Medical News

Social care reforms announced

Medical News - Tue, 01/19/2038 - 06:14

Most of the UK media is covering the announcement made in Parliament by Jeremy Hunt, Secretary of State for Health, about proposed changes to social care.

The two confirmed points to have garnered the most media attention in the run-up to the announcement are:

  • a ‘cost cap’ of £75,000 worth of care costs – after this point the state would step in to meet these care costs
  • raising the current means-testing threshold for people to be eligible for state-funded social care from £23,520 to £123,000

The government expects these changes will lead to fewer people having to sell their homes in order to pay for their long-term care needs.

Speaking in Parliament, Mr Hunt said that the current system was ‘desperately unfair’ as many older people face ‘limitless, often ruinous’ costs. The minister stated that he wants the country to be ‘one of the best places in the world to grow old’.

 

What is social care?

The term social care covers a range of services provided to help vulnerable people improve their quality of life and assist them with their day-to-day living.

People often requiring social care include:

  • people with chronic (long-term) diseases
  • people with disability
  • the elderly – particularly those with age-related conditions, such as dementia

Social care services can include:

  • healthcare
  • equipment
  • help in your home or in a care home
  • community support and activities
  • day centres

 

How does the current adult social care system work?

Currently, state funding for social care is based on two criteria:

  • means – people with assets of more than £23,520 do not qualify for funding
  • needs – most local authorities will only fund care for people assessed to have substantial or critical needs

The majority of people currently requiring social care pay for it privately. These are known as ‘self-funders’.

 

What prompted these reforms to adult social care?

Put simply, on average, the UK population is getting older.

When the welfare state was created in the early 20th century, it was not expected that people would someday routinely live into their 70s, 80s, and even 90s.

The increase in life expectancy is a good thing, however, it brings a new set of challenges.

While people are living longer, they are also spending more of their lives in ill health. Older people are more likely to have potentially complex care needs that can be expensive to manage.

Many people are currently ineligible for state-funded social care under the existing laws. To meet the costs of these care needs, these ‘self-funders’ have, in many cases, had to sell or remortgage their home, or sell other assets to pay for the costs of their care.

Without reforms, experts agree that the cost of social care for both the state (through taxes) and to ‘self-funders’ is likely to become increasingly problematic.

To try and find the best way to resolve some of the difficulties of fairly funding adult social care, the Department of Health set up a commission. This independent commission reported its findings to ministers in July 2011. The government considered these findings in its white paper on care and support published in July 2012, and in the drafting of the proposed new legislation.

 

What happens next?

The government has introduced a Social Care Bill which will need to be passed by the Houses of Parliament.

If the bill is successfully passed it is expected the amendments will come into force by 2017.

 

Edited by NHS Choices. Follow Behind the Headlines on twitter.

Links To The Headlines

Social care: Jeremy Hunt hails 'fully-funded solution'. BBC News, February 11 2013

Social care reforms: Almost 2 million pensioners will be denied state help. The Daily Telegraph, February 11 2013

Social care reform: how your family may be affected. The Daily Telegraph, February 11 2013

Dilnot 'regrets' decision to set social care cap at £75,000. The Guardian, February 11 2013

Hunt statement on adult social care cap: Politics live blog. The Guardian, February 11 2013

Categories: Medical News

Air dryers 'blown away' by paper towels in germ tests

Medical News - Fri, 11/21/2014 - 14:50

"Hand dryers 'splatter' users with bacteria," The Daily Telegraph reports.

The headline is prompted by an experimental study that compared the potential transfer of germs to the surrounding environment, users and bystanders when using three methods of hand drying:

  • paper towels
  • warm air dryers – the sort you see in most public toilets
  • modern "high-tech" jet air dryers, such as the Dyson Airblade model

Testers wore gloves coated in a solution of bacteria. Air samples taken after drying with the hand dryers showed significantly higher bacterial counts than when drying with paper towels, and were highest for the jet air dryers.

They then assessed the potential for spread to users and bystanders, this time using the proxy of gloves coated in black paint and a white body suit.

They found there was no contamination of the body after towel drying, but paint spots were on the body after the use of air dryers, which again was higher with jet dryers than standard warm air dryers.

One important limitation of this study is it essentially replicates the scenario of someone going to the toilet and then proceeding straight to the hand dryer without washing their hands first.

A more suitable test may have been to coat the gloves with the marker, wash them with soap and water as recommended, and then proceed to the hand dryers.

But the overall message of this study is consistent with current hand washing recommendations, including the use of disposable paper towels in healthcare settings.

 

Where did the story come from?

The study was carried out by researchers from the University of Leeds and the microbiology department at Leeds General Infirmary.

It was funded by the European Tissue Symposium (ETS), from whom one author reports having received honoraria.

The ETS produces paper tissue, including toilet paper, household towels and paper napkins, which may be seen as a potential conflict of interest.

The study was published in the peer-reviewed Journal of Hospital Infection.

The Daily Telegraph and the Mail Online's reporting was accurate, but neither appeared to have considered some of the limitations of this research.

 

What kind of research was this?

This was an experimental study that aimed to compare the tendency for three common hand drying methods – jet air, warm air hand dryers, and paper towels – to spread germs and contaminate the environment, users and bystanders.

Like thorough hand washing, thorough hand drying is just as important to prevent the transfer of germs from person to person or the surrounding environment.

According to hand washing protocols, the optimal way to dry hands is to use a disposable paper towel, which is then used to turn off the tap to avoid re-contaminating hands.

The main concern with using hand dryers is that people may not dry their hands as completely as they would with paper towels, and may go away while they are still damp. If hand dryers are used, it is advised that the hands are rubbed together under the dryer until they are totally dry.

However, another unclear and often speculated issue when using hand dryers is the possible transfer of aerosolised germs to the surrounding environment and people, possibly increasing the spread of infection.

This study aimed to compare the different hand drying methods, looking at whether they can contaminate the surrounding environment, users and bystanders.

 

What did the research involve?

The researchers carried out a series of hand drying tests in a single room with standard ventilation (not air conditioned). They first tested the possible contamination of the environment, and then people.

Gloved hands were immersed in a solution of lactobacilli bacteria (cultured from Actimel Danone yoghurt) before being dried with either:

  • a warm air dryer – hands were rubbed together for 30 to 40 seconds until dry
  • a jet air dryer – hands were placed into the unit and slowly drawn up and down for 15 seconds until dry
  • paper towels – four paper towels were taken from the dispenser and were rubbed over hands for 15 seconds until dry

The tests were conducted over six weeks. A total of 120 air samples were taken – 60 made after drying contaminated hands (20 collections after each drying method: 10 in close proximity, 10 one metre away) and 60 control air samples taken before hand drying. Air samplers were left running for 15 minutes after each drying process. 

They then repeated the tests, this time looking at the possible contamination of people standing nearby. This time, gloved hands were coated in black water-based paint rather than bacteria, and the user wore a disposable white hooded suit.

Another bystander in a similar suit stood diagonally adjacent to the dryer user one metre away to replicate the scenario of another user waiting to dry their hands. There was a total of 30 drying tests in this manner, 10 for each drying method.

 

What were the basic results?

The researchers found the lactobacillus count in air samples taken in close proximity to the dryers were 4.5-fold higher for the jet dryer (70.7 colony forming units, or cfu) compared with the warm air dryer (15.7cfu), and 27-fold higher compared with paper towels (2.6cfu).

Counts for the warm air dryer were also significantly higher than with paper towels.

A similar pattern was seen for the air collection one metre away, where counts were 89.5cfu with the jet dryer, 18.7cfu with the warm air dryer, and 2.2cfu with paper towels.

"Settle plates" underneath each hand dryer had the highest bacterial count for the warm air dryer (190cfu) compared with the jet air dryer (68.3cfu) and the paper towel drying (11.9cfu). Respective figures at plates one metre away were 7.8cfu, 2cfu and 0.7cfu. 

As would be expected, the control air samples taken before drying found no lactobacilli.

On the person-contamination experiments, no paint spots were seen on paper towel users. For both the jet air and warm air dryers, spots predominated in the upper body area, with the number of spots significantly higher with jet dryers (144.1) compared with warm air dryers (65.8).

The number of paint spots was higher for all body areas with jet dryers, with the exception of both arms. With both hand dryers, however, there were relatively few paint spots remaining on the hands.

The number of paint spots detectable on the bystander was generally low for both air dryers and was not significantly different between the two (average count 1.6 spots for jet dryers and 1.5 for warm air dryers).

 

How did the researchers interpret the results?

The researchers concluded that, "Jet air and warm air dryers result in increased bacterial aerosolisation when drying hands.

"These results suggest that air dryers may be unsuitable for use in healthcare settings, as they may facilitate microbial cross-contamination via airborne [spread] to the environment or bathroom visitors."

 

Conclusion

Overall, this experimental study found the airborne spread of lactobacilli bacteria from contaminated hands was significantly higher with air dryers than with paper towels. Of the two, jet dryers caused higher air bacterial counts than standard warm air dryers.

Similarly, when assessing spread on to the body of the user and bystander using the proxy measure of black paint dispersal, there was no contamination of the body with paper towels, but paint spots were on the body after use of air dryers, again higher with jet dryers than standard warm air dryers.

It is well known that thorough hand drying is as key to preventing spreading infection as thorough hand washing. One of the recognised problems with hand dryers is that people may not dry their hands as completely as they would with paper towels.

What is less clear, and is often speculated about, is the possible transfer of aerosolised germs to the surrounding environment and people, possibly increasing the spread of infection.

This study appears to demonstrate cause for this concern. However, there are some points worth consideration when interpreting this study:

  • One important limitation of the study is it may not replicate the real-life condition of someone having just thoroughly washed their hands with soap and water, and then drying their hands. In this experimental situation, the users had gloved hands contaminated with either lactobacilli or black paint and then dried their hands. In effect, this may be seen more to replicate the scenario of someone going to the toilet and then proceeding straight to the hand dryer without washing their hands first. A more suitable test may have been to coat the gloves with either bacteria or black paint, wash them with soap and water as recommended, and then proceed to the hand dryers to see how many bacteria or paint were spread.
  • The spread of heavier black paint may also not be equivalent to the spread of viruses and bacteria, though it may represent the spread of water.  
  • Aside from the assessment of the surrounding environment and bystanders, another important area of consideration would also be to compare how much bacteria remained on the surface of the users' hands after drying with each of the three methods. This is of equal importance in knowing how much bacteria remains on the users' hands that could be transferred to other surfaces. It would be valuable to know whether there was any difference. This study has not specifically examined this aspect, though in fact it did note few paint spots remained on the hands after drying with either of the hand dryers.
  • It also would have been valuable to consider comparing the amount of bacteria or paint left on the towel dispenser or hand dryers after use, and how much of this would usually be transferred to the next person's hands during hand drying.

Despite these limitations, the overall message of this study is consistent with current handwashing recommendations, particularly when it comes to healthcare settings.

Of course, disposable paper towels are not available in all facilities. If only hand dryers are available, hands need to be rubbed together until they are completely dry.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Hand dryers 'splatter' users with bacteria, scientists warn. The Daily Telegraph, November 20 2014

Modern hand dryers are 'much worse' at spreading germs around a room than paper towels, study claims. Mail Online, November 20 2014

Links To Science

Best E, Parnell P, Wilcox MH. Microbiological comparison of hand-drying methods: the potential for contamination of the environment, user, and bystander. The Journal of Hospital Infection. Published online August 26 2014

Categories: Medical News

Breastfeeding voucher scheme 'shows promise'

Medical News - Fri, 11/21/2014 - 14:50

"Initial results of a controversial scheme offering shopping vouchers to persuade mothers to breastfeed have shown promise," BBC News reports.

The scheme, which has attracted controversy since it was announced, aimed to tackle the problem of low rates of breastfeeding in the UK compared with other developed nations. Mothers who live in the poorest areas of the country have been found to be more likely to prefer bottle feeding.

This pilot scheme has tested whether it is possible to try to boost breastfeeding rates by offering new mothers shopping vouchers if they breastfeed their baby until specific ages.

The scheme was available to just over 100 women who gave birth to babies over a six-week period and lived in three areas of Derbyshire and south Yorkshire. The breastfeeding rate in these areas at six to eight weeks was 21-29%.

In the period where vouchers were available, 34.3% of women were breastfeeding at six to eight weeks. Both mothers and healthcare staff reported high levels of satisfaction with the scheme.

The researchers report they are now planning further studies in the form of a randomised controlled trial to see how effective the voucher scheme is at boosting breastfeeding rates.

 

Where did the story come from?

The study was carried out by researchers from the University of Sheffield and was funded by the Medical Research Council National Prevention Research Initiative.

The meeting abstract was published in the peer-reviewed medical journal, The Lancet.

It has been published prior to being presented at The Lancet's annual conference on Public Health Science, held jointly with the London School of Hygiene and Tropical Medicine, University College London, the UK Health Forum, and in partnership with the European Public Health Association.

The media reporting of the study was good, providing background information about the scheme and why some people are opposed to it – most critics have questioned why a scheme should reward mothers for doing the best for their child while penalising mothers who are unable to breastfeed.

It is a fair point, though a pragmatic answer would be that it's not about the mother, but the child. Also, increased breastfeeding rates may lead to a reduction in the number of childhood illnesses the NHS has to deal with, so a voucher scheme could actually save the NHS money in the long term.

But we will need to wait for the results of the planned randomised controlled trial before more detailed effectiveness and cost benefit information becomes available.

 

What kind of research was this?

This was a feasibility study to see whether it was both acceptable and possible to give women financial incentives to increase breastfeeding rates, prior to performing a randomised controlled trial to see if these financial incentives were effective. 

The results of this study have been published in the form of a meeting abstract. This means the method and results are only described briefly, and a full appraisal of the strengths and limitations of the study can't be performed. This study is actually still ongoing and the results from some time points are still being collected.

 

What did the research involve?

The researchers wanted to test whether it was acceptable and possible to give women financial incentives for breastfeeding, as young women in deprived areas are less likely to breastfeed.

They offered vouchers for breastfeeding to women with babies born within a 16-week period who lived in three neighbourhoods in Derbyshire and south Yorkshire, where breastfeeding rates were less than 30%.

The vouchers were available when their babies were five different ages:

  • two days
  • 10 days
  • six weeks
  • three months
  • six months

The vouchers were for supermarkets and high street shops for a value of £40 at each time point, so each woman could receive a maximum of £200.

To receive the vouchers, the woman and her healthcare professional had to sign statements saying she had been breastfeeding.

The researchers then interviewed 36 healthcare providers and 18 women to get their views on the scheme.

 

What were the basic results?

Fifty-eight of the 108 women (53.7%) who could have joined the scheme chose to do so.

  • 48 women (44.4%) claimed vouchers when their babies were two days old
  • 45 women (41.7%) claimed vouchers when their babies were 10 days old
  • 37 women (34.3%) claimed vouchers when their babies were six to eight weeks old

The researchers are still collecting data for the three and six-month time points.

Mothers and healthcare staff who participated reported high levels of satisfaction with the scheme.

 

How did the researchers interpret the results?

The researchers say that, "The scheme was both deliverable and acceptable to mothers and healthcare staff in this field of study.

