researchers then measured the changes in the gene expression after the breakfasts and found that 39 genes are involved in the inflammation process (that has a role in the build-up of fatty deposits in the blood vessels ) and 35 of them were less active after eating the high-phenol virgin olive oil.

The researchers concluded that the study could partly explain why the risk in cardiovascular disease is reduced in Mediterranean countries where the diet is rich in virgin oliver oil.

Critics say that this study helps our understanding of the effect of olive oil on gene activity but it is difficult to confirm that the changes in gene activity is responsible for the reduction in risk of cardiovascular disease. The small size of the study, all participants with metabolic syndrome, gene expression after one meal and the lack of follow up for long-term outcomes are just some of the limitations that may affect the results of the study.

Source : Antonio Camargo, Juan Ruano, Juan M Fernandez, Laurence D Parnell, Anabel Jimenez, Monica Santos-Gonzalez, Carmen Marin, Pablo Perez-Martinez, Marino Uceda, Jose Lopez-Miranda and Francisco Perez-Jimenez. "Gene expression changes in mononuclear cells from patients with metabolic syndrome after acute intake of phenol-rich virgin olive oil". BMC Genomics, 2010

Too much added sugars may increase heart disease risk

2010-04-27T11:47:00.006Z

A new JAMA study found that consuming a higher amount of added sugars in processed foods may increase cardiovascular disease risk factors.

The study analysed the US government nutritional data and blood lipid levels in more than 6000 adults and found that the highest consumption of added sugars was 46 teaspoons per day and the lowest was about 3 teaspoons daily. It also found that high consumption of added sugars was significantly correlated to lower levels of good cholesterol (high-density lipoprotein cholesterol, HDL-C) and higher levels of triglycerides, which are important risk factors for cardiovascular disease.

The authors said that this is the first study that examined the the association between added sugars consumption and lipid measures and found that total consumption of sugars in the US has substantially increased. People should cut down their added sugars consumption and further studies on the effect of reducing added sugars and other carbohydrates on lipid profiles are needed.

Source: J. A. Welsh, A. Sharma, J. L. Abramson, V. Vaccarino, C. Gillespie, M. B. Vos. "Caloric Sweetener Consumption and Dyslipidemia Among US Adults". JAMA 2010; 303 (15): 1490 (Full text via Athens)

Should aspirin be used for migraine relief?

2010-04-26T09:36:00.007Z

A new Cochrane systematic review found that high dose aspirin can reduce migraine headache within 2 hours.

The review compared the use of aspirin to placebo or other migraine drugs including 13 studies and 4222 patients with migraine attacks. The amount of aspirin used in these studies varied between 900 - 1000 mg. Patients were randomly assigned to either a single dose of aspirin or a placebo or an active drug.

Researchers found that 24% of aspirin users were pain-free within 2 hours comapred to 11% of placebo users, aspirin also reduced the symptoms of nausea and vomiting, but aspirin plus antiemetic reduced these symptoms significantly compared with placebo. They concluded that 1000 mg of aspirin is effective for migraine relief, similar to the effect with sumatriptan.

Critics say that it is important to note that the over-the-counter standard aspirin is only 75mg and evidence has shown that regular use of aspirin may increase stomach problem or bleeding, taking high dose aspirin may increase these side effects. Also the effectiveness of aspirin may not apply to everyone as only a quarter of patients in these studies were pain-free after 2 hours.

Source : Kirthi V, Derry S, Moore RA, McQuay HJ. "Aspirin with or without an antiemetic for acute migraine headaches in adults (Review)". The Cochrane Library 2010, Issue 4

Do multivitamin tablets increase breast cancer risk?

2010-04-20T14:34:00.007Z

Multivitamin supplements are widely used, but a large study involving 35,000 Swedish women aged 49 to 83 found that those who regularly took multivitamins had a higher risk of breast cancer than women who did not.

Based on self-reported questionnaire data, the researchers analysed the women's use of multivitamins as well as details about their health and lifestyle, followed up for 9.5 years until December 2007 to assess the cancer risk. They found that women who took multivitamins were 19% more likely to develop breast cancer than non-users. They also found that women who had taken these supplements for 3 years or more and those who took 7 or more pills a week were at increased risk of breast cancer than non-users, however the increase was very small.

The researchers concluded that "multivitamin use is associated with an increased risk of breast cancer" but they noted that other studies have had conflicting results. The authors said that this study carries an important public health message and recommend women to eat healthy diet instead of using supplements.

Critics say that this study was based on self-reported data that could affect the results. Further research is needed, it is not possible to say which of the supplements may contribute to breast cancer risk.

Source: "Multivitamin use and breast cancer incidence in a prospective cohort of Swedish women". American Journal of Clinical Nutrition, March 24 2010 (full text via Athens)

Brisk walking can reduce stroke risk in women

2010-04-20T13:21:00.004Z

A large study published in Stroke found that women who walked two or more hours a week or walked briskly lowered the risk of stroke by more than a third.

The researchers followed nearly 40000 women aged over 44 for about 12 years to investigate the link between the levels of physical actitivity and the risk of having a stroke. The participants reported periodically on their physical activities via a questionnaire. 579 women had a stroke during the follow-up years.

The researchers said they have found a borderline significant link between the time spent on physical activities and stroke risk but they did not find a link between vigorous activity and reduced stroke risk. The lead author said the study was observational and physical activity was self-reported, further study is needed on more hemorrhagic strokes and with more ethnically diverse women.

Source: "Physical Activity and Risk of Stroke in Women". Stroke, published online April 2010 DOI

High GI food may increase women's heart risk

2010-04-19T13:08:00.004Z

According to a study published in the Archives of Internal Medicine, consuming carbohydrates with high glycemic index (GI) such as white bread, sweets and sugary cereals appears to be associated with the risk of coronary heart disease in women but not men. However, not all carbohydrates have the same effect on blood glucose levels.

Italian researchers studied 47,749 adult men and women who completed dietary questinnaires. They found that women who consumed the most carbohydrates overall had approximately twice the risk of heart disease as those consumed the least. Women whose diet had the highest glycemic load had 2.24 times the risk of heart disease than those with the lowest glycemic load.

The researchers concluded "we tentatively suggest that the adverse effects of a high GI diet in women are medicated by sex-related differences in lipoprotein and glocuse metabolism" and that further studies are needed to verify the link between high-glucose foods and cardiovascular disease in men.

