April 2009 – Helen Jaques

NHS hospital choice advert banned

April 30, 2009 1 Comment

The Advertising Standards Agency has banned an NHS advertising campaign that promotes patient choice on the grounds that the adverts are “misleading”.

The adverts – part of the Good News You Choose campaign conducted by NHS North East – tell patients that they can choose which hospital and at what time they have their treatment.

However, the ASA has upheld a complaint filed by a GP that these claims could not be substantiated – because the NHS could not prove that most patients would be able to exercise their choice in practice they could not make the claims.

A spokesman for the ASA told the BBC, “We considered the ad suggested patients could always choose the date, time and place of their appointment for non-emergency, planned referral but, because NHS North East had not provided evidence that showed that was the case, we considered the ad could mislead readers.”

According to NHS North East, the purpose of the advert was to convey the message that the choice of hospital rested with patients rather than with GPs, as has traditionally been the case, not state how an appointment could be booked or confirmed.

On April 1 this year, government rules changed so that patients referred to see a specialist can choose where they will be treated, including at a private hospital. The new legislation aims to give people more flexibility so that they can fit hospital appointments around their work, family or other commitments.

Neurology

Heavy alcohol consumption can lead to essential tremor

April 27, 2009 26 Comments

tremor Drinking three or four alcoholic drinks a day can double the risk of developing essential tremor – or ‘the shakes’ – in old age, suggest new findings from a Spanish research group. In a report published earlier this year, the same researchers found that individuals with essential tremor were four times more likely to develop Parkinson’s disease than people without the shakes.

Essential tremor is a progressive neurological disorder characterised by uncontrollable shaking of the hands or, in some cases, the head, jaw, face, feet or tongue. An estimated 650,000 people in the UK and five million in the US over the age of 60 are affected by this disorder.

Scientists don’t really know what causes essential tremor. They do know, however, that people with this disorder have damage in the cerebellum part of their brain, including loss of neurons called Purkinje cells. Given that alcohol is known to be toxic to the cerebellum, Louis and colleagues investigated whether alcohol consumption had an effect on the development of essential tremor.

This study assessed lifetime alcohol consumption and neurological symptoms in more than 3,000 people aged 65 years or older. At initial assessment, more than half (1,838 people; 56%) of the participants were found to have had at least one alcoholic drink per day over their lifetime. During the subsequent 3 years, 76 people developed essential tremor.

Individuals who drank 3-4 alcoholic drinks each day were twice as likely to develop essential tremor than those who drank less. In fact, just one or two drinks a day increased the risk by 30%.

The authors suggest that ethanol, a known cerebellar toxin, lowers the threshold for developing ET – a disorder involving the cerebellum. It is also possible that individuals who develop essential tremor use alcohol to self medicate, thus making their shaking worse.

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Louis E et al. (2009) Population-based study of baseline ethanol consumption and risk of incident essential tremor. Journal of Neurology, Neurosurgery & Psychiatry 80 (5): 494-497 DOI: 10.1136/jnnp.2008.162701

Neurology

Jeremy Paxman and Jane Asher to donate brains for research

April 20, 2009 No Comments

Brainiacs Jeremy Paxman and Jane Asher have both pledged to donate their brains for research into Parkinson’s disease – after they’re dead of course.

The Parkinson’s Disease Society has launched a campaign to increase awareness about brain donation as part of national Parkinson’s Awareness Week.

According to research commissioned by the Parkinson’s Disease Society, only 27% of people have considered donating their brain. Conversely, 29% of people know someone affected by Parkinson’s disease.

The Society is hoping to double the number of people on the Parkinson’s Brain Donor Register by the end of 2009. Over 1,000 people have already signed up.

Parkinson’s is an incurable neurodenerative disease that is caused by loss of dopamine-producing nerve cells in the brain. Dopamine is responsible for co-ordinating movement, so sufferers of Parkinson’s disease have trouble with movements such as walking and talking. Parkinson’s disease is characterised in particular by hand tremor, which is the first symptom for 70% of affected individuals.

Only humans get Parkinson’s disease, so it is crucial that scientists have access to human brain tissue in order to develop new treatments. Researchers hope to understand the causes and pathology of the disease by comparing brains from Parkinson’s patients with brains from healthy individuals – that’s where the Brain Bank donors come in.