"The scheme was extended (and will continue until at least December 2014) in all three areas. A randomised controlled trial testing the effectiveness of the scheme is now planned."

 

Conclusion

This study tested whether it is possible and acceptable to try to boost breastfeeding rates by offering new mothers vouchers if they breastfeed their baby until specific ages.

The scheme was available to just over 100 women who gave birth over a six-week period, and who lived in three areas of Derbyshire and South Yorkshire. In these areas, the breastfeeding rate at six to eight weeks was 21-29%.

In the period where vouchers were available, 34.3% of women were breastfeeding at six to eight weeks. Both mothers and healthcare staff reported high levels of satisfaction with the scheme.

The researchers report they are now planning a randomised controlled trial to see how effective the voucher scheme is at boosting breastfeeding rates.

The results of this study have been published in the form of a meeting abstract. This means the methods and results are only described briefly, and a full appraisal of the strengths and limitations of the study can't be performed.

Similarly, there is no information provided about the women who took part in the study, such as their age, medical history, family circumstances and support network.

In addition, this study is actually still ongoing and the results from some time points are still being collected.

Hopefully, the publication of the upcoming randomised controlled trial, which could be in either 2015 or 2016, will help assess how effective the scheme is and whether it is likely to be cost effective.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Early results in breastfeeding vouchers trial. BBC News, November 20 2014

Scheme offering shopping vouchers to mothers who breastfeed to be extended. The Guardian, November 20 2014

NHS to 'bribe' thousands of mothers to breastfeed. The Daily Telegraph, November 20 2014

Links To Science

Relton C, Whelan B, Strong M, et al. Are financial incentives for breastfeeding feasible in the UK? A mixed methods field study. The Lancet. Published online November 19 2014

Categories: Medical News

Cancer guidelines may improve diagnosis rates

Medical News - Thu, 11/20/2014 - 16:00

“Doctors to get more help to spot cancer early,” The Guardian reports. The National Institute for Health and Care Excellence (NICE) has produced new revised draft guidelines that may help GPs pick up on possible early warning signs of cancer. 

The aim of the draft guidelines is to improve early cancer diagnosis in children, young people and adults of all ages. The draft guidelines have been primarily written for GPs and are an update of the 2005 guidelines that were last partially updated in 2011.

 

What are the possible early warning signs of cancer?

It is misguided to think of cancer as a single disease. Cancer is an umbrella term for a wide range of different conditions, in the same way as the term “infection”.

With that in mind, specific cancers can present with a wide range of symptoms, most of which are similar to trivial conditions, such as indigestion or a sprained joint.

What you need to watch out for are symptoms that are:

  • persistent – last for more than two weeks
  • unexplained – there seems to be no logical reason why a symptom(s) develops

Specific red flags you need to watch out for include:

  • cough that lasts longer than three weeks
  • unexplained and persistent changes in bowel habits, such as chronic diarrhoea or constipation
  • unusual bleeding, such as noticing blood in your stools or urine
  • you notice an unusual, irregular and possible itchy mole on your skin
  • unexplained weight loss

Read more about possible early warning signs and symptoms of cancer

 

What has prompted the recommendations?

All NICE guidelines are updated every few years to ensure the recommendations have taken into account the latest evidence and any improvements in diagnostic techniques and treatments.

Additional reasons for these particular guidelines to have been updated are that, as the media has pointed out, the UK is just missing its target of treating 85% of people with suspected cancer within 62 days (current reported figures are 82.5%). NICE reports that signs and symptoms of cancer can often be non-specific and overlap with other less serious conditions. They also say that each GP only sees, on average, eight new cases of cancer each year out of 6,000 to 8,000 appointments. As the appointments only last 10 minutes each, NICE wanted to provide practical guidelines for GPs to use to help them spot when to initiate further tests.

 

What are the new recommendations and how do they differ from existing ones?

The draft guidelines give clearer and updated information on the recognition of early signs and symptoms of over 200 different types of cancer and the criteria that warrant further investigations or referral to specialists. The threshold for whether a sign or symptom could indicate cancer has been lowered compared to the previous guidance.

The main difference from before is that the information in the guidelines has been presented in a new format to make it easier to find the relevant recommendations. The information is laid out in tables according to particular symptoms, such as fatigue, cough or rectal bleeding, and tables according to the site of possible cancer, listing the typical signs and symptoms to look for. In each case, the next steps, such as investigations and referral thresholds, have been provided.

The timing of referrals has been updated to include situations that warrant “very urgent” referrals, where a person should be seen within 48 hours. This is in addition to the previously described referral timings, such as “urgent” referrals, where a person needs to be seen within two weeks, and immediate referrals.

Finally, there is a new section that covers patient information, support and safety netting.

 

How accurate is the reporting?

The Daily Telegraph’s rather alarmist headline that “tired patients should be fast-tracked for cancer tests” is not related to any new guidance. Persistent or unexplained fatigue has long been a recognised symptom of a number of cancers, including leukaemia in children and adults, lung cancer and ovarian cancer, and this recommendation was present in the original 2005 guidelines.

In general, the media focussed on reporting the number of people who have not met the government target of treating 85% of people with suspected cancer within 62 days. NICE reports that research has estimated that late diagnosis contributes to between 5,000 and 10,000 deaths within five years of diagnosis per year.

Somewhat tellingly, all of the UK media ignore the issue of overdiagnosis, which is where people undergo tests or diagnostic procedures that they don’t actually need. The natural assumption is probably to think “better safe than sorry”, but many diagnostic procedures themselves carry small risks of complications. For example, current evidence suggests that a colonoscopy (used to diagnosis bowel cancer) carries a one in 150 chance of causing excessive bleeding, a one in 1,500 chance of creating a hole in the wall of the bowel and a one in a 10,000 chance of causing death.

Therefore, it’s important to be sure that the potential risk of a suspected disease is high enough to justify the risks associated with diagnosis.

 

What happens next?

The draft guidance is out for public consultation until Friday 9 January 2015. This means that any relevant patient groups, organisations, Clinical Commissioning Groups (CCGs) and other GP-led bodies can register and then comment on the:

  • new recommendations 
  • old recommendations that have been reviewed but remain unchanged
  • recommendations that are due to be removed

These comments can then be taken into account before the final version of the guidelines are published, which is anticipated to be May 2015.

The NICE draft guidelines are free to access online. After the consultation period, when the full guideline is published, it should guide patient care.

Though it will give recommendations for which signs and symptoms should warrant further investigation or referral, NICE clearly states that “the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer”.

Analysis by
Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Doctors to get more help to spot cancer early. The Guardian, November 20 2014

GPs urged to double cancer referrals in NHS guidelines. BBC News, November 20 2014

GPs told tired patients should be fast-tracked for cancer tests. The Daily Telegraph, November 20 2014

Doctors to get fresh guidelines to help spot cancer early. ITV News, November 20 2014

GPs To Get Better Cancer Diagnosis Guidelines. Sky News, November 20 2014

GPs can't be expected to know every cancer symptom, Government says. The Independent, November 20 2014

Doctors urged to test patients with coughs for cancer: GPs given guidance over fears they are dismissing early warning signs. Daily Mail, November 20 2014

Categories: Medical News

Is growth in ADHD 'caused by marketing'?

Medical News - Thu, 11/20/2014 - 14:10

"The global surge in ADHD [attention deficit hyperactivity disorder] diagnosis has more to do with marketing than medicine, according to experts," the Mail Online reports.

But these experts are sociologists, not clinicians, and they present no new peer-reviewed clinical evidence.

That said, they do highlight some interesting interconnected trends about ADHD that are worth attention.

The principal concern of the authors is that ADHD is being medicalised – that is, for a variety of reasons, children who may be simply "naughty" and high spirited are being misdiagnosed with ADHD, and are wrongly being treated with powerful medications such as methylphenidate, better known as Ritalin.  

This study concludes that the "global expansion" of ADHD and its subsequent medicalisation has been driven by five major causes:

  • drug industry lobbying
  • the influence of US-based psychiatry
  • the adoption of looser criteria for diagnosis
  • the influence of ADHD patient advocacy groups
  • the growth of information on the internet

This is a well-researched and interesting article which reflects current concerns about the medicalisation of symptoms that might be viewed as part of the human condition, rather than a disorder that needs drug treatment.

However, this is an opinion piece and is not the last word on this controversial subject.

If you are worried about a child or other relative's behaviour, it is important to see a health professional such as a GP.

Many children go through phases where they are restless or inattentive. This is often completely normal and does not necessarily mean they have ADHD.

 

Where did the story come from?

The study was carried out by researchers from Brandeis University in the US. There is no information about external funding.

It was published in the peer-reviewed journal Social Science and Medicine.

The Mail Online's coverage was reasonably accurate, but it used the old journalistic cliché "experts say", implying there is a single expert opinion on a subject.

This is very rarely the case, especially when you are dealing with a subject as controversial as ADHD.

 

What kind of research was this?

This was a narrative review that looked at the evidence for an increase in ADHD across the globe. The authors say how in the US, ADHD has been medicalised for 50 years, but this approach is now being applied internationally.

They document the growth of ADHD diagnosis and treatment in the UK, Germany, France, Italy and Brazil, and look at the possible causes of this expansion.

This article was a narrative review, which means it is subject to selection bias, and is not a systematic review, which looks at all of the available evidence on a topic and uses this information to draw conclusions.

This potential selection bias means the authors may have selected articles to fit their theory.

ADHD is defined as a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.

There is a school of thought that the diagnosis of ADHD can be prone to medicalisation, where normal human behaviour is defined and treated as illness. 

But others argue this condition is being picked up more frequently as a result of better education and recognition of symptoms.

 

What does the study say?

The study looked at evidence for the "globalisation" of ADHD and the increase in the use of ADHD medication, such as methylphenidate (Ritalin).

In particular, it examined the prevalence and treatment of ADHD in five countries – the UK, Germany, France, Italy and Brazil.

In the UK, the authors state ADHD is now the most prevalent behavioural disorder, with an estimated 3-9% of children and adolescents having the condition.

Drug treatment for ADHD has also been on the rise here, with one recent report suggesting methylphenidate (Ritalin) prescriptions rose by 11% in GP practices, and by 24% in private practice from 2011-12. 

The authors partly ascribe this increase to changes in diagnostic criteria used in the UK. In the past, the UK adopted criteria from the World Health Organization (WHO) for a condition then called hyperkinetic disorder.

But there is now a greater use of US criteria globally, which uses different terminology and provides a lower threshold for diagnosis.

The article goes on to look at what it says are the major trends behind this rise in diagnosis and treatment in some countries.

Influence of drug companies

In the past, drugs for ADHD were heavily marketed in the US, but as this market has become saturated, the industry has expanded into international markets and promoted ADHD drug treatment around the world – first in western Europe, but also in other countries such as Brazil, Mexico and Japan.

Influence of US psychiatry

There has especially been a move towards "biological" psychiatry, where mental and behavioural disorders are treated with drugs rather than psychotherapy. More psychiatrists across the globe are now trained in the US and import US practices into their countries of origin.

Recent growth in the adoption of different criteria for ADHD

The authors say until the 1990s, many countries used the International Classification of Mental and Behavioral Disorders (ICD), published by WHO, which has strict criteria for ADHD. But since then, other countries have adopted the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, which has a lower threshold for diagnosis of ADHD.

Wide availability of information on the internet

The authors say there is "endless information on various sites about ADHD from numerous sources, including pharmaceutical websites". In particular, they point out the availability of ADHD checklists based on US screening devices. These allow internet users to "measure" certain behaviours that could lead to a possible ADHD diagnosis, prompting more consumers to ask for drug treatment.

Influence of ADHD advocacy groups

These groups often work closely with drug companies and promote drug treatments. The authors point out how in some countries, such as France and Italy, ADHD rates are lower. This is thought to be a result of a cultural tradition of using psychoanalytic rather than drug-based approaches for behavioural problems, and restrictions on the use of ADHD medication.

 

How did the researchers interpret the results?

The authors predict the medicalisation of ADHD will expand further to cover more countries.

This could also happen to other conditions, and divert attention away from "important social and structural approaches" to global health, they argue.

 

Conclusion

This is an interesting paper that shows there has been an increase in ADHD diagnosis and treatment in several countries, including the UK, and examines the reasons why this may have occurred. The possible "medicalisation" of ADHD has been an issue of concern and debate for some time.

As the authors note, the paper has some limitations. They selected countries where there is available published literature on ADHD, so their conclusions may not be generalisable to other countries.

Further research is needed to explore the approaches to ADHD in parts of the world that have received less attention, such as Asia, eastern Europe, the Middle East and Africa.

The authors used research on ADHD to support their opinion about the medicalisation and globalisation of this disorder. Others might disagree, arguing that more awareness has led to an increase in diagnosis, and drug treatment can be helpful in many cases.

If you are worried about a child's or other relative's behaviour, it's important to see a GP or other healthcare professional. Many children go through phases where they are restless or inattentive. This is often completely normal and does not necessarily mean they have ADHD. 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Rise in ADHD cases is 'due to marketing, not medicine': Study blames increase on drug companies, pushy support groups, and people self-diagnosing online. Mail Online, November 19 2014

Links To Science

Conrad P, Bergey MR. The impending globalization of ADHD: Notes on the expansion and growth of a medicalized disorder. Social Science and Medicine. Published online October 8 2014

Categories: Medical News

Have antibiotic changes upped heart infections?

Medical News - Wed, 11/19/2014 - 14:50

"Rates of a deadly heart infection have increased after guidelines advised against giving antibiotics to prevent it in patients at risk," BBC News reports. But there is no evidence of a direct link between the two.

In 2008, the National Institute for Health and Care Excellence (NICE) produced guidelines regarding the use of antibiotics to prevent infective endocarditis – a potentially fatal infection of the lining of the heart that comes after bloodstream infection.

Prior to this guidance, common practice was to give antibiotics as a preventative measure to patients undergoing invasive procedures who were at increased risk of infective endocarditis (for example, patients with certain heart conditions).

In the 2008 guidance, NICE recommended that people undergoing dental or invasive surgical procedures were no longer given antibiotics as prevention for endocarditis, as the overall risks outweighed the benefits.

The current study examined trends before and after the guidance to see what effect the advice may have had on both antibiotic prescribing and rates of endocarditis.

This study demonstrates that the number of antibiotic prescriptions prior to invasive dental work or surgery significantly decreased after 2008. The rates of infective endocarditis have significantly increased since 2008, with an estimated 35 additional cases per month.

This is a valuable study, although this analysis of trends does not prove causation – that is, that reduced antibiotic prescribing in light of the NICE recommendations has directly caused the increase in cases. 

NICE has announced a review of their guidelines, although current recommendations remain unchanged until the review takes place.

 

Where did the story come from?

The study was carried out by researchers from Taunton and Somerset NHS Trust, the University of Surrey, the University of Sheffield School of Clinical Dentistry, John Radcliffe Hospital in the UK, and the Mayo Clinic and Carolinas Medical Center in the US.

Funding was provided by Heart Research UK, Simplyhealth and the US National Institutes of Health.

It was published in the peer-reviewed medical journal The Lancet.

BBC News provides a good account of this study.

 

What kind of research was this?

This study aimed to examine the trends before and after the publication of NICE's 2008 guidance on the prevention of infective endocarditis in people undergoing invasive procedures.