Source: "Dietary Glycemic Load and Index and Risk of Coronary Heart Disease in a Large Italian Cohort: The EPICOR Study". Arch Intern Med, 2010; 170 (7): 640-647

Maternal deaths drop worldwide

2010-04-19T10:36:00.003Z

The Lancet published an article online on 12 April that has found significant decline in maternal deaths worldwide. This finding however is very different from a new UN study claiming that the number of women dying in childbirth remains high at 500,000 a year.

The Lancet study is based on the data collected from 181 countries between 1980 and 2008 provided by the Univeristy of Washington and found that maternal deaths have fallen from about 500,000(1980) to about 343,000 (2008). Many experts are surprised by the finding as they have assumed little progress made in this area.

According to the journal editor, The Lancet was pressured by some advocate groups to delay the publication of the new finding fearing loss of funding, but he said that the new data shows improvements and should encourage politicians to spend more on women's health.

Source: "Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5". The Lancet, Early Online Publication, 12 April 2010

Should patients be given a voice in drug-safety reporting?

2010-04-19T10:04:00.003Z

An oncologist, Ethan Basch, wrote in the March 11 issue of NEJM, that current clinician-based approach to adverse symptom reporting is based on clinicians’ impressions of patients’ symptoms, not on patients’ direct symptom reports. He said that evidence has shown that clinicians responsible for collecting and reporting adverse symptoms in clinical trials systematically downgrade the severity of patients’ symptoms and often miss the side effects, as a result vital information about drug safety is missing .

He argued that doctors, researchers and regulators should pay more attention to patients’ symptom reports while taking a drug because it could help identify symptoms earlier during a course of treatment and reduce preventable harm.

He said that technologies are now available for collecting information directly from patients and patients should be given the tools to self-report adverse symptoms in clinical trials such as online reporting between clinic visits, this can capture a lot of baseline symptoms before the drug is approved including those symptoms that researchers did not anticipate.

He concluded that “patient self-reporting would enhance the capture of subjective elements of safety information and patients are entitled to know the impressions of their peers”, such information would also help clinicians to evaluate the drugs.

Source: "The Missing Voice of Patients in Drug-Safety Reporting". NEJM 362(10):865-869 (full text via Athens)

Statins raise small diabetes risk

2010-02-23T12:22:00.007Z

Statins have been used as cholesterol-lowering drugs to prevent heart attacks and strokes although trials of statins have produced conflicting results.

A new report based on a meta-analysis of 13 randomised controlled trials of statins between 1994 and 2009 involving 91,000 patients showed that there was a clear link between statin treatment and a small but significant increased risk of diabetes - 9% increase over 4 years in those using the drug than those without the treatment. The researchers said that the risk is very low and outweighed by the benefits of this drug and concluded that patients with moderate or high cardiovascular risk should not stop taking this drug.

Critics say this is a well-conducted review, when all the results were combined into a meta-analysis, the diabetes risk was relatively small, however various unidentified cofounding factors may have affected the observed results. The study was published in The Lancet online.

Source: "Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials". The Lancet, Early Online Publication, 17 February 2010

Can aspirin reduce breast cancer recurrence?

2010-02-23T11:21:00.007Z

According to a new study published online in the Journal of Clinical Oncology, there was an association between frequent use of aspirin and lower risk of dying from cancer.

Researchers used survey data from US Nurses' Health Study to examine the effect of aspirin on breast cancer recurrence and survival including over 4000 nurses between 1980 and 2006. They found that women who took aspirin after finishing breast cancer treatment were half as likely to die from the disease compared with those who did not use aspirin regularly. However, the researchers pointed out that the participants were all nurses, the results may not be applied to the general population and they called for a randomised controlled trial to establish whether aspirin really caused the reduced risks they had found.

Previous studies on aspirin's anticancer effects have come to mixed conclusions, experts warned that patients should not start taking aspirin as there are risks associated with taking aspirin including bleeding and gastrointestinal complications.

Source: Holmes MD, Chen WY, Li L, et al. "Aspirin Intake and Survival After Breast Cancer". Journal of Clinical Oncology 2010 ( f/t via Athens)

Gastric banding achieved more weight loss in obese teens

2010-02-22T14:52:00.005Z

According to a study published in the February 10 issue of JAMA, gastric banding achieved significant weight loss than lifestyle intervention in severely obese adolescents.

Australian researchers conducted a randomised controlled trial to compare the outcomes of gastric banding with a lifestyle program on adolescent obesity including 50 people aged between 14 and 18 with a BMI >35. The study, carried out between 2005 and 2008, was followed up for 2 years.

The researchers found that more than 50% weight loss was achieved by 84% in the gastric banding group compared with just 12% in the lifestyle group. The average weight loss was about 34 kg in the gastric banding group and only 3 kg in the lifestyle group. The differences between the 2 groups were significant for all weight measures at 24 months with 24 in the gastric banding group and 18 in the lifestyle group completed the study.

The authors concluded that "Among obese adolescent participants, use of gastric banding compared with lifestyle intervention resulted in a greater percentage achieving a loss of 50% of excess weight" and "There were associated benefits to health and quality of life".

Critics say there are limitations to the study including recruitment bias, small number of participants and short follow-up period. An accompanying editorial "Surgical Treatment of Obesity in Adolescence" notes that this study provides important evidence about the bebefits and risks of bariatric surgery.

Source:"Laparoscopic Adjustable Gastric Banding in Severely Obese Adolescents : A Randomized Trial" JAMA. 2010;303(6):519-526 (f/t via Athens)

Serotonin deficit may cause SIDS

2010-02-22T13:40:00.011Z

A new study published in JAMA found that the brainstems of babies who have died from Sudden Infant Death Syndrome (SIDS) had lower level of serotonin than those babies who died from other causes. SIDS is still the leading cause of death in infants.

Previous studies had found that serotonin levels have been linked to SIDS, but this study sheds light on the defect in the infants' brain that might account for SIDS.

The researchers found that in 35 of the 41 SIDS babies, serotonin levels were 26 % lower than in those who died of other causes and levels of an enzyme that stimulates serotonin production were 22 % lower. Serotonin receptor was 50 % lower in SIDS babies.

Experts say that this is an important advance in the understanding of what's wrong with the brainstem of SIDS babies but there is still a long way to go to finding a detection test and then a treatment. The authors emphasized avoiding known risk factors such as bed sharing, soft bedding and smoking.

