March 2010 – Helen Jaques

Trachea transplants and awful articulation: doing the BMJ podcast

March 29, 2010 No Comments

Last week my colleague Sally Carter and I had a go at doing the news roundup for the BMJ podcast.

First, Sally spoke about the passing of the health reform bill in the US and all the BMJ‘s coverage of the legislation itself and the bill’s rocky passage. Then I covered a remarkable news story about a British boy who received fledgling trachea transplant built with his own stem cells that then grew into a fully functioning organ within his body.

I’ve always had trouble with public speaking and being articulate during presentations, so I was very nervous about doing my first podcast. Despite our countless rehearsals, Sally and I both found it quite hard to simultaneously speak fluently and get all the facts into our segments. The experience was a lot of fun though and I think the finished product turned out OK. Have a listen and let me know what you think.

BMJ Podcast 26 March 2010: Variolae Vaccina

Sexual health

Backpackers in Australia are a sexual health risk

March 24, 2010 No Comments

Young people, especially Brits, famously head to Australia in their droves in search of travel, adventure, and, crucially, some hot weather. In 2009-09, 560,105 international backpackers visited Australia, representing 10.9% of all international visitors.

It seems that backpackers in Oz aren’t just looking for fun and sun though – according to a new study they’re also looking for flings, and are bringing sexually transmitted diseases with them.

Research published in the journal Sexually Transmitted Infections has found that international backpackers in Sydney had a higher number of sexual partners and drunk more alcohol than native Australians. Backpackers also had higher rates of chlamydia and more previous sexually transmitted infections than locals.

The authors of this study retrospectively looked through the medical records at the Sydney Sexual Health Centre and identified 5,702 backpackers – people who had been born outside of Australia and been in the country for less than two years – and 7256 comparison patients – natives or people who had lived in the country for longer than 2 years. The average age of the backpacker group was 25 and almost half had come from the UK.

Backpackers were twice as likely to report drinking alcohol at hazardous levels than were comparison patients. More than a quarter (27%) of female backpackers reported drinking more than 17.5 units of alcohol a week, equivalent to about eight glasses of wine, whereas only 14% of comparison women drank at this level. A total of 17% of male backpackers drank more than 35 units of alcohol a week, roughly 15 pints of beer, compared with 5% of comparison men.

About 40% of backpackers reported having had two or more sexual partners in the previous 3 months, compared with 30% of comparison patients. Interestingly, condom use was low in both the backpacker group and the comparison group: two thirds of each group reported having had unprotected sex.

When it came to rates of sexually transmitted infections, backpackers were more likely to be diagnosed with chlamydia (7% vs 5%) and have a history of sexually transmitted infections (15% vs 10%). However, locals were more likely to have genital warts.

The authors point out the public health implications of their findings – international backpackers are a potential risk population for either acquiring sexually transmitted diseases or transmitting them to other travellers or local residents. “Although we could not determine the extent of the risk of transmission to local residents from our study,” they say, “it has been demonstrated that being born overseas or having a partner from overseas was a risk factor for chlamydia infection in Sydney women.”

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McNulty A et al. (2010) The behaviour and sexual health of young international travellers (backpackers) in Australia. Sexually Transmitted Infections DOI: 10.1136/sti.2009.038737

Cancer

News reports on cancer don’t give the full story

March 22, 2010 1 Comment

Cancer stories seem to make the news on a daily basis. For example, just today in the UK there are stories about a gene that could predispose non-smokers to lung cancer, how infertile men are at raised risk of prostate cancer, and how testing for the HPV virus during cervical screening doesn’t help pick up women who might go on to develop cervical cancer.

But it’s not just a case of “all publicity is good publicity.” Research published recently in Archives of Internal Medicine has shown that newspaper and magazine stories on cancer tend to focus on survival and aggressive treatments but steer clear of covering treatment failure, side effects of treatment, end of life care, and death.

The authors of this study looked at 436 500-word articles from top American newspapers and magazines, such as Chicago Tribune, New York Times, Newsweek, and Time. The 312 newspaper articles and 124 magazine pieces largely covered breast cancer (35.1%) and prostate cancer (14.9%), two of the most common types of cancer in the US.

Articles were more likely to focus on people who had survived or been cured of cancer than on people who had died of the disease (32.1% vs 7.6%). In fact, those articles that covered individual patients (173 articles; 216 individuals), more than three quarters covered success stories and only a fifth told the story of someone who had died of cancer.

Few articles (13.1%) pointed out that aggressive treatments such as chemotherapy can fail or that late stage cancer can be incurable. Moreover, less than a third highlighted the side effects associated with such treatments, like pain, hair loss, and nausea.