The researchers aimed to look at:

  • changes in the prescription of antibiotics for the prevention of infective endocarditis
  • changes in the number of cases of infective endocarditis diagnosed

Infective endocarditis means infection and inflammation of the inner lining of the heart chambers (endocardium).

People with existing conditions affecting their heart valves or the structure of their heart are most at risk, as they are more at risk of having existing blood clots (thrombus) present in the heart, in which an infection can start.

The infection is caused by bacteria that have circulated in the bloodstream and reached the heart, so any invasive surgical or dental procedures could potentially carry a risk.

The most common bacterial cause of infective endocarditis is Streptococcus viridans – bacteria that are naturally present in the mouth and throat.

Invasive dental work can therefore potentially lead to these bacteria entering the bloodstream.

Symptoms of infective endocarditis are variable, but commonly include fever and general symptoms of being unwell, such as flu-like symptoms, aches and pains, loss of appetite and weight loss.

A person may also present symptoms after a blood clot has travelled from the heart and lodged in another part of the vascular system (for example, with a stroke).

People also usually have new heart murmurs. The condition carries a fairly high mortality risk, and treatment usually involves intravenous antibiotics, and sometimes surgery.

Prior to 2008, a single dose of amoxicillin (or clindamycin for patients allergic to penicillin) was recommended before invasive dental work for people who were at moderate to high risk of developing infective endocarditis.

In March 2008, NICE concluded that antibiotic prophylaxis (prevention) for infective endocarditis for people undergoing invasive surgical or dental procedures was no longer routinely recommended.

This was generally because the benefits of prophylaxis were outweighed by risks associated with antibiotics – both to the individual and in terms of population health in general in contributing to antibiotic resistance.

Equivalent guidance produced in the US and Europe is said to have also reduced the number of people for whom antibiotic prophylaxis is recommended.

But the US and Europe have not recommended antibiotic use is stopped altogether, as we have in this country.

The researchers aimed to see what effect the NICE recommendations have had on the number of infective endocarditis cases.

 

What did the research involve?

The researchers aimed to look at the change in prescriptions for antibiotic prophylaxis from January 2004 to March 2013, and to look at hospitalisation for a main diagnosis of infective endocarditis from January 2000 to March 2013 in England.

The prescriptions data came from the NHS Business Services Authority, from where they also got data on the number of individuals accessing dental care services.

Data for incidence of infective endocarditis and its associated mortality came from national hospital episode statistics (HES) and used standard diagnostic codes to identify infective endocarditis.

The researchers carried out statistical analyses looking at changes in incidence of infective endocarditis before and after the introduction of the guidelines in 2008, accounting for changes in population size.

For each case they identified, they also looked back to see if this person had been "high risk" in terms of having a susceptible heart condition or a previous episode of infective endocarditis.

 

What were the basic results?

Before 2008, the prescribing of antibiotics for the prevention of infective endocarditis was fairly constant.

After the introduction of the NICE guidance, it fell significantly from an average of 10,900 prescriptions per month from January 2004 to March 2008, to only 2,236 prescriptions per month from April 2008 to March 2013. Most prescriptions were for amoxicillin, and 90% were issued by dentists.

There were 19,804 cases of infective endocarditis between 2000 and 2013. Prior to 2008, there had been a steady upward trend in the number of cases, but from March 2008 onwards there was a steep increase in the number of cases above the projected historical trend. This amounted to an additional 0.11 cases per 10 million people each month.

By March 2013, there were an estimated 35 more cases per month than would have been expected had the previous trend continued. This increase in the incidence of infective endocarditis was significant for both individuals at high risk of infective endocarditis and those not considered to be at risk.

The researchers calculated 277 antibiotic prescriptions would need to be issued to prevent one case of infective endocarditis (number needed to treat, or NNT).

 

How did the researchers interpret the results?

The researchers say: "Although our data do not establish a causal association, prescriptions of antibiotic prophylaxis have fallen substantially and the incidence of infective endocarditis has increased significantly in England since the introduction of the 2008 NICE guidelines."

 

Conclusion

This is valuable and timely research, which has looked at trends before and after NICE's 2008 guidance on the prevention of infective endocarditis in people undergoing invasive procedures. This examined:

  • changes in the prescription of antibiotics for the prevention of infective endocarditis
  • changes in the number of cases of infective endocarditis diagnosed

NICE's recommendation was based on an examination of the evidence of the effectiveness of antibiotics in preventing infective endocarditis, weighing the benefits and health outcomes (such as reduction in illness and deaths), risks and costs.  

The data collected by this study comes from reliable data sources, and the researchers took various steps to make sure their data collection was as complete and accurate as possible.

The results demonstrate a clear decrease in antibiotic prescribing as the NICE guidance came in – as would be expected – but also a significant increase in the number of infective endocarditis cases diagnosed since then.

The increase in cases was seen both in those who would be considered to be at risk of the condition and those without risk factors.

As the researchers highlight, this analysis of trends cannot prove causation. It cannot prove that the decrease in the prescription of preventative antibiotics before invasive procedures was directly responsible for the increase in the number of cases of infective endocarditis that has been seen subsequently, even though this may seem the likely cause.

We only know the number of diagnosed cases – we do not know what the actual cause in the individual cases was, and whether the person had, or had recently had, any dental or surgical procedures.

As the researchers say, they did not have reliable data on specific bacterial causes, which would have been useful – for example, in indicating whether it was bacteria normally present in the mouth, and so may have followed dental procedures. 

Other factors may be responsible for the change in trends, such as a change in the number of high-risk invasive procedures performed, or a change in the number of people at high risk of infective endocarditis.

However, the researchers did look into this and did not find a significant enough increase in the number of high-risk people with mechanical heart valves, or those having procedures for congenital heart disease, that could account for the trend.

It's also of note that there was an increase in infective endocarditis in people who weren't considered to be at risk of the condition – these people wouldn't routinely have been expected to have been offered antibiotic prophylaxis before the 2008 guidelines.

In light of this study, NICE has announced they will now review their guidelines. Until the review takes place, however, current recommendation are unchanged.

Even if there is a direct link between the 2008 guidelines and the rise in the number of cases of infective endocarditis, there are still other issues to consider.

Could it be justified to issue 277 antibiotic prescriptions to prevent one case of infective endocarditis, given the unnecessary exposure of many individuals to antibiotics, and given what we know about the growing threat of antibiotic resistance?

As with many aspects of public health, issues are never as clear cut as some media reporting would lead us to believe.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Heart infection rates rise after antibiotic use cut. BBC News, November 18 2014

Links To Science

Dayer MJ, Jones S, Prendergast B, et al. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis. The Lancet. Published online November 18 2014

Categories: Medical News

Report links obesity to advanced prostate cancer

Medical News - Wed, 11/19/2014 - 13:35

"Being overweight raises risk of men developing aggressive prostate cancer," The Guardian reports.

A major new report from the World Cancer Research Fund has found strong evidence obesity increases the risk of aggressive prostate cancer.

This report, which considered the results from 104 studies involving more than nine million men, looked at diet, nutrition, physical activity, weight and the risk of prostate cancer.

It also found strong evidence that being tall – a marker of developmental factors in the womb, childhood and adolescence – increases the risk of prostate cancer.

The report found limited evidence for a link between diets high in dairy products or calcium and an increased risk of prostate cancer, and low blood levels of vitamin E or selenium and an increased risk of developing cancer. 

The report recommends maintaining a healthy weighteating a healthy diet and being physically active to reduce your risk of cancer. These recommendations seem both sensible and well founded.

 

Who produced the report?

The report was produced by the World Cancer Research Fund International as part of their Continuous Update Project.

This report aims to update a report from 2007 by analysing global prostate cancer prevention and survival research linked to diet, nutrition, physical activity and weight.

The results were well reported by the media.

 

What evidence did the report look at?

The report is based on the findings of a systematic review performed by a team at Imperial College London, and its interpretation by a panel of independent experts.

The systematic review included randomised controlled trials, and cohort and case-control studies identified from the Medline database.

The results from 104 studies were analysed. This included more than nine million men, 191,000 of whom had prostate cancer.

 

What are the main findings of the report?

The report found strong evidence that:

  • being overweight or obese (measured by body mass index [BMI], waist circumference, or waist-hip ratio) increases the risk of advanced prostate cancer (advanced, high-grade, or fatal prostate cancer)
  • developmental factors in the womb, childhood and adolescence that influence growth are linked to an increased risk of prostate cancer – for example, taller men are at an increased risk of prostate cancer
  • beta-carotene, a pigment found in certain plants and fruits (consumed from diet or supplements), had no substantial effect on the risk of prostate cancer

There was limited evidence that:

  • higher consumption of dairy products increases the risk of prostate cancer
  • diets high in calcium increase the risk of prostate cancer
  • low plasma (blood) alpha-tocopherol concentration (vitamin E) increases the risk of prostate cancer
  • low plasma (blood) selenium concentration increases the risk of prostate cancer

The report made no conclusions about whether a number of other factors increased or decreased the risk of prostate cancer. For example:

  • cereals (grains) and their products
  • dietary fibre
  • potatoes
  • non-starchy vegetables
  • fruits
  • pulses (legumes)
  • processed meat
  • red meat
  • poultry
  • fish
  • eggs
  • total fat

This is not an exhaustive list. For the complete list, you can download the report for free (PDF, 2.49Mb).

No conclusions were made because the studies identified were either poor quality, their results were inconsistent, or too few studies were identified.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Being overweight raises risk of men developing aggressive prostate cancer. The Guardian, November 19 2014

Obesity 'raises prostate cancer risk': 10% of cases could be prevented if men kept themselves at a healthy weight. Daily Mail, November 19 2014

Links To Science

World Cancer Research Fund International. Diet, nutrition, physical activity and prostate cancer (PDF 2.49Mb). November 2014

Categories: Medical News

Does being poor make your teeth fall out?

Medical News - Tue, 11/18/2014 - 19:08

"People with lower income end up with eight fewer teeth than the rich," The Independent reports.

The headline is prompted by a new study based on a 2009 national dental health survey of adults over the age of 21 in England. It found strong links between socioeconomic status (how well off a person is) and oral health.

The most extreme result was that the poorest fifth of elderly people had up to eight fewer teeth than the wealthiest fifth.

The finding that those who are worst off in society have poorer oral health than the wealthiest may not surprise many, and may well correlate with poorer health in general.

However, the study provides food for thought on whether the extent of the difference is acceptable or preventable.

The study's authors argue the routes of these inequalities require action "addressing risks, beliefs, behaviours, and the living environment", and that these factors may be just as important as affordable access to professional dental treatment.

Read more advice about dental health and how to mind those gaps.

 

Where did the story come from?

The study was carried out by researchers based at the University of Newcastle and the University of London, and was funded by the UK Economic and Social Research Council as part of the Secondary Data Analysis Initiative.

It was published in the peer-reviewed Journal of Dental Research.

The report opens with a quote from Chilean poet Pablo Neruda: "Rise with me against the organisation of misery". This quote highlights the authors' conclusion that the differences they have found are avoidable and are a product of the way our society is organised.

The media generally reported the story accurately, with many carrying a similar quote from the lead study author, who stated that, "It's probably not a big surprise that poorer people have worse dental health than the richest, but the surprise is just how big the differences can be and how it affects people."

Most of the headlines led with the figure that the poorest elderly people had up to eight fewer teeth than the richest. This result was not reported in the main results section of the publication, but was only mentioned in the discussion section, as this finding was not adjusted for confounders. Nonetheless, this does not diminish its significance in the wider context.

 

What kind of research was this?

This was a secondary analysis of a pre-existing dataset originating from a 2009 national dental health survey in England.

Oral health inequalities associated with socioeconomic status are widely observed, the research team says, but may depend on the way both oral health and socioeconomic status is measured.

The aim of this study was to investigate inequalities using diverse indicators of oral health and four socioeconomic determinants for age and cohort.

Using a pre-existing dataset is a relatively quick and simple approach to investigate the link between socioeconomic status and oral health.

The main limitation in using existing datasets, however, is often they do not collect all the data required for analysis.

This is because the original survey and data collection would have been designed for a specific purpose, which may be different from the purpose of the secondary analysis.

 

What did the research involve?

Researchers used existing data collected from a 2009 UK adult dental health survey to investigate how socioeconomic status was linked to oral health for adults.

This survey was based on a nationally representative sample of 11,380 individuals (among which 6,469 adults had an oral examination) providing information on individual dental health and socioeconomic status. The team restricted data analysis to adults over the age of 21.

The researchers wanted to see whether using different measures of socioeconomic status and oral health made a difference to how they were related, so they used multiple measures of each.

Oral health measures included:

  • the presence of tooth decay
  • the existence of teeth that couldn't be restored because of decay
  • the number of decayed, missing and filled teeth
  • the existence of any periodontal pocket (where the gums pull away from the teeth, creating a pocket) of 6mm or more
  • the number of natural teeth
  • having three or more unfilled upper spaces (to capture how the teeth might look)
  • a composite measure of excellent oral health (21 or more teeth, 18 of which are "sound", with no decay or pockets greater than 4mm)

Socioeconomic measures included:

  • income
  • education
  • index of multiple deprivation occupational social class

The analysis looked for links between each of the four measures of socioeconomic status and the seven measures of oral health.

The analysis took account of multiple confounders, including:

  • age
  • sex
  • marital status
  • region of residence
  • longstanding illness
  • self-assessed health

 

What were the basic results?

The team consistently found people with lower incomes, lower occupational class, higher deprivation, or low educational attainment had the worst oral health outcomes. However, the size and significance of these inequalities depends on the clinical outcome used.

The two simple tooth decay measures – presence of tooth decay and the existence of more than one tooth that could not be restored as a result of decay – were still strongly associated with income after adjustment for confounders.

By contrast, the presence of any teeth with pockets of 6mm or more (severe periodontal disease), having unfilled upper spaces (untreated aesthetic impairment), and not having excellent overall oral health were weakly associated with income.

The number of teeth showed little or no income gradient in the young. By contrast, in older adults, those in the poorest fifth of income lost many more teeth than those in the top fifth, and the gradient was strong.

After adjustment for confounders, those in the poorest fifth had on average 4.5 fewer teeth than the richest fifth (95% confidence interval [CI], 2.2 to 6.8) but there was no difference in younger groups.

For periodontal disease, income inequalities were mediated by other socioeconomic variables and smoking, while for anterior spaces the relationships were age dependent and complex.

 

How did the researchers interpret the results?

The authors concluded that, "Oral health inequalities manifest in different ways in different age groups, representing age and cohort effects. Income sometimes has an independent relationship, but education and area of residence are also contributory.

"Appropriate choices of measures in relation to age are fundamental if we are to understand and address [oral health] inequalities."

In their discussion of the results, the researchers also added that, "In the oldest group, a huge difference between richest and poorest (based on current income) has opened up, and the unadjusted marginal difference was nearly eight teeth." This is the figure that made most of the media headlines.

 

Conclusion

This study provides a sharp look at the link between socioeconomic status and oral health. The finding that those worse off in society have poorer oral health is no surprise, and may well correlate with poorer health in general.

But what needs to be considered now is whether the extent of the difference is preventable. The most extreme result was that the poorest fifth of elderly people had up to eight fewer teeth than the wealthiest fifth.