Source: "Brainstem Serotonergic Deficiency in Sudden Infant Death Syndrome" JAMA 2010;303(5):430-437. ( f/t via Athens)

The Lancet retracted the MMR and autism paper

2010-01-21T14:57:00.015Z

The Lancet issued a press release on Tuesday 2 February 2010 following the GMC's decision on the paper by Wakefield et al in 1998 stating that several elements of the paper are incorrect. "In particular, the claims in the original papaer that children were consecutively referred and that investigations were approved by the local ethics committee have been proven to be false. Therefore we fully retract this paper from the published record."

The study, published in The Lancet, claimed 8 of the 12 children showed signs of autism within days of receiving the MMR vaccine. The lead author, Andrew Wakefield, suggested that there might be a link between the vacciantion and autism. Although it was a very small study with only 12 children, the findings had caused a massive drop in the uptake of the MMR vaccine and sparked panic over the MMR vaccine around the world.

In the same issue of The Lancet, a commentary " Vaccine adverse events: causal or incidental?" written by 2 American vaccine specialists was also published. They pointed out that Wakefield's paper lacked epidemiological evidence to support the causal association with MMR vaccine and warned that such claim would cause confusion and fear among the media and the public. Unfortunately their message was not picked up by the media and the general public had little access to research articles.

The GMC found that Wakefield had no ethical approval nor relevant qualifications to carry out the tests on children. He also failed to declare that he had received money from a law firm representing the parents to carry out the research. Questions were raised on how Wakefield's research was scrutinised by the Royal Free and UCL Medical School where he worked at the time. A subsequent investigation by The Royal Free Hospital in 2004 reported that Wakefield's work on children was "appropriate". However, The Lancet issued a partial retraction of the interpretation from 10 of the 12 authors except Wakefield and one other author. See "The lessons of MMR" The Lancet, 363, 6 March 2004, pp 747–749 ( full text via Athens)

Some critics say the Lancet retraction is a bit too late while others say that the retraction will not change the situation as the MMR-autism debate continues.

See also: "The Lancet retracts controversial MMR research paper". Independent ,2 February 2010

Concerns raised on high prescription errors in children

2010-01-21T14:06:00.004Z

A study, carried out in 2005 by the Univeristy of London involving a children's hospital, 3 general teaching hospital and 1 non-teaching hospital in London, looked at prescription errors given to children in hospital. The study was published in Archives of Disease in Childhood.

During the study, pharmacists found 391 prescription errors and 429 administration errors in the 3000 prescriptions they exmined over a 2-week period. Errors included incomplete prescriptions, wrong dose, how the drugs should be prepared or how they should given to the patients. One mistake was picked up by the nurse, on 5 occasions, the researchers intervened to prevent the patient suffering the harm.

The researchers believe that their findings show a general picture across Britain and still stand today. The author said prescribing for children is very difficult because most drugs are formualted for adults, doctors have to calculate the dose for children. Much more needs to be done to improve prescribing to children.

They call for better education for doctors on prescription skills and electronic prescribing to be introduced in hospitals. See also post on GMC study on prescription errors in hospitals.

Source: "Minimising medication errors in children”Archives of Disease in Childhood 2009 ;94:161-164

Too much TV viewing shortens lives

2010-01-21T12:28:00.007Z

Nearly 9,000 Australian adults, divided into 3 groups, were tracked for roughly six and a half years by researchers: those who watched TV less than 2 hours per day, between 2 and 4 hours, and more than 4 hours.

Researchers found that those who watched TV more than 4 hrs had a 46% higher risk of death from all causes and an 80% higher risk of cardiovascular death, each hour watching the TV per day increased the risk of death from cardiovascular disease by 18% and the risk of cancer death by 9%. The study was published online in Circualtion.

Researchers found a strong connection between TV hours and death from cardiovascular disease not only in overweight and obese people, but also among those who had a healthy weight. The lead author said "sitting for long periods has unhealthy influence on blood sugar and blood fats".

Source: Television Viewing Time and Mortality. The Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Circulation. Published online before print January 11, 2010

Higher antibiotic doses to bigger people

2010-01-18T12:47:00.006Z

Two doctors said in The Lancet Viewpoint, although drug treatments are tailored for individual patients, most dosing regimens, do not take patient's body size into consideration.

They argued that with increasing level of obesity worldwide, the standard dose of antibiotics for all adults is outdated because it may not be strong enough to clear the infection in taller and larger adults and resistance may be developed. Likewise, smaller patients may get too much drug, and suffer greater side-effects as a result.

They said that a patient's bodyweight should be taken into account when calculating their dose of antibiotics to achieve effectivenesss and safety.

Critics say that this review is based on authors' views and experience and is a valuable discussion. Changes to current prescribing would be costly and complicated, therfore further research and follow-up of previous study data would be needed.

Source:
"Adjustment of dosing of antimicrobial agents for bodyweight in adults". The Lancet, 375(9710):248-251

Editorial: "Prescribing medicines: size matters". The Lancet 2010; 375(9710): 172

Breast cancer screening controversy

2010-01-15T11:21:00.005Z

The US Preventive Services Task Force (USPSTF) has issued new guidelines calling for women to change from annual screening at age 40 to biennial mammograms at 50.

The new guidelines aimed at reducing unnecessary treatment but have caused public uproar and confusion. Radiologists say the USPSTF recommendations were "unfounded" and put forward their own guidelines in the January issue of the Journal of the American College of Radiology.

However, the USPSTF continues to recommend biennial mammograms and says that individuals should take into account one's values regarding specific benefits and harms when deciding when to start the screening.

Source: "Screening for breast cancer: U. S. Preventive Services Task Force recommendation statement" Ann Intern Med 2009; 151: 716-26.

Blood pressure drugs could reduce the risk of dementia

2010-01-14T12:03:00.006Z

American researchers investigated the incidence of dementia in 800,000 people aged 65 or over with cardiovascular disease, mostly male. The patients were divided into 3 groups according to the type of blood pressure drugs they were taking : ARBs, lisinopril or other cardiovascular drugs.

The researchers found that ARBs were associated with reduced risk of developing dementia when compared with the other 2 types of drugs. ARBs had additional effects when combined with another type of high BP drug. Those with existing dementia who took both drugs were less likely to die early or be admitted to a nursing home. The study concluded that ARBs could reduce the risk of developing Alzheimer's disease or dementia.