The Parkinson’s Brain Bank is the UK’s largest human brain bank dedicated to Parkinson’s disease and is based at Imperial College London.

After the death of a donor, the team on call at the Brain Bank dashes to collect the brain, spinal cord and a sample of cerebrospinal fluid within 24 hours. The brain is then weighed, measured and examined, and subsequently brain is divided into two halves, which are preserved differently. The right half of the brain is preserved by quickly freezing it, while the left half is placed in a fixative for about four weeks. Before freezing, tissue samples are taken from 21 different points and the nerve cells are carefully studied under a microscope.

The brain tissue is then provided to researchers around the world who are working towards a cure for Parkinson’s. Since 2002, the Parkinson’s Brain Bank has supplied tissue to more than 80 research projects around the world – including projects in the UK, Europe, USA and Canada.

Gastroenterology & hepatology, Mental health

When is a side effect not a side effect? With antidepressants and functional gastrointestinal disorders

April 6, 2009 3 Comments

ibs New research has shown that the side effects of tricyclic antidepressants reported by patients with functional gastrointestinal disorders (FGDs) such as irritable bowel syndrome (IBS) often aren’t actually real side effects of the drugs. Instead, most of the symptoms experienced by the women in the study were present before they started taking the medication, suggesting that the patients receiving antidepressants were simply over-reporting symptoms rather than experiencing side effects.

Interestingly, the authors of this study note that patients with a higher level of psychological distress were more likely to report symptoms than were less anxious patients. It is possible, therefore, that the ‘side effects’ among such patients were a result of their underlying stress and anxiety and not the antidepressants they were taking.

FGDs comprise gastrointestinal symptoms such as cramps but no clear pathology or anatomical problem. Instead, the primary abnormality is an altered physiological function (ie a change in the way the body works) rather than an identifiable structural or biochemical cause. FGDs do have a strong psychological component though, and are often triggered or exacerbated by stress. As such, antidepressants have proved effective in treating patients with FGDs; however, such drugs often have unpleasant side effects.

The authors of this study enrolled 245 women with FGDs: irritable bowel syndrome, painful constipation, functional abdominal pain, or unspeciﬁed functional bowel disorder. All patients filled in a questionnaire about their various symptoms at the start of the study, then 57 individuals were randomly assigned to receive the tricyclic antidepressant desipramine for 12 weeks and 36 were assigned a placebo for the same period of time.

At 2 weeks, both groups were reporting the same levels feeling tired in the morning, having trouble sleeping, nausea, blurred vision, headaches, and decreased appetite as they had experienced at the beginning of the study, indicating that these signs were not side effects of the tricyclic antidepressant. On the other hand, dry mouth, lightheadedness, dizziness, ﬂushing and jitters or tremors at week 2 were more common among the patients on desipramine than among those on placebo, suggesting that these particular symptoms may be related to the known anticholinergic effects of the medication. By 12 weeks, there was no difference between the two groups in the side effects reported.

Patients with a high score on the SCL-90 GSI test, a measure of psychological distress, reported more symptoms than did patients with lower scores. The authors thus state that the more symptoms a patient reports, the less likely it is that the symptoms are related to the medication.

I think this study has some interesting implications. Given that antidepressants by design are often used in anxious individuals, it seems possible that in many cases the side effects reported with this class of drugs might be due to patients reporting every single symptom they experience, however slight. Given this likelihood of over-reporting, and also the fact that the anxiety itself can cause symptoms, perhaps the side effects of tricyclic depressants are less common than we think, and these drugs might be safe to use in a broader spectrum of patients than is currently treated.

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Thiwan S et al. (2009) Not All Side Effects Associated With Tricyclic Antidepressant Therapy Are True Side Effects. Clinical Gastroenterology and Hepatology 7 (4): 446-451 DOI: 10.1016/j.cgh.2008.11.014

Infectious diseases, Technology

A gr8 way to ensure adherence to tuberculosis medication

April 2, 2009 1 Comment

An ingenious new system has been developed to make sure that patients with tuberculosis (TB) complete their entire course of treatment, thus preventing the emergence and spread of drug-resistant forms of the disease.