On a more academic note, the study shows you can get slightly different results and patterns depending on which precise measure of socioeconomic status and oral health you choose – something future studies can learn from.

These findings are likely to represent a broadly accurate picture of the state of oral health in the UK and how it is related to various measures of income inequality.

But one drawback was that only four measures of socioeconomic status were tested. There are many more that are routinely used in other types of research, but the team were limited to using the information already collected as part of the original dental health survey.

The data suggests the links between different socioeconomic factors and oral health are complex. The authors themselves highlighted some wider determinants of health that may be at play, meaning a focus on treatment may not be the best approach to tackle the variation.

They remarked that, "There are many possible paths between socioeconomic position and oral health inequality that require further unpicking. However, while increasing resources for treatment services may provide benefits, the analysis here suggests that it will not resolve inequalities.

"Upstream action addressing risks, beliefs, behaviours, and the living environment are probably as important as affordable access to professional treatment."

This follows the sentiment of the Marmot Review "Fair Society, Healthy Lives", which dominates the wider public health agenda of tackling avoidable differences in health using an "upstream" approach.

An upstream approach is when rather than trying to change people's individual behaviours (such as encouraging tooth brushing), you instead change higher environment and social forces (such as adding fluoride to the water supply), which leads to beneficial effects flowing "downstream".

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Pulling teeth: the gaps that reveal a life of hardship. The Daily Telegraph, November 17 2014

Elderly people who are poor 'have eight fewer teeth than the richest 20% of society. Daily Mail, November 18 2014

People with lower income end up with eight fewer teeth than the rich, study finds. The Independent, November 18 2014

Links To Science

Steele J, et al. The Interplay between Socioeconomic Inequalities and Clinical Oral Health. Journal of Dental Research. Published October 24 2014

Categories: Medical News

Triclosan soap linked to mouse liver cancers

Medical News - Tue, 11/18/2014 - 13:29

“A chemical ingredient of cosmetics, soaps, detergents, shampoos and toothpaste has been found to trigger liver cancer,” reports The Independent. The chemical in question, triclosan, is used in many products as an antibacterial.

Should you be worried if you have just washed your hands? Probably not. The link was found in mice, not humans, and the mice were given a much larger comparable dose than humans are ever likely to be exposed to.

The study found that mice fed high amounts of triclosan daily for six months suffered liver damage and were more susceptible to liver tumours induced by other cancer-causing chemicals.

The findings tell us very little about the potential health effects on people. However, it’s important not to be complacent. Further investigation may be warranted in humans, especially when it comes to topical application, and at lower exposure levels.

The concerns have resulted in an investigation by the US Food and Drug Administration (FDA), which regulates its use in America. The FDA said that it does not have enough safety evidence to recommend any “change to its use in consumer products”. This means that the evidence does not tell us whether or not triclosan is harming people through background exposure. Until further evidence accumulates, we will remain in the dark about this issue.

 

Where did the story come from?

The study was carried out by researchers from the University of California and was funded by US Public Health Service Grants.

The study was published in the peer-reviewed science journal PNAS.

Generally, the media reported the story accurately. The Independent, for example, took the commendable step of indicating that it was research on mice in their main headline. This prevents any incorrect assumptions that it was on humans. The body of the Independent article also appeared factual and not overly alarmist, discussing the views of different scientists who thought the chemical might pose a risk to humans, and those that thought it was too early to tell.

Conversely, the Daily Express chose to lead with the words "Cancer scare", which was an unnecessary step. The paper also took several paragraphs to explain that only mice were studied.

 

What kind of research was this?

This was a laboratory study using mice to investigate the potential cancer-promoting properties of triclosan.

Triclosan [5-chloro-2-(2,4-dichlorophenoxy)phenol; TCS] is a synthetic, broad-spectrum antibacterial chemical used in a wide range of consumer products, including soaps, cosmetics, therapeutics and plastics. The general population, the researchers point out, are exposed to triclosan because of its prevalence in a variety of daily care products, as well as through waterborne contamination. They say it is linked to a variety of health and environmental effects, and wanted to investigate the effect on the liver.

Researchers often use mice because, as mammals, they share similar biology with humans. Hence, research on mice can tell us what might happen in humans, without directly experimenting on them. The caveat is that there is no guarantee that results in mice will be replicated in humans as, while similar, the biology of the two organisms is not identical, and the differences can sometimes be crucial.

 

What did the research involve?

The research involved two groups of mice: one fed a normal diet and the other a diet supplemented with triclosan. After eight months on the diets, the mice were killed and their livers removed and analysed for physiological and genetic signs that the chemical was promoting cancer growth.

In a second experiment, the research team injected two groups of mice with a chemical that causes the development of cancerous liver tumours, to see whether giving triclosan (this time given in their drinking water) influenced the development of the tumours thereafter.

 

What were the basic results? Effect of long-term triclosan in the diet on liver biology

Through physiological and genetic analysis, the results suggested that triclosan increases liver cell proliferation, induces liver scarring and reactive oxygen species accumulation. Taken together, the team concluded this was a sign that triclosan damaged the liver cells, implying they may be more likely to become cancerous.

Effect of triclosan after tumour promoting injection

Triclosan-treated mice had a higher tumour number, bigger tumour size and greater tumour incidence than mice given the tumour-promoting injection alone. The number of detectable liver cancers was around 4.5 times higher in triclosan-treated mice than in control mice.

Approximately 25% of mice receiving the tumour promoting injection only exhibited small cancerous nodules, whereas more than 80% of triclosan-treated mice developed tumours. Maximal tumour diameter was also 3.5-fold larger in triclosan-treated mice.

 

How did the researchers interpret the results?

The study authors acknowledged that, “animal studies require higher chemical concentrations than predicted for human exposure”, but said their study, “demonstrates that TCS [triclosan] acts as a HCC [liver cancer] tumour promoter and that the mechanism of TCS-induced mouse liver pathology [disease] may be relevant to humans.”

 

Conclusion

This small mouse study raises the prospect that triclosan may have tumour promoting-properties that could be relevant to humans but, on its own, does not provide any conclusive evidence that it does.

Firstly, the findings in this small group of mice need to be replicated by other research teams to ensure they are reliable. This should include the effect of triclosan at different levels of exposure and through different exposure paths, such as through food, water or skin. The latter would be of particular relevance to humans, given that much of our exposure to triclosan is topical (via the skin) rather than oral.

The current mouse study, as the authors acknowledged, “require[d] higher chemical concentrations that predicted for human exposure”. This means the mice were given very high amounts of the chemical relative to what you might expect the average person to be exposed to in real life.

The second issue is that even if the results are found to be reliable in mice, there is no guarantee that the same effects will be the seen in humans, irrespective of exposure levels or exposure route. While humans and mice share many biological mechanisms and similarities as common mammals, their differences can be crucial during disease processes.

At present, we simply don’t know if similar results would be found in people. It would also be unethical to give someone a high dose of something on the premise that you are trying to prove it causes cancer. Therefore, it is likely that large and long-term cohort studies, using natural exposure levels, will give us the best evidence on the potential health effects of triclosan.

As a result, there are many unanswered questions around this research and the potential harms (or lack of) associated with triclosan that may warrant further investigation. This is especially due to its ubiquitous use in a range of both commercial and healthcare products.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Cancer scare: Could your liquid hand gel be harming your health? Daily Express, November 17 2014

Toothpaste chemical may increase risk of cancer, warn scientists. The Daily Telegraph, November 18 2014

Triclosan: Soap ingredient can trigger liver cancer in mice, warn scientists. The Independent, November 17 2014

Links To Science

Yueh M-F, et al. The commonly used antimicrobial additive triclosan is a liver tumor promoter. Proceedings of the National Academy of Sciences of the United States of America. Published November 17 2014

Categories: Medical News

'Food environment' needs changing, doctors argue

Medical News - Mon, 11/17/2014 - 15:00

"A Mediterranean diet may be a better way of tackling obesity than calorie counting, leading doctors have said," BBC News reports.

In a recently published editorial, they also argue the NHS should do more to encourage its staff to eat more healthily.

As this was an editorial, and not new evidence, it cannot prove the Mediterranean diet, which is characterised by vegetables, fruits, beans, whole grains, olive oil and fish, is "best". But the article does raise some interesting points.

They argue that the obesity epidemic is intrinsically linked to an unhealthy food environment – one in which easy access to cheap, high-energy, nutrient-poor junk food promotes poor choice by default.

Doctors cannot just issue calorie control and exercise advice ("eat less, move more"), but need to encourage healthier eating overall. The Mediterranean diet has been linked to improved cardiovascular health, as we discussed in 2013.

The authors also point out the need to promote healthy eating within the NHS – for example, providing healthy meal options for both patients and staff.

That way, healthcare professionals can inform patients and the public about how diet can improve health by leading by example.

 

Where does the story come from?

The story follows an editorial published in the peer-reviewed Post Graduate Medical Journal. It was authored by three professionals with affiliations to Frimley Park Hospital in Surrey, the Academy of Medical Royal Colleges in London, and NHS England. The authors declare no conflicts of interest.

The authors discuss the current obesity epidemic and the effect that different approaches can have on this, referencing various publications.

They do not provide any methods for identifying the various studies they reference, and this does not appear to be a systematic review.

It is not known whether all the literature relevant to the issue of healthy eating has been considered.

Therefore, this editorial must be considered as the views and opinions of the authors based on their knowledge of the literature and expert opinion. We do not know whether another systematic review of the subject would reach the same conclusions.

 

What do the researchers say about the obesity problem?

The researchers explain how the obesity epidemic currently costs the NHS about £6 billion a year, while obesity-related diseases such as diabetes cost even more.

Our diet is a powerful determinant of our weight and health. However, as the authors consider, the decisions that we make about the food we buy is often made without full conscious awareness, and we can be seduced by the brightly coloured packaging of confectionery at the till.

The authors discuss foods that have been the particular focus of attention in trying to reduce the risk of cardiovascular disease.

Fruit, vegetables, nuts, olive oil and oily fish – common in Mediterranean cuisine – contain α-linoleic acid, polyphenols and omega-3 fatty acids, which are believed to reduce inflammation and the formation of fatty blood clots in the arteries. This reduces the risk of heart diseases, such as heart attacks.

The researchers say it's estimated that increasing the world's consumption of fruit and vegetables by one portion a day, and nuts by two servings a day, would prevent 5.2 million cardiovascular deaths worldwide within a year.

It is also estimated that reducing people's sugary drink consumption by 15% would, within a year, prevent 180,000 people from becoming obese in the UK, and save the NHS £275 million.

The researchers say real progress will only be made when "the need for a healthier food environment" is understood. As they say, collective action is needed so that an individual's choices about what to eat default to healthy options rather than junk food: "healthy choice must be the easy choice".

There is currently an oversupply of cheap, high-energy, nutrient-poor food, such as confectionery, crisps and sugary drinks, in vending machines, food trollies and food outlets in NHS hospitals – the places that should be promoting positive healthy messages.

Not only does this impact on the choice of patients and visitors, but also NHS staff – half of whom are estimated to be overweight or obese.

As the researchers also consider, the effects of regular physical activity will be undermined if someone has a poor diet: "you can't outrun a bad diet".

 

What do they say about specific diets?

The researchers discuss "weight cycling" – rapid loss and regain – and how this has been associated with high blood pressure, poor blood sugar and blood fat control, and poor overall cardiovascular outcomes.

US research shows most people on rapid diets regain most of their lost weight, and two-thirds do not gain any health benefit.

In contrast, they discuss one trial that randomised 7,500 high-risk adults to either the Mediterranean diet (41% total fat, supplemented with extra virgin olive oil or nuts) or low-fat dietary advice.

They report the Mediterranean diet was associated with a 30% reduction in major cardiovascular disease events within three months.

It is unclear how this effect was calculated and whether it was compared with the low-fat group. The researchers report these reductions in cardiovascular disease risk were irrespective of weight.

They also report another study, which showed how adopting a Mediterranean diet after a heart attack is almost three times as effective as a statin at reducing mortality.

The researchers also mention another trial, which found an energy-unrestricted, high-fat, low-refined carbohydrate diet (restricting carbohydrates without fibre) resulted in more weight loss and a better blood fat profile one year later when compared with a low-fat diet.

 

What suggestions to the authors make?

The researchers suggest that introducing evidence-based nutrition into the training of doctors and nurses would increase their understanding of the science of healthy eating, and also allow better-informed nutrition discussion between health professionals and patients.

They also say the NHS as an employer is in a key position to set a national example by supporting 1.4 million staff to stay healthy and serve as "health ambassadors" in their local communities.

The researchers say it is time to get across the evidence base that healthy dietary change rapidly improves outcomes, and put this into the heart of the NHS.

They report the key recommendations of the "Five Year Forward View" published by NHS England and partner organisations in October 2014, which set out a vision for the future of the NHS:

  • Make information about the evidence base for healthy diets easily available to NHS staff and patients.
  • NHS employers to implement the Workplace Wellbeing Charter and require commissioners to consider this when assessing tenders.
  • Implement National Institute for Health and Care Excellence (NICE) guidance on promoting healthy workplaces throughout the NHS.
  • Reduce access to processed foods high in fat, salt and sugar on NHS premises.
  • Provide healthy diet options for all staff, including night staff.
  • Call for NHS institutions to objectively monitor and publish sales and quantities of foods deemed unhealthy, in addition to the degree of adherence to national food standards.

 

Conclusion

The focus of this research is on changing the dietary environment to a healthy rather than an unhealthy one, particularly within the NHS.

The media has focused on the Mediterranean diet, but this is not the sole focus of the study. Reports on the Mediterranean diet come from two brief references to two trials within the editorial.

From the information provided in this editorial alone, it is not possible to comment on the reliability and comprehensiveness of all the information provided.

As stated, this does not appear to be a systematic review. Therefore, without knowing the methods the researchers used, it's not possible to say whether all the relevant evidence relating to the issue of healthy eating has been considered.

With only examples of a few dietary trials discussed, we do not know whether all the evidence relevant to the comparative effectiveness of different dietary approaches (for example, Mediterranean versus low fat) has been examined.

Without looking at the individual studies behind the data in this editorial, it is also not possible to review how accurate and reliable the effectiveness data and estimates are likely to be, or how they were calculated – for example, estimates on reduction of cardiovascular deaths and obesity with specific alterations to food intake.

Nevertheless, the overall message of this editorial – to make the dietary environment a healthier one – is sensible and consistent with recommendations made by other health organisations.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Mediterranean diet is best way to tackle obesity, say doctors. BBC News, November 17 2014

Links To Science

Malhotra A, Maruthappu M, Stephenson T. Healthy eating: an NHS priority A sure way to improve health outcomes for NHS staff and the public. Postgraduate Medical Journal. Published online November 16 2014

Categories: Medical News

Just one kiss 'spreads 80 million bugs'

Medical News - Mon, 11/17/2014 - 14:15

"A single 10-second kiss can transfer as many as 80 million bacteria," BBC News reports. Dutch scientists took "before and after" samples from 21 couples to see the effect an intimate kiss had on the bacteria found in the mouth.

By studying the couples, the scientists discovered the bacteria found on the tongue are more similar among partners than unrelated individuals, but are not correlated with kissing behaviour.