Citics say that there are limitations which may have affected the results: the subjects were not randomly assigned a treatment, each group of people might have different diseases such as diabetes or cardiovascular disease and the follow-up period was too short for a condition such as dementia. Further work is needed to include both male and female.

Source: N-C Li, Lee A, Whitmer RA, et al. "Use of angiotensin receptor blockers and risk of dementia in a predominantly male population: prospective cohort analysis". BMJ 2010; 340: b5465

Choose C-sections only when there is a medical reason

2010-01-14T10:53:00.008Z

According to a survey by the World Health Organization(WHO) published online in The Lancet, women who had caesarean sections without a medical reason were 10 times more likely to be admitted to intensive care, required blood transfusions or encountered complications.

The WHO study reviewed nearly 110,000 births in 9 Asian countries in 2007-08 and found that about 27% of the births were done by C-sections, 2/3 of the hospitals surveyed make more money if C-sections were carried out. The authors warned that C-sections should be opted for only when there is a medical indication to improve the outcome.

In the UK, nearly a quarter of births are carried out by C-sections despite the evidence against it.

Source: "Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007—08" The Lancet, Early Online Publication, 12 January 2010 ( f/t via Athens)

Why so few heart attack survivors take advantage of rehab?

2010-01-12T13:25:00.005Z

A new reserach published in Circualtion has found, as in many other studies, that cardiac rehab improves the survival rate of heart attack survivors.

The study tracked more than 30,000 Medicare patients aged over 65 for 4 years and found that
those who completed 36 sessions of rehab had a risk reduction of 47% in death and 31% in heart attack than those who had fewer sessions. However only 18% attended all 36 sessions and drop-out rate was high.

Other studies have shown that patients who attended even a few sessions improved their survival rate significantly, but most heart attack survivors did not go to rehab and those who went did not stick to it. Why don't patients take advantage of it?

Some cardiologists say that successful rehab required strong self-discipline and perserverance as well as respect in the medical community supported by adequate resources. A study published in 2007 in Circualtion found that cardiac rehab was provided to about 14% of patients hospitalised for heart attacks and 31% who had bypass surgery.

Source: Bradley G. Hammill “Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries” Circulation. 2010;121:63-70 ( f/t via Athens)

Mozart's music may help premature babies gain weight

2010-01-12T12:12:00.006Z

A group of Israeli doctors from the Tel Aviv University medical centre carried out a small study involving 20 healthy premature babies to look at the effects of music on short-term metabolic efficiency. The study was published in Pediatrics.

The babies were randomly assigned to either exposure to Mozart's music for 30 minutes or no music, then alternative treatment was given the next day. The researchers measured the babies' resting energy expenditure (REE) during the exposure period and comapred the way the babies responded to the music with their metabolism during music-free period. The study did not measure the changes in weight.

The study found that exposure to Mozart's music for 30 minutes reduced the babies' REE, although the mechanism was unclear, it appeared that the music has relaxed the babies and this effect might increase the babies' weight gain. However the researchers were cautious about the clincal implications of their findings and said that more research is needed.

Other research has found the "Mozart effect" has improved the IQ in college students, lowered heart rates, stress level etc, later studies challenged these findings.

Source: Lubetzky R, Mimouni FB, Dollberg S et al. Effect of Music by Mozart on Energy Expenditure in Growing Preterm Infants. Pediatrics Vol. 125 No. 1 January 2010

Tea and coffee drinkers have a lower risk of developing type 2 diabetes

2009-12-21T14:30:00.003Z

Australian researchers conducted a systematic review and meta-analysis that pooled data from more than 30 studies of the association between tea and coffee consumption and the risk of developing type 2 diabet. About a million of participants were involved.

They found that "high intake of coffee, decaffeinated coffee, and/or tea is associated with a reduction in the risk of new-onset type 2 diabetes" and the compound magnesium and antioxidants in tea and coffee may be involved.

Critics said the studies lacked sufficient data on the effects of these beverages or their components on measures of hyperglycaemia and insulin sensitivity, therefore the mechanisms involved is still unknown. It may not be possible to generalise these findings to other populations because only a small number of particpants were non-white.

Further research into the effect of these beverages on diabetes is warranted, but it is advised that people should not increase their tea or coffee consumption based on these findings.

Source: Huxley R, Man Ying Lee C, Barzi F, et al. "Coffee, Decaffeinated Coffee, and Tea Consumption in Relation to Incident Type 2 Diabetes Mellitus". Arch Intern Med 2009; 169: 2053-2063

25 techniques to improve trainees' bedside skills

2009-12-21T12:52:00.005Z

"Stanford 25" is a list of 25 fundamental physical examination techniques and their diagnostic benefits developed by Stanford Medical School to teach the interns to improve their skills at the bedside. It is published in the Christmas issue of the BMJ.

Abraham Verghese, professor of medicine at Stanford, wrote in the editorial, that the bedside skills of trainees in the US are declining as a result of the over-use of modern diagnostic tests. He argued that physical examination along with the taking of a good history are necessary and important in the diagnosis of clinical signs because many of them such as rebound tenderness, lid lag, tremor etc cannot be detected by an imaging test. He said that the Stanford 25 also gives "junior faculty members a repertoire of skills to teach when they are at the bedside."

Editorial : "In Praise of the Physical Examination", Abraham Verghese, Ralph Horwitz. BMJ 2009;339:b5448

Junior doctors to be tested for prescribing skills

2009-12-21T10:42:00.007Z

A study commissioned by the GMC into the causes and prevalence of prescribing errors by Foundation Year doctors found that 8.9% of the prescriptions issued by doctors had errors, some of which could harm patients.

124,260 prescriptions were checked by pharmacists in 19 hospital trusts in north-west England and 11,077 errors were found. The errors included omitting drugs, wrong doses, patients’ allergies not taking into account, illegible handwriting or ambiguous orders.

When the hospital doctors were interviewed about their mistakes, some admitted they relied heavily on pharmacists and nurses as “safety net” to help catch the errors. It was found that junior doctors were ill prepared in medical school where they filled out only a few prescription forms a year, but have to complete dozens of prescriptions a day when they start as junior doctors.

The chairman of British Pharmacological Society (BPS) Prescribing Committee, Professor Simon Maxwell, said that the evidence indicated that there are serious medication errors and “such an error rate would not be acceptable”. He believed that focus on training in prescribing can improve the standards and is calling on the doctors to take the National Prescribing Assessment before they are qualified.

