Serotonin deficit may cause SIDS

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

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

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

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

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

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

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

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?

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

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

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

"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

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

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

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

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

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

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

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

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