In contrast, the researchers found that for bacteria in saliva to be similar, couples need a relatively high kiss frequency and a short time since their last kiss.

The researchers also estimated that a 10-second kiss transfers 80 million bacteria. These results suggest many of the transferred bacteria are not able to take hold on the tongue.

Some of the media reporting has suggested that this transfer of bacteria that occurs during a kiss is good for us.

The idea is plausible, but is not proven by the evidence presented in the current study. Sometimes, as the song goes, "a kiss is just a kiss".

 

Where did the story come from?

The study was carried out by researchers from the Netherlands Organisation for Applied Scientific Research (TNO) Microbiology and Systems Biology and Micropia, Natura Artis Magistra (Artis Royal Zoo), and VU University Amsterdam, The Netherlands.

It was funded by Natura Artis Magistra and TNO.

The study was published in the peer-reviewed scientific journal Microbiome. This study is open access, meaning it can be read online for free.

The story was well reported by BBC News. But the Daily Mail's coverage was less accurate, as its headline stated: "Kissing for ten seconds passes on 80 million bugs – but it keeps you healthy! Bacteria transferred helps improve immune system". The study made no assessment of immune function, so this statement is unsupported.

 

What kind of research was this?

This was a series of experiments on people that aimed to determine:

  • whether the mouths of kissing partners are colonised with similar bacteria 
  • if the frequency with which couples kiss and the amount of time since the last kiss influences the bacteria present in the mouth
  • the number of bacteria transferred by kissing

 

What did the research involve?

The researchers studied the bacteria in the mouths of 21 couples, including one female and one male gay couple.

The researchers collected saliva samples and samples from the back of the tongue before and after an intimate kiss of 10 seconds. Bacteria were identified by analysing the DNA sequences present in samples.

Couples were also asked to report their last year's average kiss frequency and the period of time since their last intimate kiss.

One of the partners was asked to consume 50ml of a probiotic yoghurt drink containing the bacteria Lactobacillus and Bifidobacteria.

Again, saliva and tongue samples were collected before and after an intimate kiss of 10 seconds. The researchers estimated bacterial transfer after an intimate kiss by tracking these marker bacteria.

 

What were the basic results?

The bacteria found in tongue samples were more similar for couple members than for unrelated individuals. An intimate kiss did not significantly increase the similarity in the bacteria found in tongue samples. 

The bacteria found in saliva were not more similar for couple members than for unrelated individuals, and an intimate kiss did not significantly increase the similarity in the bacteria found in saliva samples.

However, the researchers did see a correlation between the similarity of bacteria found in the saliva of couples and self-reported kiss frequencies, and the reported time since the last kiss.

The researchers estimated that 80 million bacteria are transferred per 10-second intimate kiss.

 

How did the researchers interpret the results?

The researchers concluded that, "This study indicates that a shared salivary microbiota [bacterial flora] requires a frequent and recent bacterial exchange, and is therefore most pronounced in couples with relatively high intimate kiss frequencies.

"The microbiota on the dorsal surface of the tongue is more similar among partners than unrelated individuals, but its similarity does not clearly correlate to kissing behaviour, suggesting an important role for specific selection mechanisms resulting from a shared lifestyle, environment, or genetic factors from the host."

They go on to say that, "Furthermore, our findings imply that some of the collective bacteria among partners are only transiently present, while others have found a true niche on the tongue's surface allowing long-term colonisation."

 

Conclusion

This study has investigated the effects of intimate, or french kissing, on the bacteria found in the mouth.

By studying 21 couples, it found the bacteria on the tongue are more similar among partners than unrelated individuals, but are not correlated with kissing behaviour.

In contrast, the researchers found that for bacteria in saliva to be similar, couples need a relatively high kiss frequency and a short time since their last kiss.

The researchers also estimated that a 10-second kiss transfers 80 million bacteria.

These results suggest that kissing transfers many bacteria, but many of the transferred bacteria are not able to take hold on the tongue.

This is interesting research, but the findings have limited implications. They do not tell us whether kissing is beneficial or not – for example, in terms of causing illness or, conversely, increasing our immunity by exposure to a greater range of bacteria.

Though, of course, a kiss with the right person can be fun.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

One kiss 'shares 80 million bugs'. BBC News, November 17 2014

Kissing for ten seconds passes on 80 million bugs - but it keeps you healthy! Bacteria transferred helps improve immune system. Daily Mail, November 17 2014

Links To Science

Kort R, Caspers M, van de Graaf A, et al. Shaping the oral microbiota through intimate kissing. Microbiome. Published online November 17 2014

Categories: Medical News

'Good ways to pop a pill'

Medical News - Fri, 11/14/2014 - 18:36

“Just a spoonful of water helps the medicine go down: Scientists discover the best way to swallow tablets,” explains the Mail Online today.

In fact, scientists haven’t necessarily discovered the “best” ways to take your medicine, they have simply tested two options and found that they work well – and neither involves just a spoonful of water.

The best ways to swallow medicine – according to the new research cited by the Mail – are a “pop-bottle” method for tablets and a “lean-forward” technique for capsules.

German researchers asked adults with and without swallowing difficulties to swallow 16 tablets and capsules of different shapes and sizes using 20ml of water, with their eyes shut. The most difficult tablet and capsule were then chosen to test whether the two alternative techniques were better.

The pop-bottle method was rated easier to use for swallowing tablets by 60% of participants regardless of whether they had an initial swallowing difficulty. The lean-forward technique for capsules improved swallowing in 89% of people. Overall, 86% of the people said they would use the techniques in the future.

Both techniques appear to have been successful for the majority of people, and may be worth a go if you have mild difficulty swallowing pills. If you have a more general swallowing problem, speak to your GP or pharmacist about different techniques for taking medicine or alternative formulations, such as medicine in liquid form.

 

Where did the story come from?

The study was carried out by researchers from the University of Heidelberg and was funded by the Fette Compacting GmbH, the German Research Foundation, and the German Federal Ministry of Education and Research.

The study was published in the peer-reviewed medical journal Annals of Family Medicine.

The Mail Online helpfully provided diagrams to explain the two techniques, but it did not accurately reflect the experiment. Slurping from a tablespoon of water was not tried in this research, although in each of the initial pill-swallowing experiments 20ml (about a tablespoon) of water was used, but this was not found to be the most effective method.

 

What kind of research was this?

This cross-sectional study aimed to determine the optimal technique for swallowing tablets and capsules. Difficulty in swallowing pills can lead to non-compliance with medication or the need to have it administered in a different form, so the researchers wanted to find out the easiest way that the majority of people would find to take them.

 

What did the research involve?

To investigate different swallowing techniques, 151 adults from the general population in Germany were enrolled in the study. They were asked to swallow 16 dummy pills of different sizes and shapes with their eyes closed using 20ml of water, and rate the ease of swallowing. The largest tablet and capsule that had caused the most difficulty were then chosen to be swallowed again to test two particular techniques – the “pop-bottle method” for the tablet and the “lean-forward technique” for the capsule – to see if they made it easier to swallow them.

Pop-bottle method

The pop-bottle method involves placing the tablet on the tongue, tightly closing the lips around the top of a plastic bottle filled with water, and swallowing in a “swift suction movement” to overcome the “volitional phase of swallowing” (the conscious act of swallowing). No air should enter the bottle as you swallow, and the bottle will squeeze in on itself as you drink the water. This method was devised for tablets because they are usually of high density.

Lean-forward technique

The lean-forward technique requires swallowing the capsules whilst in an upright position, with the head bent forward. This version was deemed appropriate for capsules, as they are usually very light.

The researchers then compared the rating of these two techniques, with the initial rating of how easy the tablet and capsule had been to swallow.

 

What were the basic results?

Compared to swallowing with 20ml of water, the pop-bottle method improved the ease of swallowing the tablet for 60% of people. This included people who had not found it difficult in the first place.

The capsule swallowing was tested only 35 times, and the lean-forward technique was rated better by 89% of participants. This compared to the capsules lodging in the back of the throat on 10 out of 33 occasions without the technique.

Overall, 86% of participants said they would now use these techniques for swallowing pills.

 

How did the researchers interpret the results?

The researchers conclude that, “this study showed for the first time that two targeted techniques to facilitate tablet and capsule intake were remarkably effective and easy to adopt in the general population, including patients with swallowing difficulties, and should therefore be generally recommended”.

 

Conclusion

This study has demonstrated that two specific techniques for swallowing tablets and capsules were beneficial in the majority of people studied. This included people who have trouble swallowing the pills as well, as the controls who didn’t normally have swallowing problems.

While the results of this study seem impressive for these techniques, it should be noted that they were compared to swallowing the pills with just 20ml of water, which is equivalent to a sip or a small mouthful, if you have a small mouth.

The participants also had their eyes closed during this phase of the experiment, which may have been disorientating and made swallowing a pill more unnatural. Also, by the time the participants tested the new techniques, they would have just swallowed 16 tablets, so it could be argued that they would have got more used to doing so by then.

Nevertheless, it is encouraging to have two new techniques to try if you do have difficulty swallowing pills. However, bear in mind that the authors suggest the pop-bottle technique carries some potential risk of getting the pill lodged in your airway (aspiration).

If you have a condition where you have problems with swallowing in general (dysphagia), it may be better to try new techniques under medical supervision.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Just a spoonful of water helps the medicine go down: Scientists discover the best way to swallow tablets. Mail Online, November 13 2014

Just a spoonful of water: doctors find best method for swallowing pills. The Guardian, November 10 2014

Links To Science

Schiele JT, et al. Two Techniques to Make Swallowing Pills Easier. Annals of Family Medicine. 2014;12:550-552.

Categories: Medical News

Do people who take weight loss pills eat unhealthily?

Medical News - Fri, 11/14/2014 - 12:40

"Are slimming pills fuelling the obesity epidemic?" asks the Mail Online, reporting on research that suggests dieters "mistakenly believe they can eat whatever they want" after taking weight loss drugs.

There is nothing in the research to prove the Mail's headline. In fact, its headline was prompted by US experiments on the effects of marketing a weight management treatment as a "drug" or a "supplement".

The research looked at whether the difference would change healthy lifestyle beliefs and behaviour, and whether this is influenced by knowledge about weight remedies and nutrition.

Researchers found that when people were shown an advert for something marketed as a drug, it led to them eating more cookies (an unhealthy behaviour) than when the same treatment was advertised as a supplement.

They further found giving people more knowledge about weight loss remedies was more effective at mediating this unhealthy eating than giving them more knowledge about nutrition in general.

Very limited conclusions can be drawn from this study, and it does not provide evidence that taking weight loss treatments encourages unhealthy lifestyle behaviours, or that these remedies make people think they can eat what they want. These experiments were very specific one-off scenarios in relatively small samples of young adults.

Most importantly, this US study has little bearing in the UK, where drugs are not marketed to the public. Prescribed weight loss treatments have a specific set of criteria controlling their prescription.

This study is not conclusive. We don't know whether – and how – taking weight loss drugs directly influences people's beliefs about health and nutrition.

 

Where did the story come from?

The study was carried out by professors of business and marketing from three business schools in Philadelphia and New Hampshire, in the US.

Financial support was provided by the Collaboration to Reduce Disparities in Hypertension (CHORD) project funded by the Pennsylvania Department of Health, and from the Ackoff Fund of the Wharton Risk Management and Decision Processes Center.

The study was published in the peer-reviewed Journal of Public Policy and Marketing.

The Mail's conclusion that, "dieters using slimming pills mistakenly believe they can eat whatever they want" cannot be made based on this set of experimental studies, which have limited application to the situation in the UK.

The study also provides no evidence that slimming pills are fuelling the obesity epidemic.

 

What kind of research was this?

This was an experimental study conducted in the US. It explored the impact of the marketing of weight management remedies on healthy lifestyle behaviours. These remedies are described as covering "products or services designed to reduce risk and offer solutions to challenges consumers face".

The researchers investigated three main questions:

  • How does marketing of weight management remedies (specifically, the marketing of products labelled as drugs versus those labelled supplements) affect actual healthy behaviour?
  • Is the impact of weight management remedy marketing rooted in erroneous beliefs about remedies themselves? Or is the impact of weight management remedy marketing more driven by the consumer's choice between remedies (such as drugs versus supplements)?
  • Previous research has not specifically tested the impact of "health literacy" on consumer response to weight management marketing. The researchers wanted to investigate the impact of two critical dimensions of health literacy: "nutritional knowledge" and "remedy knowledge".

The researchers conducted three experiments examining these questions, which were centred on their three theories.

 

What did the research involve?Study one: how weight management remedy are marketed

The researchers believed there is a difference between the marketing of drugs and supplements. They say supplements have less association with poor health, and remind consumers of the importance of other health-protective behaviours.

On the other hand, marketing something as a drug treatment could undermine, rather than enhance, healthy lifestyle behaviour. So their first theory is that, "actual unhealthy decisions and behaviour will increase after exposure to weight management drug marketing, but decrease after exposure to supplement marketing".

This first study investigated the impact of drug and supplement marketing on food consumption behaviour. They divided 138 young adults (average age 22, made up of university staff, students and other residents of the area) into six groups and exposed them to either a drug or supplement remedy message, or a no-remedy control message. They then gave them the opportunity to consume a product framed as either relatively unhealthy or healthy (via an explicit low-fat cue).

Both the drug or supplement and no-remedy message started with the line, "Avoid fatty foods and follow a sensible eating plan. This is the only way to achieve an overall healthy lifestyle." The no-remedy message ended there.

The other two added an advertisement about a weight loss treatment that stops fat being absorbed, which was described as being either a FDA-approved drug or a supplement.

Participants were then given free access to cookies, either described as being low-fat and guilt-free, or delicious and indulgent. Participants also completed questions on their views and attitudes.

Study two: how health literacy affects people's response to marketing

The second study examined health literacy. It looked at how knowledge of nutrition and remedies influenced people's response to marketing of remedies. This was to test their theory that, "Remedy knowledge will be more effective than nutrition knowledge at mitigating the negative impact of remedy marketing on healthy lifestyle decisions and behaviours".

The researchers included 356 participants, who they recruited online for a financial inducement. Each group read a short scenario describing the weight management treatment of an individual in a clinical trial. One group were told that he was given a drug or supplement, one was told he chose to have the drug or supplement, and the third group were told he was given a placebo.

Participants were then asked to rate on a scale the likelihood that the individual in the scenario would "follow a low-fat diet", "eat healthy foods", and "live a healthy lifestyle". Participants also rated the individual's likely motivation and effectiveness of the treatment. They then completed questionnaires assessing their remedy knowledge and nutrition knowledge.

Study three: how understanding of nutrition and remedies affects healthy decisions

The third study looked at the impact of information on actual health choices in the presence of weight management marketing.

In this study, 129 young adults (average age 20, again university staff, students and residents) read two articles compiled from Wikipedia, one focused on remedies and one focused on nutrition. They manipulated knowledge by providing information that would have varying relevance to healthy consumption behaviour.

For the "high-remedy knowledge" group, the article contained information about drugs and supplements, including how they support health. For the "low remedy knowledge" group, the article contained less information on health.

For the "high-nutrition knowledge" group, the article included World Health Organization (WHO) information on dietary health, including how to promote health and reduce risk. For the "low-nutrition knowledge" group, the article contained less information relevant to health.