Sources :

GMC Press Release on 03 Dec 2009

BPS press briefing on 14 December 2009
A Blueprint for safer prescribing: BPS expresses concern about poor prescribing and calls for greater collaboration in solving the problem

CT scans may raise cancer risk

2009-12-15T13:54:00.005Z

The hazards of radiation from CT scans was highlighted by some articles published in this week's Archives of Internal Medicine.

One study found that the number of CT scans has increased dramatically in recent years in the US putting patients at the risk of developing radiation-induced cancer. They estimated that the CT scans performed in 2007 will eventually cause 29,000 cancers and 15,000 death.

Another study found that radiation doses from common diagnostic CT scans are much higher than we previously thought and the amount of radiation varies wildly and much greater than is considered acceptable. Based on their findings, they estimated that at the age of 40, 1 in 270 women who get CT scan of the heart will develop cancer and 1 in 600 men. 1 in 8,100 women who get scans of the head and 1 in 11,080 men.

In an accompanying editorial, the author asked are such risks justified and concluded that "to avoid unnecessarily increasing cancer incidence in future years, every clinician must carefully assess the expected benefits of each CT scan and fully inform his or her patients of the known risks of radiation". Greater standardization across institutions is also needed.

Source: ( both f/t via Athens )
"Radiation Dose Associated With Common Computed Tomography Examinations and the Associated Lifetime Attributable Risk of Cancer" Arch Intern Med. 2009;169(22):2078-2086

"Cancer Risks and Radiation Exposure From Computed Tomographic Scans: How Can We Be Sure That the Benefits Outweigh the Risks?" Arch Intern Med 2009;169:2049-2050.

The truth about Tamiflu

2009-12-10T14:39:00.008Z

This week, the BMJ published a series of articles online about an update of an earlier review on oseltamivir’s efficacy in preventing complications from seasonal influenza. What makes it interesting is that in addition to the review itself, the journal also published an article that documents how the reviewers reached its current conclusion that has undermined previous findings for oseltamivir’s prevention of complications from influenza.

The story began
With the spread of the influenza A/H1N1 pandemic that began in April 2009, the use of antiviral drug has increased dramatically, the UK National Institute of Health Research commissioned an update of the Cochrane review of neuraminidase inhibitors such as Oseltamivir ( also known as Tamiflu) in healthy adults.

The Cochrane group that reviewed the efficacy of the antiflu drug in 2005, concluded at the time that oseltamivir was effective in reducing complications of flu among healthy adults. The review was criticised by a Japanese paediatrician, K Hayashi, who questioned the validity and reliability of the findings because one of the papers the review was based on was a meta-analysis of 10 trials of oseltamivir, all of which were funded by Roche, the drug manufacturer, only 2 were published in peer-reviewed journals while the remaining 8 were unpublished or published as abstract only. Hayashi challenged them to “appraise the 8 trials rigidly”.

The review team contacted the authors of the study and Roche with an attempt to verify the data but they said Roche failed to make the data available in the public domain. Eventually the team had to exclude the 8 trials in the new review, based on 20 trials, they found that there was little evidence that Tamiflu has effects on preventing complications like pneumonia and it can cut the length of illness by around a day. They call on governments to set up studies to monitor the drugs for safety.

Some critics say the new finding is not very new, it is generally known the evidence for prevention of flu complications is weak, many clinicians do not recommend the drug for healthy adults. However, others said in severely ill patients with flu-like symptoms, evidence shows that it offers some benefits.

The editor of BMJ said “Government around the world have spent billions of pounds on a drug that the scientific community now finds itself unable to judge”. The new review casts doubt not only in how safe and effective Tamiflu is but also how drugs are regulated and approved.

In the UK, the British government has stockpiled tens of millions of Tamiflu doses and the drug is given to healthy people with flu via a national swine flu hotline.

Source:
"Neuraminidase inhibitors for preventing and treating influenza in healthy adults: systematic review and meta-analysis". BMJ 2009;339:b5106

Editorial : "Why don’t we have all the evidence on oseltamivir"? BMJ 2009;339:b5351

Applying for specialty training: top tips

2009-12-10T10:53:00.003Z

A specialty trainee who was twice successful with specialty training applications, gives some advice to this year’s applicants based on her experience and those of colleagues.

Her advice, published in the BMJ Careers, includes :

- Establish your goal and the bottom line
- Organise your form - think in advance about how you will answer questions, sort out the certificates and job details, submit the application much ahead of the deadline etc.
- Prepare your portfolio
- Gather supporting documents
- Keep perspective

Source :"Applying for specialty training: top tips" BMJ Careers, 25 Nov 2009

Transplanting kidneys with renal masses

2009-12-09T12:06:00.007Z

According to the December issue of BJU International, surgeons at the University of Maryland have transplanted 5 kidneys that have been affected by a renal mass, 3 were cancerous. So far, 1 of the recipients has died in an accident, the remaining 4 have survived between 9 and 41 months without develoing cancer.

The head of the team, Dr Michael Phelan, said both patients and the donors were aware of the cancer in the donor kidneys and the risks including recurrence of the cancer. Before the transplanting into the recipients, the surgeons removed all visible traces of the tumours. Such approach is "controversial and considered high risk" said Dr Phelan, but "The current study provides evidence to suggest that kidneys from donors with renal masses offer a minor, yet feasible, solution to the current organ shortage" and "can be transplanted into recipients with limited life-expectancy on haemodialysis after careful removal of the renal masses".

Source : "Living-donor renal transplantation of grafts with incidental renal masses after ex-vivo partial nephrectomy" BJU International, December 2009, Volume 104, Number 11 (f/t via Athens)

Low-level laser therapy in neck pain

2009-12-08T13:09:00.005Z

Australian researchers did a meta-analysis to assess the efficacy of low-level laser therapy (LLLT) in neck pain. LLLT is a non-invasive treatment by applying low-intensity laser beam to sites of pain. The study was published in The Lancet.

Researchers pooled data from 16 RCTs involving 820 patients with chronic neck pain comparing the efficacy of LLLT using wavelength vs placebo or active control. The authors reported that although the mechanism was unknown, LLLT was found effective in short and medium-term pain relief with moderate benefits. They also said that adverse effects from this treatment were minimal.

In an accompanying editorial, the author said that "this evidence is more solid than that for many current interventions" and "LLLT is an option worthy of consideration for management of nonspecific neck pain."