TB urine test XoutTB involves a paper strips embedded with chemicals that detect metabolites of the TB drug isoniazid in a patient’s urine. The strips contain four printed numbers, a certain combination of which react and turn a new colour when exposed to the urine of patients who have taken their medication.

Patients then send a mobile phone text message reporting the numbers on their strip to a central database. Those patients who take the drugs consistently for 30 days are be rewarded with cell-phone minutes.

TB is a preventable but potentially deadly bacterial infection that kills almost 2 million people each year. Rates of TB have increased since the 1980s, in part due to the emergence of drug-resistant strains of the TB bacteria.

Drug resistance is a serious barrier to effective treatment of TB and to the permanent eradication of the disease, so serious that the World Health Organisation this week called the problem “a potentially explosive situation”.

Drug-resistant strains of TB emerge when the antibiotic used to treat the infection fails to kill all of the bacteria it targets. The surviving bacteria become resistant to that particular drug and pass this characteristic on to their descendants, thus spreading the trait.

The major cause of TB drug resistance is inadequate treatment, either because the wrong drugs are prescribed or because people don’t take the entire six-month course of medication. In particular, TB medication has considerable side effects, so to many individuals there seems little incentive or personal gain to be had from taking the whole course of medication.

The new monitoring system, developed by José Gómez-Márquez and colleagues of the Innovations in International Health program at Massachusetts Institute of Technology, provides a clear monetary incentive to encourage patients to take the medications that will improve their health and also indirectly benefit the health of others.

Education

Squeamish? Don’t worry, medical students are too

April 1, 2009 7 Comments

BMC Medical Education has just published an interesting study that examined the incidence of fainting among medical students observing surgery. Apparently, more than 1 in 10 medical students almost or completely pass out in the operating theatre.

The authors of this study surveyed 630 clinical medical students in their fourth or fifth (final) year of study at the University of Nottingham medical school in northern England. A total of 77 (12%) students reported at least one episode of near or actual operating-theatre-related loss of consciousness, also known as syncope.

The authors looked pretty closely at factors affecting whether a student was likely to faint in the theatre. Those who did lose consciousness were on average 23 years old (range 20–45 years), were more likely to be an undergraduate student than a graduate student (60 undergrads versus 17 graduates) and were significantly more likely to be female than male (68 females versus 9 males). Gynaecological operations were most likely to cause syncope among the fainters (29% of cases), followed by colorectal surgery (16%) and vascular surgery (16%).

The majority of students who passed out put their episode(s) down to the hot temperature of the theatre or the length of time spent standing. None of the fainters identified needle or blood phobias as a cause of their fainting. The authors do note, however, that 16% of episodes occurred during laparoscopic, or keyhole, surgery. Given that keyhole surgery doesn’t involve much gore and blood, this finding suggests that the operation itself remains a strong contributory factor to fainting in the operating theatre.

Interestingly, more than 50% of the students who reported surgery-related fainting were still keen to pursue a career in surgery, although 16% said that their fainting episode(s) put them off that particular career path.

As well as affecting the clinical education and career choices of medical students, such operating-theatre-related syncope also has implications for patients. In 9% of cases, the operation was affected by the medical student passing out, the most common issue being delays to surgery while the a new assisting student was brought in.

Student BMJ has some practical tips for squeamish medical students. Jessica Whitworth experienced episodes of syncope well into her penultimate year of medical school and eventually got some help from her university’s psychologist, who suggested distraction, dissociation and rationalisation techniques to overcome her problem.

I also have an illustrious history of passing out in medical circumstances. As well as several dramatic fainting episodes during work experience placements at local hospitals, I also spent a considerable proportion of my undergraduate human dissection classes with my head between my legs. In fact, a particularly gruesome lecture even made me pass out once. I find it quite reassuring to know that seasoned medical students also have this problem!

(h/t to Dr RW who pointed out this research on his blog Notes from Dr R.W.)

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Jamjoom A et al. (2009) Operating theatre related syncope in medical students: a cross sectional study BMC Medical Education 9 (1) DOI: 10.1186/1472-6920-9-14