Participants rated the readability and interest in the articles. They then looked at the advertisement for the same weight loss remedy as used in study one, which was described as a drug for all groups. They were then offered their choice of a relatively healthy snack (a strawberry) or a relatively unhealthy snack (a Lindt dark chocolate truffle).

 

What were the basic results?Study one: how weight management remedy are marketed

As the researchers expected, perceptions of the remedy as a "drug" were significantly higher when the same treatment was described as a US Food and Drug Administration-approved drug, rather than a supplement. Also, as expected, participants rated the same cookie as healthier when it was labelled as being "low-fat".

When the researchers analysed the interaction between different forms of marketing of the remedy and the cookie, they found some significant interactions. In particular, they found people who had seen the drug message ate significantly more cookies than those who had seen the supplement message and those who had not been given a remedy message.

Those who had seen the drug message also ate more cookies described as regular than low-fat. Meanwhile, those who had seen the supplement message ate significantly fewer cookies than those who had seen no remedy. Their consumption of cookies described as low-fat was also marginally, but not significantly, higher than those seeing no remedy.

Study two: how health literacy affects people's response to marketing

The researchers found that regardless of whether people were told the remedy was assigned to or selected by the subject, they expected his healthy lifestyle choices to be lower for a drug than a supplement.

In fact, when the researchers compared this with the control group, who were told the individual was taking a placebo, expected lifestyle ratings were no different than when told they were taking a supplement, but significantly less when told they were taking a drug.

Perceptions of motivation were found to mediate the effect of the remedy on lifestyle behaviour (for example, higher levels of motivation decreased the negative impact of the drug on lifestyle).

Study three: how understanding of nutrition and remedies affects healthy decisions

People with lower-remedy knowledge were more likely to choose the unhealthy snack compared with people with high-remedy knowledge. Nutrition knowledge had no significant effect on choice of snack, though unhealthy choices were more frequent with higher versus lower nutrition information.

 

How did the researchers interpret the results?

The researchers concluded that the three studies "demonstrate that exposure to drug (but not supplement) marketing for weight management encourages unhealthy consumer behavior, due to consumers' reliance on erroneous beliefs about health remedies".

When further exploring the possible mitigating role of health literacy (nutrition knowledge and remedy knowledge), they concluded that, "Remedy knowledge is more effective than nutrition knowledge at lessening the effect of weight management drug marketing on unhealthy behaviour".

 

Conclusion

This series of three experiments has investigated the effect that marketing a weight management treatment as a "drug" or a "supplement" has on healthy lifestyle beliefs and behaviour.

It also investigated whether people's understanding of health, in particular knowledge about weight remedies and nutrition, influences this.

The researchers found that believing something is a supplement encouraged "healthier" choices, rather than when people were told the same treatment was a drug. Their second experiment further suggested that weight management drugs undermine a healthy lifestyle by reducing motivation to engage in healthy behaviours.

They then found clues to suggest that knowledge of weight loss remedies mitigates effects on a healthy lifestyle – people were less likely to choose an unhealthy snack when they had been given more knowledge about the treatment. However, increased knowledge about nutrition didn't affect the healthy food choice.

This is an interesting study, but very limited conclusions can be drawn and it does not provide evidence that taking weight loss treatments encourages unhealthy lifestyle behaviours, or makes people think they can eat what they want.

These experiments were three very specific and one-off scenarios that may have very limited relevance to the real life situation. For example, in the first study, people were only shown an advertisement of a treatment marketed as a drug or supplement and were then offered a plate of cookies. They didn't actually take this treatment.

It is difficult to understand how just looking at an advertisement for a treatment you are not taking would directly cause you to eat fewer cookies just because you saw it called a supplement rather than a drug.

Given the large number of analyses that the researchers conducted, looking at interactions between a range of different scenarios, it could be possible that some of these findings may not show true cause and effect (causative) associations.

For example, in the first study, there were relatively small sample sizes in each group when they are broken down into the different remedy and food marketing conditions.

There was also no description of any attempt to ensure each group of adults was matched in terms of their usual eating habits, so any difference seen between the amount of cookies each group consumed may not be solely attributed to the messages they had just read.

But, most importantly, this study was done in the US and therefore has very limited applicability to the UK situation. Drugs are not marketed to the general public in the UK as they are in the US. Prescribed weight loss treatments are not advertised and have a specific set of criteria controlling their prescription. 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Are slimming pills FUELLING the obesity epidemic? Dieters using them 'mistakenly believe they can eat whatever they want'. Mail Online, November 13 2014

Links To Science

Bolton LE, Bhattacharjee A, Reed A. The Perils of Marketing Weight Management Remedies and the Role of Health Literacy. Journal of Public Policy & Marketing. Published online September 22 2014

Categories: Medical News

Sex with funny, rich men linked with more orgasms

Medical News - Thu, 11/13/2014 - 13:45

“Women have stronger orgasms if their partner is funny – and rich”, says the Mail Online.

This headline is wrong. And the research it’s based on, while fascinating, is rather inconclusive.

The study in question asked a small group of female students, who were in sexual relationships with men, to anonymously rate their sex lives and certain features of their partner, including estimates of wealth.

It found that how often a woman has an orgasm during sexual intercourse is linked to her partner’s family income, his self-confidence and how attractive he is. The intensity of a woman’s orgasm was related to how attractive she found her partner, how many times she had sex in a week and her overall rating of sexual satisfaction.

From this the authors conclude that female orgasms function to promote “good mate choices”.

It’s hardly surprising that this small, unrepresentative survey found that frequency and intensity of women’s orgasms and their general level of sexual satisfaction, was related to how attractive they found their partners. But it’s a leap of the imagination to conclude from this that female orgasm plays a role in choosing a healthy, fertile male with high quality genes.

It is interesting that the study found a link between frequency of orgasm and the male partner’s family income. For example, this may mean the couple had somewhere comfortable and private to go, so that they had sex more often.

There are many factors which influence the quality and frequency of orgasm, including a woman’s self confidence and awareness of her needs. This research only asked questions about orgasm during sexual intercourse (which does not happen as a matter of course). Many women who don’t achieve an orgasm through intercourse will do so in other ways.

 

Where did the story come from?

The study was carried out by researchers from the State University of New York. There is no information about external funding.

The study was published in the peer-reviewed journal, Evolutionary Psychology and appears to be available on an open access basis.

Predictably, the Mail went to town on the story. However, its headline linking orgasm intensity to the male partner’s wealth was incorrect. The study found a link between the partner’s family income and the women’s orgasm frequency – but not its intensity.

 

What kind of research was this?

This study set out to look at whether female orgasm “functions to promote good mate choices”, as the authors put it. The analysis was based on an anonymous online survey of 54 female undergraduate students, about their sexual behaviour and experience. It’s worth noting that this was not a random or representative sample – the students were all volunteers, were all enrolled in a psychology course, and were also given credit for participating.

The authors say that “mate choice” is not a trivial issue for women. There is growing evidence that features people find attractive in members of the opposite sex function as indicators of good genes and act as signals for health and fertility, they say. A number of studies show that the occurrence and frequency of female orgasm may be related to the characteristics of their partner such as attractiveness, wealth and masculinity, they claim.

 

What did the research involve?

The researchers recruited 54 female undergraduate students who volunteered to participate in an anonymous online survey. Participation was restricted to those who were in a committed relationship with a man that involved sexual intercourse.

The survey consisted of questions concerning the women’s subjective views on sexual behaviour, prior sexual experience, feelings toward their committed partner, and various estimates of features of their partner. They included questions on the male partner’s:

  • family income, financial independence, income potential 10 years from now
  • age (including the age gap between the partners)
  • grade point average (educational achievement)
  • ambition, creativity, responsibility, motivation
  • athleticism, health
  • discipline, conscientiousness, intelligence
  • sense of humour
  • level of focus and determination
  • self-confidence, leadership qualities, popularity
  • aggressiveness
  • muscularity, fatness, width of shoulders
  • physical attraction as rated by the woman and as rated by friends
  • protectiveness

Questions about sex included:

  • how often a woman had orgasm (with answers ranging from never to always or almost always)
  • how often she initiated intercourse (with answers ranging from never to always or almost always)
  • how many sexual partners she had had
  • age when she first had sexual intercourse
  • the intensity of orgasms during intercourse with her partner (with answers ranging from weak to very intense)
  • the number of orgasms experienced during a single encounter (with answers ranging from less than one to three or more)
  • level of sexual satisfaction with partner (with answers ranging from not at all to exceptional)

 

What were the basic results?

The researchers found that how often women experienced orgasm was related to how she rated her partner’s family income, his self-confidence, and how attractive she said he was.

Orgasm intensity was related to how attracted women were to their partners, how many times they had sex per week, and to their ratings of sexual satisfaction.

Those who said their friends rated their partners as attractive also tended to have more intense orgasms.

Sexual satisfaction (which could be said to be the most meaningful outcome) was related to how physically attracted women were to their partner and how they viewed the breadth of their partners’ shoulders.

Women who began having sexual intercourse at earlier ages had more sex partners, experienced more orgasms, and were more sexually satisfied with their partners.

Certain characteristics of the male partner – motivation, intelligence, focus, and determination – predicted how often women initiated sexual intercourse.

The partner’s sense of humour also predicted women’s propensity to initiate sex, how often they had sex, and it enhanced their orgasm frequency in comparison with other partners.

 

How did the researchers interpret the results?

The researchers say their findings suggest that “women in committed relations with high quality opposite-sex mates are putting a premium (wittingly or not) on traits that would confer an advantage in the psychological domain when it comes to how well her partner and, by implication, how well her male descendants could compete with other males for scarce resources.”

Orgasm intensity, they argue, may be a factor in the strength of vaginal and intrauterine contractions that accompany orgasm. These in turn could promote the movement of sperm up through the female reproductive tract and increase the chances of conception.

 

Conclusion

This was a small and unrepresentative survey of young female students which relied on the women self-reporting their sexual relationships in an anonymous online survey.

The fact that it found links between how attractive women found their partners and their quality and frequency of their orgasms as well as overall sexual satisfaction is hardly surprising. Whether the intensity or frequency of a female orgasm is a factor in choosing a mate for his genes remains only a theory. This study goes no way toward proving or disproving that theory.

Many factors affect female orgasm, including mood, knowledge, physical health and past experience. Help is available if you are finding that your sexual experiences are not satisfactory.

 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter. Join the Healthy Evidence forum.

Links To The Headlines

Women have stronger orgasms if their partner is funny - and rich, study finds. Daily Mail, 12 November 2014

Links To Science

Gallup G, et al. Do orgasms give women feedback about mate choice? Evolutionary Psychology. 2014;12:958-978.

Categories: Medical News

'Smart drug' modafinil may not make you brainier

Medical News - Thu, 11/13/2014 - 11:45

“Smart drug ‘may help improve creative problem solving’,” is the headline in The Daily Telegraph.

The media reports have been prompted by a new study on the effects of modafinil – a drug licensed to treat narcolepsy. Modafinil’s claim to fame is that it’s been touted as a so-called “smart drug” that can help brain performance, and is reportedly very popular among university students.

Researchers gave 64 healthy volunteers either modafinil or a placebo and asked them to complete a spoken language test. Contrary to the Telegraph’s headline, the people who took modafinil had slowed responses, and were no more accurate than the placebo (this claim seems based on a previous trial by one of the researchers).

The exact way modafinil promotes “wakefulness” is not fully understood. The test used in the research is only one measure of cognitive function, and modafinil may show improvements in the performance of other tests.

Modafinil is a prescription-only medicine that is licensed only for the treatment of narcolepsy. The drug is not without side effects, and has been associated with a risk of serious adverse effects, including psychiatric disorders and skin reactions.

Drug regulators say that the benefits of modafinil only outweigh the risks for the treatment of narcolepsy. Therefore, just because you can buy it online without a prescription, doesn’t mean you should.

 

Where did the story come from?

The study was carried out by researchers from the University of Cambridge, the University of Nottingham and Towson University. It was funded by the Wellcome Trust.

The study was published in the peer-reviewed journal PLOS One. This journal is open access, meaning that its contents can be read for free.

Despite referencing the current study, much of the media's reporting seemed to focus on the results of a study by one of the researchers published back in September 2014, perhaps because the press release for this study mentioned the results of the previous study. Interestingly, the title of this press release was “'Smart' drugs won't make smart people smarter”. To see just how far a message can be spun in the media, compare this to the Telegraph’s headline of, “Smart drug ‘may help improve creative problem solving’”. By contrast, The Times' headline was spot on.

 

What kind of research was this?

This was a randomised controlled trial that aimed to determine the effects of modafinil (a licensed treatment for narcolepsy) on the performance of healthy people in the Hayling Sentence Completion Test. The Hayling test involves listening to sentences with a missing word and providing either the missing word or a word unrelated to the sentence.

Narcolepsy is a rare sleep disorder where there is disturbance of the normal sleep-wake cycle and people suffer from excessive daytime sleepiness. The researchers performed this experiment because it has been suggested that modafinil might improve task performance, while slowing it – a phenomenon that has been referred to as “delay-dependent cognitive enhancement”. Modafinil is reportedly used off-label (outside of its licensed indication) by some healthy people, notably students, as a “smart drug” to try to enhance cognitive performance. One student website’s survey estimates that 20% of students may have taken modafinil, with almost half buying it online and many taking it daily.

A randomised controlled trial is the ideal way to determine the effects of modafinil.

 

What did the research involve?

The researchers randomised 64 healthy people to take a single oral dose of 200mg modafinil, or a placebo.

Two hours after people were given modafinil or placebo, the researchers assessed their performance on the Hayling Sentence Completion Test.

The Hayling test consisted of 30 sentences, each missing the last word, which were constructed to strongly constrain what the missing word should be.

In the first section, people were asked to listen to sentences, and were asked to provide, as quickly as possible, a word that correctly and sensibly completed the sentence.

Participants were then asked to complete sentences, as quickly as possible, with words unrelated to the meaning of the sentences in every way.

Both responses and reaction times were recorded, and the performance of people who were randomised to modafinil compared to those randomised to placebo.

 

What were the basic results?

People who took modafinil took significantly longer to provide a word.

There was no difference in the number of errors made on the test between people who received modafinil and people received placebo, showing that modafinil did not improve accuracy.

 

How did the researchers interpret the results?

The researchers concluded that in this study, “participants administered modafinil took significantly longer to perform the Hayling Sentence Completion Test across task sections than placebo-treated participants, without showing any improvement with regard to errors on the task”.

 

Conclusion

Modafinil is reported to be frequently used outside of its licensed indication (treatment of narcolepsy) to enhance cognitive performance. This study has cast doubt upon these supposed effects. In this RCT, modafinil slowed responses while having no effect on the accuracy of performance on the Hayling Sentence Completion Test.

The exact way modafinil promotes wakefulness is not fully understood. The Hayling Sentence Completion Test is only one measure of cognitive function, and it may be that modafinil has different effects on the performance of different tests. For example, modafinil has been a way to aid concentration and avoid distraction while studying. As one student website put it: “it’s a big boost to lazy people to force themselves to work”.