Critics warned that all 16 trials had relatively small sample sizes from 20 to 90 subjects, so the risk of bias could not be ruled out. Furthermore, many of the trials did not provide data on the side effects nor withdrawls and drop-outs that would affect the trial outcome.

Source :
Chow R, et al "Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials" Lancet 2009; DOI: 10.1016/S0140-6736(09)61522-1. (f/t via Athens)

Editorial: Guzman J "Neck pain and low-level laser: Does it work and how?" Lancet 2009; DOI: 10.1016/S0140-6736(09)61837-7. ( f/t via Athens)

Risk of blood clots after surgery is higher and lasts longer than thought

2009-12-07T12:54:00.012Z

Studies have shown that the risk of developing blood clot after major surgery is high but a new study pubished in BMJ Online First on 4 December found that this risk is higher and continues for up to 3 months after surgery.

The research was a large prospective study that tracked 947,454 women, average age 56, who were diagnosed with venous thromboembolism through the NHS breast screening programme between 1996 and 2001. The reserachers checked hospital admission and death records, followed for an average of 6.2 years and compared the risk of blood clots for those who did not have surgery with those who did have surgery.

The researchers found that within 6 weeks post operation, women who had day case surgery were 10 times more likely to have blood clots than those who had no surgery. The risk for those who had surgery in the hospital were nearly 70 times higher. At 7 to 12 weeks after surgery, the risk of blood clots was 6 times higher for the day case surgery group than the no surgery group and 20 times higher for the inpatient surgery group.

They also calculated different risks for different surgery and found that the incidence of blood clots in the 12 weeks after surgey :

1 in 45 had developed blood clots after hip or knee replacement;
1 in 85 after cancer surgery;
1 in 815 after day surgery;
1 in 6,200 women who did not have surgery

The researchers warn that the risk of developing blood clot after surgery is higher and lasts for longer than previously thought and suggest that doctors should extend the time that preventive measures such as blood thinning drugs or wearing stockings are used.

Critics say that despite the lack of data on how many of the participants were taking preventive measures, this study is important because it broadens our understanding to current evidence of the risk of potential fatal blood clot after surgery and the findings may have implications for prolonged prophylaxis after surgery.

Source:
Editorial : Cohen TA. Prevention of postoperative venous thromboembolism. BMJ 2009; 339: b4477 (f/t via Athens)
Sweetland S, Green J, Liu B. et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ 2009; 339: b4583 ( f/t via Athens)

Specialty training for doctors in England

2009-12-03T14:14:00.018Z

Postgraduate medical training in the UK is changing, if you are considering postgraduate specialty training and seeking information on application to specialty training in England and related topics, the following documentations may help you get started with the process.

Information on the process and timetable for medical specialty training recruitment in 2010 is regularly updated on the Medical Specialty Training (England) website.

You can start by reading this BMJ article “Recruitment to medical specialty training (England) 2010” as a quick guide to the application process.

The followings aim to give F2 doctors an overview of the recruitment and application process :

Getting started

Planning your cv

Completing an application form

Preparing for the interview

Assessment centres

Preparing your portfolio

e-portfolios

Also useful :

Advise to doctors on making the most of an e-portfolio - BMJ article

Improving your chances of getting the dream job – BMJ Careers series Aug 2008

More than an interview to land the job - BMJ article Aug 2005

Writing CVs and handling job interviews - BMJ article Jun 2004

Should healthy people use low-dose aspirin routinely?

2009-11-27T10:06:00.005Z

Low-dose aspirin is widely used as secondary prevention of cardiovascular disease in people who have had heart attacks or stroke. The latest issue of the Drug and Therapeutics Bulletin (DTB) examined whether healthy people who have not had cardiovascular events should use low-dose aspirin as primary prevention.

The DTB study is not a systematic review but looked at current research evidence and expert opinion. It pointed out that although aspirin is not specifically licensed for use as primary prevention in the UK, various guidelines including NICE and SIGN recommend aspirin for primary prevention in certain groups of people such as those with type 2 diabetes and high blood pressure.

However, DTB found that current evidence does not support routine use of low-dose aspirin in these groups due to the potential risk of serious bleeds and its low effect on death rates. It says "it is hard to recommend starting aspirin for primary prevention" and concludes that "... low -dose aspirin prophylaxis should not be routinely used for primary prevention."

Source: "Aspirin for primary prevention of cardiovascular disease?" Drug and Therapeutics Bulletin 2009;47:122-125 (Relevant BNF section: 2.9)

Burnout and medical errors among American surgeons

2009-11-26T15:57:00.005Z

The American College of Surgeons commissioned a self-reporting survey in June 2008 to measure burnout and quality of life among American surgeons. Researchers asked questions including emotional exhaustion, depersonalization and personal accomplishment and others.

Just under 8000 out of the 25,000 surgeons responded to the survey, overall 40% of the respondents said they were burnout, 9% of those responded said having made a major medical mistake in the last 3 months. Researchers found that those who said they had made an error also showed more signs of depression and emotional exhaustion, however it was not clear whether the distress led to more errors or the errors caused more distress. They also found that the number of overnight calls and hours worked were not associated with the errors reported.

The results were published online on November 23 in the Annals of Surgery. The authors said that " although surgeons do not appear more likely to make errors than physicians in other disciplines, errors made by surgeons may have more severe consequences for patients due to the intereventional nature of surgical practice".

Sources: "Burnout and Medical Errors Among American Surgeons"Annals of Surgery (f/t via Athens)

How undergraduates improve compliance with handwashing

2009-11-26T14:56:00.010Z

The MAPS (Measure to Achieve Patient Safety ) program was developed at UCLA Medical Centre to lead the improvement of the patient safety in the hospital as a result of the Institute of Medicine's report on the poor patient safety standards in America - patient identification and handwashing in particular.

Since 2004, 20 undergraduates and 2 student leaders have been selected each year to take part in the MAPS program. They were given training in observing compliance with handwashing guidelines and adherence to rules in patient identification. About 700-800 observations per month were reported to clinicians and departmental leads. Handwashing increased from 50% to 93% and nurses' checking of 2 patient identifiers at medication administration increased from 50% to 95%.

This program was published in Academic Medicine, the author said that MAPS program has been widely accepted by clinical staff and has made significant contribution to the UCLA's safety programs. It is also easily adaptable in other academic centres.

Source: "Observation and measurement of hand hygiene and patient identification improve compliance with patient safety practices". Academic Medicine. December 2009. 84(12):1705-1712. (f/t via Athens)

Paracetamol weakens children's response to vacciantion

2009-10-29T13:36:00.009Z

Paracetamol is sometimes given to infants to reduce their risk of developing fever or a fit caused by fever. In the UK, paracetamol (acetaminophen) is sold over the counter, also present in brands such as Panadol and Calpol. In the US it is more commonly available as Tylenol.

A study published in The Lancet, funded by GlaxoSmithKline Biologicals of Belgium, investigated the effect of giving paracetamol to infants during and immediate after vaccination.

459 healthy infants aged between 9 and 16 weeks were recruited from 10 centres in the Czech Republic and randomised to receive either paracetamol administered every 6 to 8 hrs during the 24 hrs following vaccination or to receive no paracetamol. The parents knew the treatment assigned to their babies.

Researchers found that in both groups, fever above 39.5 degrees C was uncommon, however lower proportion of babies in the paracetamol group had temperature above 38 degrees C. After the primary vaccine doses, more paracetamol doses had to be given to the babies in the control group than the treatment group. They also found that the antibody concentrations following the primary immunisations were significantly lower in the paracetamol group than in the control group and the response varied depending on the vaccination type given.

They concluded that "Although febrile reactions significantly decreased, prophylactic administration of antipyretic drugs at the time of vaccination should not be routinely recommended since antibody responses to several vaccine antigens were reduced."

Critics say this is an important study because there was very few published studies on this issue but further study is needed to demonstrate whether the immunity offered by flu vaccination might be reduced by paracetamol. It may be wise not to give paracetamol routinely to babies as a preventive measure.

Source: "Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials" The Lancet 2009; 374: 1339-1350 (press release or f/t via Athens)

To screen or not to screen for cancer ?

2009-10-27T15:42:00.006Z

For decades, people always believe cancer screening saves lives, but a study published in JAMA last week expressed concerns about the harm caused on patients who undergo breast and prostate cancer screening.

Dr Laura Esserman and colleagues who carried out the study found that screening often finds harmless or non-life-threatening tumors that could have gone unnoticed, this has led to huge increase in cancer diagnosis and unnecessary and aggressive treatment for patients while the most lethal, fast-growing cancers are often missed.

They reported 40% increase in breast cancer diagnosis but only 10% decline in late stage cancers. The rate of breast cancer overdiagnosis is as high as 1 in 3 for non-invasive cancers. Similarly, diagnosis in prostate cancer rocketed with the PSA test introduced in the 1980s, but most men with high PSA level turn out not to have cancer. Patients diagnosed with these cancers are often aggressivley and overtreated with radiation and surgery leading to long term harm.

The authors pointed out that the dilemma for breast and prostate cancer is that it is difficult to distingush dangerous cancers from harmless ones and the idea that some cancers are not dangerous and might go away on their own is not always accepted.

Although routine screening has identified more early stage cancers, it has not led to a corresponding reduction in mortality rate in breast and prostate cancer. The study concluded that "screening has value but we need to undertsand what it can and cannot do......., less screening is not necessarily a bad thing" and urged clinicians to rethink the use of breast and prostate cancer screening.

The American Cancer Society (ACS), as a result of the findings of this study, has acknowledged that the benefits of early screening has been overstated.

Source: "Rethinking screening for breast cancer and prostate cancer" JAMA. 2009;302(15): 1685-1692. (f/t via Athens)

Minimally invasive surgery vs open surgery for prostate cancer

2009-10-27T14:10:00.004Z

Despite limited data on outcome, the use of minimally invasive radical prostatectomy (MIRP) has surged as a result of aggressive marketing of the potential benefits over conventional open surgery even at greater costs.

A study published in JAMA reported mixed results. It was a population-based observational cohort study that identified nearly 2000 men who had MIRP and nearly 7000 had traditional surgery.

The researchers found that use of MIRP increased from 9% in 2003 to 43% in 2006-7. White and Asian living in high income areas are more likely to opt for MIRP. They also found that MIRP was associated with shorter hospital stay and fewer blood transfusion or other postoperative complications. However MIRP was associated with incontinence and erectile dysfunction in the long term.

The authors concluded that their findings reflected "a society and health care system enamored with new technology that increased direct and indirect health care costs but had yet to uniformly realize marketed or potential benefits during early adoption."

Source: "Comparative Effectiveness of Minimally Invasive vs Open Radical Prostatectomy". JAMA 2009;302(14):1557-1564. (f/t via Athens)

Does virus cause CFS?

2009-10-20T11:38:00.008Z

A new study published in Science suggested that the virus XMRV that may play a role in prostate cancer has a strong link with ME, also known as CFS (chronic fatigue syndrome). It was a case control study that looked for the presence of a retrovirus in the white blood cells of people with CFS.

Researchers compared blood samples from 101 patients with CFS with those from 218 people without. They found that the virus was present in the blood of 67% of the CFS patients, compared with 3.7% of the people without CFS. They also found that the virus XMRV could be transmitted to prostate cancer cells in laboratory experiments.

They concluded that XMRV may be a contributing factor in the develoment of CFS and suggested that the virus could be responsible for some of the abnormal immune response in CFS patients. However, larger studies are needed before any conclusions can be drawn.

Critics say this research has identified a link between XMRV virus and CFS but does not prove the virus causes CFS because it is not clear if the infection occured before the disease is developed. Other limitations of the study include small number of patients tested, there is no report on the characteristics of the healthy people whose blood samples were used and contamination of blood samples could not be ruled out completely. However, the findings would be of interests to patients and doctors.

Source:Vincent C. Lombardi 1, Francis W. Ruscetti et al "Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome" Published Online October 8, 2009 Science. DOI: 10.1126/science.1179052 (subscription needed)

who are most vulerable to swine flu?

2009-10-20T09:04:00.002Z

The NEJM published 2 papers last week on hospitalised patients with H1N1 flu. The findings help remind us who are most vulnerable to swine ful.

One group of researchers found that between June and August 2009, 722 patients with H1N1 virus infection were admitted to an ICU during the winter in Australia or New Zealand.

Of the 722 patients, 92.7% were under 65, 9.1% were pregnant women, 28.6% of the adult patients had a body-mass index (BMI) >35, 32.7 % with asthma and chronic pulmonary disease. The highest age-specific incidence of ICU admission was among infants under the age of 1 whereas the highest number of ICU admissions was among patients 25 to 49 years of age.