However, most importantly, modafinil is a prescription-only medication that is licensed only for the treatment of narcolepsy. The drug is not without side effects; it has been associated with a risk of serious adverse effects, including psychiatric disorders and skin reactions, as well as reducing the effectiveness of hormonal contraceptives.

This study has only assessed the one-off use of this drug in a relatively small sample of people. The study has not looked at safety outcomes, and we don’t know what adverse effects there might be for healthy individuals regularly taking this drug solely for the purpose of trying to enhance cognitive performance.

The European Medicines Agency has concluded that the benefits of modafinil-containing medicines continue to outweigh the risks only for the treatment of narcolepsy. This prescription drug cannot be recommended for any other use. Therefore, it would be unwise to buy modafinil (or similar products) online without a prescription from your doctor.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Smart drug "may help improve creative problem solving". The Daily Telegraph, November 12 2014

Smart drugs make bright students worse in tests. The Times, November 12 2014

Links To Science

Mohamed AD, Lewis CR. Modafinil Increases the Latency of Response in the Hayling Sentence Completion Test in Healthy Volunteers: A Randomised Controlled Trial. PLOS One. Published November 12 2014

Categories: Medical News

Long-term mobile phone use and brain cancer

Medical News - Thu, 11/13/2014 - 11:28

"Do mobile and cordless phones raise the risk of brain cancer?" asks the Mail Online.

There are now more mobile phones than people in the UK, so you would expect the commonsense answer to be a resounding "no". But, as we never get tired of saying, it's a bit more complicated than that.

The Mail Online reports on the latest study looking for evidence of a link between mobile and cordless phone calls and brain tumours. This large Swedish study found more than 25 years' use of mobile phones trebled the (very small) risk of glioma, the most common type of brain tumour.

The study matched healthy volunteers with people who had been diagnosed with a glioma, and asked them to estimate the amount of time they had ever spent using mobile and cordless phones. This ranged from less than one year to around 25 years.

The researchers found:

  • any mobile phone use increased the risk of glioma by a third
  • using 2G phones for 15 to 20 years doubled the risk
  • 3G phone (smartphones) use for 5 to 10 years gave four times the risk (the research was carried out before the launch of 4G phones)

However, some of these results were based on very small numbers and so may not be reliable. And this type of study cannot prove that mobile phones cause brain tumours.

It has not taken into account other factors, including exposure to chemicals or occupational hazards, despite collecting this information. Even so, it could not account for every possible confounder.

It is also rather unlikely that the estimates for the extent of mobile phone usage are accurate. So, it remains unclear whether there are long-term cancer risks associated with mobile phone use.

 

Where did the story come from?

The study was carried out by researchers from the University Hospital in Örebro, Sweden and was funded by Cancer- och Allergifonden, Cancerhjälpen, the Pandora-Foundation for Independent Research, and the Berlin and Kone Foundation, Helsinki, Finland.

It was published in the peer-reviewed medical journal Pathophysiology, and appears to be available on an open-access basis.

The Mail Online has reported the story reasonably accurately, and put the findings into context, citing a previous large study looking at the risk of mobile phone use and brain cancer.

 

What kind of research was this?

This was a case-control study that aimed to see if there was an association between mobile phone use and the development of a type of brain tumour called glioma.

In this study, cases (people who have a glioma) were matched with controls (people of the same age without brain tumours). The researchers then looked at a variety of factors that each group had been exposed to.

This is a type of epidemiological study, which can identify potential risk factors for developing a brain tumour. However, this kind of study cannot prove that any of these factors directly caused the brain tumour.

 

What did the research involve?

The researchers contacted all adults aged 20 to 80 who were newly diagnosed with a brain tumour in central Sweden from 1997-2003, and all cases throughout Sweden aged 18 to 75 from 2007-09.

They recruited 1,498 (89%) people – 879 men and 619 women. The majority (1,380) had a glioma. The researchers matched each case by age and gender at random using the Swedish Population Registry to obtain a control group of 3,530 people.

A questionnaire was sent to all cases and controls to determine their exposure to mobile phones and cordless desktop phones. As mobile phones have changed during this timescale, the type of mobile phone exposure was recorded, including:

  • first generation – output power 1 Watt, 900 MHz
  • second (2G) generation – pulsed output power of tens of microWatts (mW), 900 or 1800 MHz
  • third generation (3G) – output power tens of mW, amplitude modulated

The questions asked about:

  • preferred ear for using a mobile or cordless phone
  • number of years of exposure and average daily use
  • overall working history
  • exposure to different chemicals
  • smoking habits
  • X-ray exposure to the head and neck
  • hereditary traits for cancer

If any of the answers were unclear, a follow-up telephone interview was conducted by someone who was not informed if the person was a case or a control.

The researchers performed statistical analyses to take socioeconomic status into account.

 

What were the basic results?

Any mobile phone use increased the risk of glioma by a third (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1 to 1.6).

More than 25 years' use of mobile phones trebled the risk of glioma (OR 3.0, 95% CI 1.7 to 5.2). This was based on 29 cases and 33 controls.

For the longest possible periods of use of newer mobile phones:

  • 2G phone use for 15 to 20 years doubled the risk of glioma (OR 2.1, 95% CI 1.5 to 3.0)
  • 3G phone use for 5 to 10 years gave four times the risk of glioma (OR 4.1, 95% CI 1.3 to 12) – this was based on 12 cases and 14 controls

Use of cordless phones also increased the risk (OR 1.4, 95% CI 1.1 to 1.7), with the greatest risk seen in people who had used cordless phones for 15 to 20 years (OR 1.7, 95% CI 1.1 to 2.5). This was based on 50 cases and 109 controls.

The odds of glioma increased significantly for every 100 hours of use and for every year of use.

First using a mobile or cordless phone before the age of 20 increased the odds of glioma more than first use at older ages.

 

How did the researchers interpret the results?

The authors report that this study gives further support to their previous research, in which they concluded that gliomas "are caused by RF-EMF [radiofrequency electromagnetic field] emissions from wireless phones, and thus regarded as carcinogenic, under Group 1 according to the IARC [International Agency on Research on Cancer] classification, indicating that current guidelines for exposure should be urgently revised".

 

Conclusion

This case-control study found mobile phone use is associated with an increased risk of the commonest type of brain tumour, glioma. But this type of study cannot prove that mobile phone use caused the brain tumours, as it cannot account for confounding factors.

Indeed, despite collecting data on variables such as exposure to chemicals and occupation, this information was not taken into account during the statistical analyses.

A further limitation of the study was that the extent of mobile phone use was estimated retrospectively up to a 25-year time period.

It is highly unlikely these estimates would be accurate because of factors such as memory recall, and patterns of mobile phone usage have changed substantially over the years.

There is also the possibility of cases having recall bias after receiving a brain cancer diagnosis and therefore overestimated their mobile usage.

Additionally, many of the calculations were based on very small numbers, which reduces the reliability of the findings.

This study does not prove that mobile phones cause brain cancer, and the long-term effects of mobile phone use remain unclear.

What is clear is that brain tumours are relatively uncommon. While this is a good thing, it means that "proving" what, if any, environmental factors cause them is likely to require a great deal of long-term research effort. 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Do mobile and cordless phones raise the risk of brain cancer? Study finds risk is three times higher after 25 years of use. Mail Online, November 12 2014

Links To Science

Hardell L, Carlberg M. Cell and cordless phone risk for glioma - Analysis of pooled case-control studies in Sweden, 1997-2003 and 2007-2009. Pathophysiology. Published October 28 2014

Categories: Medical News

Watching 'Dad's Army' won't stop you going blind

Medical News - Wed, 11/12/2014 - 13:20

"Fancy an episode of Dad's Army? How watching TV and films can save your eyesight," is the curious headline in the Daily Express.

Its headline is a rather abstract interpretation of research testing the potential for new computer eye-tracking software to help diagnose chronic glaucoma.

In glaucoma, pressure in the eyeball rises, damaging the optic nerve and threatening sight. Chronic glaucoma develops gradually, and loss of peripheral vision is usually the first sign.

The software being studied was designed to detect differences in eye movements between people with healthy eyes and those with glaucoma.

This study included just 44 older people with chronic glaucoma and 32 people of a similar age with healthy vision.

The computer software produced "scan paths", mapping eye movements while people watched three different film and TV clips, which indicated areas of visual loss.

As the news reports noted, one of the clips was from the ever-popular BBC sitcom "Dad's Army", although what was in the TV clips was irrelevant to the study or the patients' eyesight.

The computer software had fairly good accuracy for detecting glaucoma – about three-quarters of the people with glaucoma were correctly identified as having the condition using this test.

But we can only draw very limited further conclusions currently. We don't know whether the software will be affordable and become widely available, or whether it would offer any improvements on current methods used to detect chronic glaucoma.

 

Where did the story come from?

The study was carried out by researchers from City University London and was funded by a project grant awarded by Fight for Sight.

It was published in the peer-reviewed medical journal, Frontiers in Aging Neuroscience.

The media headlines give a misleading interpretation of this study. It is not possible for you to tell whether you have chronic glaucoma simply by watching an episode of "Dad's Army".

The historical sitcom just happened to be one of the TV clips that researchers showed people while tracking their eye movements using specialised computer software.

Even then, the software was not completely accurate at distinguishing which people did and did not have glaucoma. And we don't know that this test is an improvement on standard diagnostic tests.

 

What kind of research was this?

This was a diagnostic study where a control sample of elderly people with healthy vision, and another sample of people with glaucoma, received standard visual examinations. They also watched film and TV clips while a computer tracked their eye movements.

Researchers wanted to see whether they could differentiate between people with and without glaucoma by examining eye movements while someone watches a film.

Glaucoma is a condition where there is raised pressure in the eyeball. This can damage the optic nerve that carries visual information from the retina to the brain. The eye pressure increases because there is a blockage to the channels that drain aqueous fluid from the eye.

The patients in this study had chronic glaucoma, where the pressure in the eye gradually rises, causing a gradual loss of peripheral vision. Chronic glaucoma is more common with increasing age and can often run in families.

Current checks for chronic glaucoma include testing someone's peripheral visual fields, using a machine to measure the pressure in the eyeball, and looking at the back of the eye (retina) to check that the area where the optic nerve attaches to the eye looks healthy. Treatments can involve eye drops and laser surgery.

Chronic glaucoma is different from acute glaucoma, where the pressure in the eye suddenly rises very rapidly. Acute glaucoma is a medical emergency and needs immediate treatment to save the sight in the eye.

The researchers wanted to provide evidence that people with a diagnosis of chronic glaucoma can be distinguished from a group of age-matched healthy people by only using their visual scan paths while they watch a film or TV programme.

 

What did the research involve?

The researchers recruited 44 adults aged 63 to 77 with chronic glaucoma from Moorfields Eye Hospital in London. They deliberately recruited a sample of people who had variable degrees of visual field loss.

A comparison group of 32 adults (aged 64 to 75 years) with healthy vision were recruited from an eye clinic where they had received standard eye examinations. Both people with glaucoma and controls had no other significant health problems.

All participants had their visual fields tested using the optimal test designed to identify the early visual field loss associated with early glaucoma, the Glaucoma Hemifield Test (GHT), using a Humphrey Field Analyser (HFA).

The GHT was "outside normal limits" for all people with glaucoma and "within normal limits" for the controls.

The HFA mean deviation is the overall measure of the severity of the clinical field defect, and people with glaucoma were classed as having early disease if their mean deviation was better than -6dB in both eyes, and advanced disease if worse than -12dB.

The researchers outlined how people in the latter category would normally have symptoms and would most likely fail the visual field component for fitness to drive.

Best corrected visual acuity was also tested for all participants. There was little difference between people with glaucoma and healthy controls.

The main experiment involved participants viewing three separate TV and film clips taken from the 1970s TV comedy "Dad's Army", the 2006 film "The History Boys", and the 2010 Vancouver Winter Olympics men's ski cross event.

While they watched, the movements of the eye were tracked using special optical software. The software builds a scan path, illustrating the person's quick eye movements (called saccades) and fixations while they are watching. This scan path can indicate areas of vision loss.

 

What were the basic results?

Scan paths were built for each of the three film clips taken for both people with glaucoma and the controls – a total of 205 film clips.

Using a statistical measure known as the ROC curve, the researchers found the use of scan paths to detect chronic glaucoma was 0.85 (95% confidence interval [CI] 0.82 to 0.87) – with 1 indicating a perfectly accurate test, and 0.5 a useless diagnostic test with results no better than chance.

The result of 0.85 suggests scan paths obtained from this computer programme were a good – but not completely accurate – method of distinguishing between people with and without glaucoma.

The technique had a sensitivity of 76% (95% CI 58 to 86%), indicating roughly three-quarters of people with glaucoma would be accurately detected by using this test.

At this detection rate, the specificity was 90%, meaning 9 out of 10 people without glaucoma would accurately test as being free from the condition.

 

How did the researchers interpret the results?

The researchers concluded that, "Huge data from scan paths of eye movements recorded whilst people freely watch TV-type films can be processed into maps that contain a signature of vision loss.

"In this proof of principle study we have demonstrated that a group of patients with age-related neurodegenerative eye disease can be reasonably well separated from a group of healthy peers by considering these eye movement signatures alone."

 

Conclusion

This research demonstrates that a particular software application has fairly good accuracy for distinguishing between people with and without chronic glaucoma.

The scan paths that the software built, mapping eye movements while watching TV or film clips, were able to accurately pick up about three-quarters of those with glaucoma. Meanwhile, 9 out of 10 people without the condition accurately tested as being free from glaucoma.

The researchers appropriately call this a proof of concept study, in that they have demonstrated that the technique can reasonably separate people with and without chronic glaucoma.

But we can only draw limited further conclusions at this time. This study only tested a fairly small sample of people, and we don't know whether the same accuracy results would be obtained if a separate, bigger sample were tested.

We also don't know whether this test could offer any improvements on current methods for detecting chronic glaucoma. For example, it is not known whether the test could detect peripheral field defects any earlier than current standard visual field tests (combined with pressure testing), and so ultimately lead to the earlier detection and treatment of chronic glaucoma.

Of course, the ultimate aim of earlier detection is to improve outcomes for people in terms of preserving their vision. However, the current stage of research can offer no indication of whether this treatment could help "save your eyesight", as the Express headline suggests. As yet, no study has examined the longer-term outcomes of people with chronic glaucoma detected solely using this test.

Overall, these results suggest this software could have potential as a diagnostic technique to detect visual field loss in chronic glaucoma. However, it remains to be seen whether this test will ever be widely used in diagnostic practice, or how it would supplement or replace current standard tests.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Fancy an episode of Dad's Army? How watching TV and films can save your eyesight. Daily Express, November 12 2014

How watching Dad's Army could help detect the leading cause of blindness. Daily Mail, November 11 2014

Links To Science

Crabb DP, Smith ND, Zhu H. What's on TV? Detecting age-related neurodegenerative eye disease using eye movement scanpaths. Frontiers in Aging Neuroscience. Published November 11 2014

Categories: Medical News

Health workers 'neglect hygiene late in their shifts'

Medical News - Wed, 11/12/2014 - 13:20

“Visit hospital in the morning to be sure of a doctor with clean hands,” reports The Daily Telegraph.