Source : "Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand". Published at www.nejm.org October 8, 2009 (10.1056/NEJMoa0908481)

Another group of researchers studied 272 patients who were hospitalized with 2009 H1N1 influenza in the US from April 2009 to mid-June 2009.

Of the 272 patients studied, 7% died, the median age of patients who died was 26. 45% of the patients were children under 18, and 5% were 65 or older, 73% of the patients had at least one underlying medical condition, asthma was the most common condition in both children and adults.

Source: "Hospitalized Patients with 2009 H1N1 Influenza in the United States, April–June 2009", Published at www.nejm.org October 8, 2009 (10.1056/NEJMoa0906695),

Dabigatran vs warfarin - RE-LY trial

2009-10-15T10:12:00.004Z

At the European Society of Cardiology (ESC) congress in August 2009, researchers reported that a potential thrombin inhibitor, dabigatran etexilate, was more effective than warfarin in reducing strokes and embolism events in people with atrial fibrillation (AF) – a form of irregular heartbeat. The NEJM also released a simultaneous online report of this new trial.

The authors said that warfarin treatment needs regular monitoring because it can cause bleeding and other complications and argued that there is a need for a new anticoagulant drugs that are safe, effective and convenient to use. Dabigatran is already licensed for use in people having hip and knee replacement surgery.

The study, known as the RE-LY trial, the Randomized Evaluation of Long-term Anticoagulation Therapy, recruited over 18,000 people with AF, average age of 71, from 44 countries and 951 centres, who had at least one other risk factor for stroke. People with severe heart valve disorder, condition that increased the risk of bleeding, liver disease, poor kidney or pregnant women were excluded.

Participants were randomly assigned to receive either 110 mg or 150 mg of dabigatran twice a day or warfarin treatment. Participants receiving dabigatran were blinded to what they were taking but those received warfarin were not. Participants were followed up for an average of 2 years.

The researchers found that those who took dabigatran reduced their risk of stroke and systemic embolism by 34%, also reduced risk of bleeding than warfarin. They concluded that the lower dose of dabigatran was as effective as warfarin for preventing stroke and embolism events, the higher dose was more effective than warfarin for preventing these events and there was no need for regular monitoring .

Critics noted that the higher dose of dabigatran was associated with higher risk of heart attack and had more gastric symptoms when compared to warfarin. More patients discontinued taking dabigatran than those with warfarin after 1 and 2 years of follow up due to serious adverse events. They also cautioned that the design that patients and physicians knew of the treatment allocation can bias the outcomes and that long term outcomes should be explored before the drug is licensed for people with AF.

In an accompanying editorial, the author said that dabigatran had greater risk of nonhemorrhagic side effects, “patients already taking warfarin with excellent INR control have little to gain by switching to dabigatran”, however other patients who have AF and at least one additional risk factor for stroke could benefit from it.

The study was funded by Boehringer Ingelheim, the manufacture of dabigatran. All outcome events were assessed by 2 independent investigators who were blinded to the treatment assigned to the participants.

Source: Connolly SJ, Ezekowitz MD, Yusuf S et al. "Dabigatran versus Warfarin in Patients with Atrial Fibrillation". NEJM 2009; 361(12):1139-1151

Online editorial - Gage B. "Can We Rely on RE-LY?". NEJM August 30, 2009

telomeres and the 2009 Nobel Prize

2009-10-09T14:40:00.005Z

3 American scientists, Elizabeth H. Blackburn, Carol W. Greider and Jack W Szostak, won the 2009 Nobel Prize in Medicine for their research into telomeres and telomerase that led to new insights into aging, cancers and some inherited disease and could lead to new treatments for the diseases.

Their work solved one of the mysteries of how cells duplicate without losing pieces of the chromosomes. Chromosomes are strands of DNA that carry genes. Blackburn found that at the end of each of the chromosomes was the repeating DNA sequence – CCCCAA. Szostak had developed mini-chromosomes and found that each time the cells divided, the mini-chromosomes degraded and eventually vanished completely.

Blackburn and Szostak collaborated in 1980 and made mini-chromosomes with the CCCCAA sequences at either end. They found that when these were injected into yeast, the DNA sequence protected the chromosomes when they were copied. They called the caps “telomeres”. In 1984, Greider, Blackburn’s student, discovered the enzyme, “telomerase”, that makes telomeres.

Further studies discovered that healthy telomeres delayed the aging process in cells, prompting research into anti-aging treatments. Related studies found that defective telomeres had affected the division of bone marrow stem cells and overactive telomerase was associated with the development of cancer.

However, a member of the Prize Committee said that large questions remain to be answered about the working of telomeres and telomerase. Merck, a drug company, is currently running a trial of a cancer vaccine designed to train the body to attack tumor cells that produce telomerase.

Hypertension paradox

2009-10-09T14:34:00.003Z

What is the paradox?

Dr Aram Chobanian, a world-renowned cardiologist and the Dean of the Boston University Medical School, wrote in the NEJM special article that despite the remarkable successes in lowering blood pressure in patients with hypertension, the prevalence of hypertension continues to increase worldwide. The number of people with uncontrolled blood pressure is also increasing.

He reviewed the development of the anti-hypertensive drug therapy and other evolving approaches such as lifestyle modifications. He recommended a new treatment algorithm for the management of stage 1 and 2 hypertension.

He noted that recent data indicated that about 28% of Americans with hypertension are unaware of their condition, 39% are not receiving treatment and 65% do not have their BP controlled. The controlled rates are even worse in patients with chronic kidney disease, diabetes, and other cardiovascular dysfunction in whom target BP levels of 130/80 mm Hg are recommended.

With the prevalence of hypertension continues to increase worldwide, he asked “what can be done to reverse this trend”. He pointed out that “salt intake and body weight are particularly important in the age-related increase in BP” but some countries such as Finland and GB have achieved significant reductions in dietary sodium through aggressive efforts including education and working with the food industry.

He said that “the failure to adopt healthy lifestyles has been a critical factor in this increase” and must be addressed urgently. He urged a national strategy to promote physical activities combined with changes in dietary intake.

This article was presented as the Shattuck lecture of the Massachusetts Medical Society and available as open access at the NEJM website.

Source: “The Hypertension Paradox — More Uncontrolled Disease despite Improved Therapy” NEJM 2009, 361(9):878-887