The Telegraph cites a US study which found healthcare workers often fail to wash their hands and are more likely to wash their hands as advised at the beginning of their shift (not necessarily the morning) than at the end.

Researchers used electronic ID tags for healthcare workers with detectors placed on soap dispensers and hand gels in patients’ rooms to collect data on when the workers washed their hands.

They found that, at most, workers washed their hands on 42.6% of the occasions that they should have. This figure reduced to 34.8% of occasions by the end of a 12-hour shift. Workers were also more likely to wash their hands after longer time off between shifts.

Despite national and local instructions on hand hygiene and infection control, it’s clear from this study that healthcare workers will forget or not bother. And it seems that the more tired – or less rested a worker is – the more likely they are to forget or overlook handwashing rules.

If you’re in hospital or you’re visiting an inpatient, you also have a responsibility to wash your hands before entering areas where patients are and wherever prompted, as well as when leaving. And don’t be afraid to ask health professionals if they’ve washed their hands too.

 

Where did the story come from?

The study was carried out by researchers from the University of Pennsylvania and the University of North Carolina at Chapel Hill and was funded by the Wharton Dean’s Research Fund and the Wharton Risk Management and Decision Processes Center.

The study was published in the peer-reviewed Journal of Applied Psychology.

The media reported the story fairly accurately, although both the Mail Online and the Telegraph made the error of suggesting that professionals in hospitals have cleaner hands in the morning. In fact the research found that workers were more likely to clean their hands at the start of a shift. As hospitals are open round the clock with shifts overlapping, this could be at many different times of the day. If you’re in doubt,  ask your health professional if they’ve washed their hands – they shouldn’t mind you asking.

The Telegraph’s headline focussed just on doctors, when they had actually only made up 4% of the health workers studied. The Mail Online illustrated its story with a photo of a surgeon washing his hands in an operating theatre environment, but the study did not involve any preparation around surgery.

 

What kind of research was this?

This was an observational study which compared the number of times health workers complied with the expectation that they should wash their hands both on entering and exiting a patient’s room. As the study was only conducted using radiofrequency equipment, it is not able to provide any explanation for why hands were not washed on each of these occasions.

 

What did the research involve?

The researchers obtained data from a company that uses “radiofrequency devices” to monitor whether health workers use hand hygiene measures on entering and exiting patient’s rooms. Radiofrequency devices use wireless technology to detect and record devices that have electronic tags implanted in them.

56 units from 35 US hospitals were fitted with these devices to measure hand hygiene opportunities between 2010 and 2013. In this case the radiofrequency devices comprised a “communication unit” attached to soap dispensers and hand sanitisers in patients’ rooms, and radio-frequency badges worn by hospital workers to track their movement and use of the dispensers. From this data, the researchers were able to calculate the number of opportunities that should have led to hand hygiene (the “compliance”), such as every time the health worker entered and exited a patient’s room, and the number of actual episodes.

They collected data from 4,157 health workers, which included:

  • nurses (65%)
  • patient care technicians (12%)
  • therapists (7%)
  • doctors (4%)
  • clinical directors, infection prevention specialists, and others (12%)

The researchers assumed shift patterns and time off work by at least a seven hour gap between the last time they had exited a room and the next time they entered. They excluded any shifts of more than 12 hours.

 

What were the basic results?

The main results were:

  • hand washing “compliance” reduced from 42.6% of opportunities during the first hour of a shift to 34.8% in the last hour of a 12-hour shift
  • increasingly frequent interactions with patients and more time spent in patients’ rooms reduced hand washing compliance
  • hand washing frequency improved after more days off between shifts
  • taking an additional half day off (12 hours) was associated with a 1.3% increase in hand washing compliance
  • the more hours worked in the previous week, the faster the hand washing compliance reduced during a shift

Using the results of a Swiss study which found that a 1% increase in hand washing reduced the number of infections by 3.9 per 1,000 admitted patients, the researchers calculated that:

  • the decrease in hand washing compliance would cause 7,500 unnecessary infections per year across the 34 hospitals they studied
  • this would equate to 0.6 million infections across all US hospitals per year
  • if 5.82% of hospital acquired infections are fatal, this would mean there would be 35,000 unnecessary deaths per year in the US

 

How did the researchers interpret the results?

The researchers concluded that their findings suggest that immediate and continuous demanding work environments result in a gradual reduction in compliance with professional standards over the course of aday. They want future research to look at what changes can be made that might improve compliance with hand washing.

 

Conclusion

This study has found that the compliance with the expectation for health workers to use soap or hand sanitiser both on entering and exiting patients’ rooms was, at best, only 46%. They also found that this reduced over the course of a shift to just 34.8%.

This is even more surprising given that the health workers knew they were being monitored and were wearing the badges.

Reasons for this seemingly low overall compliance rate include that there may have been occasions where there was no direct patient contact (such as just talking to the patient). However, this does not account for why the compliance rate changed over the course of a shift, and is not a valid excuse under the protocol for washing hands. The researchers suggest that the reduced compliance, especially over the course of a shift is due to depleted “mental reserves”. However, the study did not look at how any interventions might improve the compliance.

This study highlights our natural human fallibility – especially when tired. Even with protocols, guidelines and diktats, we tend to forget or neglect to do very important things. In this case, health professionals forgot vital hand hygiene when dealing with patients.

However, it’s worth bearing in mind that this study was carried out in the US, where hospital set-ups are likely to be different (for instance, the patients are described as having their own rooms, which is less common in NHS hospitals).

In the UK, NICE recommends that all healthcare workers should always clean their hands thoroughly, immediately before and immediately after coming into contact with a patient or carrying out care, and even after wearing gloves.

When visiting someone in hospital, you should also be vigilant about washing your hands before and after entering a patient’s room and in other areas of the hospital.

If you are concerned about the hand hygiene of doctors, nurses or anyone else who comes into contact with you or the patient you are visiting, ask them whether they have cleaned their hands.

 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter. Join the Healthy Evidence forum.

Links To The Headlines

Hospital patients ‘more likely to see doctors and nurses with clean hands if they have appointment in the morning’. Mail Online, 11 November 2014

Visit hospital in the morning to be sure of a doctor with clean hands. The Daily Telegraph, 11 November 2014

Links To Science

Dai H, et al. The Impact of Time at Work and Time Off From Work on Rule Compliance: The Case of Hand Hygiene in Health Care. Journal of Applied Psychology. 3 November 2014

Categories: Medical News

Genes tweaked to 'starve' prostate cancer cells

Medical News - Tue, 11/11/2014 - 15:10

"Prostate cancer could be 'halted' by injections," reports The Independent.

While this headline rather simplifies the research findings, the research it's based on demonstrates an interesting way to stop prostate cancer – for mice, at least.

In the research, mice with a "model" of prostate cancer were treated with chemicals that inhibit a protein called SRPK1. As a result, the growth of their cancer was reduced.

The researchers performed additional experiments, which showed SRPK1 is involved in the control of how new blood vessels grow. Blood vessels are required to bring oxygen and nutrients and remove waste, which is thought to be key for tumour growth.

Without SRPK1, blood vessel formation was reduced – suggesting that this could "starve" the tumours (as the Mail puts it) of food and oxygen.

Interestingly, this study suggests SRPK1 inhibitors may be used to treat prostate cancer, and potentially some other forms of cancer.

Because this has only been tested on mice, we have no way of knowing if the treatment will be safe for men with prostate cancer, let alone more effective than other treatments currently available.

 

Where did the story come from?

The study was carried out by researchers from the University of Bristol, North Bristol NHS Trust, the University of the West of England and the University of Nottingham.

It was funded by Prostate Cancer UK, the Biotechnology and Biological Sciences Research Council, the Medical Research Council, Cancer Research UK and the Richard Bright VEGF Research Trust.

The study was published in the peer-reviewed medical journal Oncogene.

The media reporting was generally accurate, although the headlines might be construed as misleading, as they seem to imply that a new prostate cancer treatment is available.

But these headlines are based solely on the results of experiments on cells grown in the laboratory and on mice. We'll have to wait and see if the proposed therapy is safe and effective enough to treat men with prostate cancer.

 

What kind of research was this?

This was a laboratory and animal study that built on the results of previous research.

Blood supply is required to bring oxygen and nutrients, and remove waste from tissues – including tumour tissue. The growth of new blood vessels (known as angiogenesis) is believed to be essential for tumour growth.

Angiogenesis is caused by the protein vascular endothelial growth factor (VEGF). However, a different form of the protein can be made in a process called splicing, which does the reverse and actually inhibits the growth of new blood vessels.

The researchers recently found the choice of "form" of VEGF is controlled by another protein called SRSF1.

When SRSF1 is modified by another protein called SRPK1, it favours the formation of the form of VEGF, which promotes the formation of new blood vessels. When it is not modified, it favours the formation of the form of VEGF that inhibits the growth of new blood vessels.

In this study, the researchers wanted to see whether:

  • levels of SRPK1 or SRSF1 are increased in prostate cancer cells
  • modification of the VEGF form produced is able to reduce tumour growth in animals

They wanted to see if there was potential for SRPK1 inhibitors to be used as a prostate cancer treatment.

 

What did the research involve?

The researchers first looked at the levels of SRPK1 and SRSF1 in 17 human prostate cancer samples.

They then performed a series of experiments on prostate cancer cells grown in the laboratory.

Following this, they looked at the growth of the prostate cancer cells injected into mice.

 

What were the basic results?

The researchers found levels of both SRPK1 and SRSF1 were higher in malignant (cancerous) areas compared with benign (non-cancerous) areas in the 17 human prostate cancer samples they examined.

When the researchers modified prostate cancer cells so they didn't make SRPK1, they found cells then made more of the form of VEGF that inhibits the growth of new blood vessels. However, the cells were still able to grow, divide and move as normal.

The researchers then injected the prostate cancer cells (either unmodified, or modified so they didn't make SRPK1) into mice. The researchers found the modified prostate cancer cells grew slower, formed smaller tumours, and had fewer blood vessels. 

The researchers then did experiments with chemical inhibitors of SRPK1. They found the chemical inhibitors had similar effects to modifying the cells so they didn't make SRPK1.

When mice with a model of prostate cancer were treated with injections of chemical inhibitors of SRPK1, the growth of tumours was inhibited.

 

How did the researchers interpret the results?

The researchers say the results suggest that, "modulation of SRPK1 and subsequent inhibition of tumour angiogenesis by regulation of VEGF splicing can alter prostate tumour growth, and supports further studies for the use of SRPK1 inhibition as a potential anti-angiogenic therapy in prostate cancer".

 

Conclusion

In this study, researchers have found treating a mouse model of prostate cancer with chemicals that inhibit a protein called SRPK1 reduced cancer growth.

The researchers performed additional experiments, which showed SRPK1 is involved in the control of angiogenesis (the growth of new blood vessels). Blood vessels are required to bring oxygen and nutrients, and remove waste from tissues.

The formation of new blood vessels is thought to be key for tumour growth, and without SRPK1, blood vessel formation was reduced.

This study has suggested SRPK1 inhibitors could be used to treat both prostate and other forms of cancer. However, this study only trialled the potential therapy in mice.

Further studies are needed to show that the treatment is safe for men with prostate cancer. If that is confirmed, more work will be needed to show it is effective in treating men with prostate cancer. 

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Prostate cancer could be 'halted' by injections. The Independent, November 10 2014

Prostate cancer breakthrough as scientists STARVE tumours of their blood supply - stopping them growing and spreading. Mail Online, November 10 2014

Genetic discovery offers new hope for prostate patients. The Times, November 11 2014

Prostate cancer could be 'switched off' with injection. The Daily Telegraph, November 10 2014

Links To Science

Mavrou A, et al. Serine–arginine protein kinase 1 (SRPK1) inhibition as a potential novel targeted therapeutic strategy in prostate cancer. Oncogene. Published November 10 2014

Categories: Medical News

Claims cannabis 'rewires the brain' misleading

Medical News - Tue, 11/11/2014 - 10:26

"Cannabis use 'shrinks and rewires' the brain," reports The Daily Telegraph, with much of the media reporting similar "brain rewiring" headlines.

The headlines are based on a study that compared the brain structure and connections of cannabis users with those of non-users.

The researchers identified several differences between cannabis users and non-users in a region of the brain called the orbitofrontal cortex.

This is part of the reward network, and is enriched with cannabinoid 1 receptors. These bind THC, the active ingredient in cannabis.

Some of the differences seen by the researchers were associated with how long people had used cannabis or the age they started using the drug.

However, although brain differences were found, it is not clear they were caused by cannabis use. It is possible that brain differences mean it is more likely that certain people use cannabis.

 

Where did the story come from?

The study was carried out by researchers from the University of Texas, The Mind Research Network and the University of New Mexico.

It was funded by the US National Institute on Drug Abuse.

The study was published in the peer-reviewed medical journal PNAS. This article was open access, so is free to read online.

The media generally reported the results of this study along the lines of The Guardian's headline: "Smoking cannabis every day 'shrinks brain but increases its connectivity'." But these headlines are misleading.

This study did find differences between the brains of cannabis users and non-users, but because it was only a snapshot in time, we can't tell if the brain differences were caused by cannabis.

It is possible that brain differences mean it is more likely that certain people use cannabis. These could be pre-existing differences in the parts of the brain associated with feelings of reward, and people with this brain structure are more likely to try or persist in using cannabis.

 

What kind of research was this?

This was a cross-sectional study that compared the brain structure and connections of people who used cannabis with the brain structure of non-users to see if there were any differences.

Although this type of study can identify differences in brain structure and connections between cannabis users and non-users, it cannot show that the differences were caused by cannabis use: people with different brain structures may be more likely to use cannabis, for example.

 

What did the research involve?

The researchers used magnetic resonance imaging (MRI) scans to look at the brains of 48 cannabis users, who were using cannabis at least four times a week over the previous six months, and 62 non-users.

The cannabis users varied in age, and the non-users were chosen because they were the same sex and age as the users.

The researchers also used the marijuana problem survey to assess the negative psychological (such as feeling bad about marijuana use), social (such as family problems), occupational (such as missing work), and legal consequences of marijuana use over the previous 90 days.

 

What were the basic results?

The researchers identified several differences between the brains of cannabis users and non-users.

These differences were in a region of the brain called the orbitofrontal cortex. This is part of the reward network of the brain, and is enriched with cannabinoid 1 receptors that bind THC (the "active" ingredient in cannabis).

The researchers found the orbitofrontal cortex was smaller in cannabis users, but there was more connectivity.

Some of the brain differences were correlated with behaviour related to cannabis. Some brain differences varied with duration of use, and some of the differences were associated with the age a person had started using cannabis.

 

How did the researchers interpret the results?

The researchers say that their findings "suggest that chronic marijuana use is associated with complex neuroadaptive processes, and that onset and duration of use have unique effects on these processes".

 

Conclusion

Links To The Headlines

Smoking cannabis every day ‘shrinks brain but increases its connectivity’. The Guardian, 10 November 2014

Cannabis use 'shrinks and rewires' the brain. The Daily Telegraph, 10 November 2014

Smoking cannabis every day 'warps your brain and shrinks grey matter', scientists warn. Daily Mail, 10 November 2014

Links To Science

Filbey FM, et al. Long-term effects of marijuana use on the brain. PNAS. Published 10 November 2014

Categories: Medical News