Only two articles (0.5%) exclusively covered palliative or hospice care for when treatment options had run out, whereas more than half (57.1%) instead focused solely on aggressive treatment.

Given that one in every two men and one in every three women in the US will be diagnosed with cancer in their lifetime, half of whom will die from their cancer or related complications, this optimistic skew in media reporting of cancer is somewhat misleading.

Cancer news coverage is known to affect the beliefs and behaviours of patients; for example, media coverage of mammography screening is known to increase the use of mammography in women. As such, “The tendency of the news to report on aggressive cancer treatments and survival but not on alternatives is also noteworthy given that unrealistic information may mislead the public about the trade-offs between attempts at heroic cures and hospice care,” say the authors.

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Fishman, J., Ten Have, T., & Casarett, D. (2010). Cancer and the Media: How Does the News Report on Treatment and Outcomes? Archives of Internal Medicine, 170 (6), 515-518 DOI: 10.1001/archinternmed.2010.11

Cardiovascular medicine

Winter getting you down? It might also be making you unhealthy

March 19, 2010 No Comments

Do the long nights and shoddy weather over the winter months make you feel low? If so, you could also be at raised risk of cardiovascular disease and being overweight, according to new research in PLoS ONE.

This study of 11,545 Norwegian adults found that people who were classified as having considerable variations in mood across the seasons had a higher BMI and waist to hip ratio, and higher levels of fat in their blood, than people who were less affected by the seasons.

In addition, women who had “high seasonality” tended to do less exercise and were more likely to smoke daily than their “low seasonality” counterparts. All these factors add up to an elevated risk of cardiovascular disease, according to the study authors.

The most well known variant of seasonal mood changes is seasonal affective disorder (SAD), which is characterised by severe episodes of depression that only occur during a particular time of year. SAD affects an estimated 7% of the UK population every winter between September and April, in particular during December, January, and February. Seasonality is distinguished by milder variations in mood rather than major lows, although high seasonality combined with a propensity for depression is thought to be a risk factor for SAD.

People with SAD or high seasonality tend to eat more, gain weight, and feel more sleepy during episodes. This could be advantageous from an evolutionary point of view, because it could facilitate energy storage and promote reproductive potential in the seasons optimal for conception, gestation, and lactation. In the modern world, however, we have access to resources all year round and don’t have to worry about energy storage, so seasonality may conversely be a stress factor.

In the new PLoS ONE study, all individuals in Hordaland county, Norway, born between 1953 and 1957 (i.e. aged 40–45 years) were invited to participate, 63% of whom said yes. These 8,598 men and 9,983 women filled in questionnaires about their seasonal fluctuations in mood and behaviour and about their health behaviours. Blood samples were taken and height, weight, waist circumference, hip circumference, and blood pressure were measured.

In both men and women, weight, BMI, waist-hip ratio, and blood levels of triglycerides increased as the level of seasonality increased. For example, the average BMI for men with low seasonality was 25.9, a touch overweight but otherwise fine, but for men with high seasonality to the point of having SAD the average BMI was 27.1, definitely overweight.

Women with high seasonality were about 20% less likely to do at least three hours of exercise a week than their less affected counterparts, and tended to drink and smoke more. Furthermore, the association between seasonality and BMI in women was affected by when the researchers took their measurements: BMI increased over autumn and winter in women with high seasonality.

Given the high BMI, weight, and blood fat levels in people with high seasonality, the authors state that “Overall it seems to be fair to conclude that subjects with high seasonality have an elevated risk for cardiovascular disease.” They do point out that a cross-sectional study such as theirs can’t pinpoint causation though: we don’t know whether high seasonality causes poor health or whether poor health is responsible for high seasonality.

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Øyane N et al. (2010) Increased Health Risk in Subjects with High Self-Reported Seasonality. PLoS ONE 5 (3). DOI: 10.1371/journal.pone.0009498

Public health, Sexual health

A healthy life leads to a healthy sex life

March 16, 2010 No Comments

Being in good or excellent health increases the quality and quantity of sex for middle aged and older people, according to a big study that delved into the sex lives of 6,000 American adults aged 25-85. Plus being fit can keep you sexually active into a ripe old age, unlike your unhealthy peers.

The study also had a whole raft of other expected findings, some rather expected (e.g. men are more interested in sex) and others maybe less so (such as more than a third of men aged 75-85 are sexually active, as are 17% of women the same age).

The cross sectional study, published in the BMJ, looked at two large American health surveys: the national survey of midlife development in the United States (MIDUS), which assessed in 1995-6 adults aged 25-74, and the national social life, health and aging project (NSHAP), which in 2005-06 looked at people aged 57-85.

Overall, men were more likely than women to be sexually active and be interested in sex. Between 69% and 87% of men of all ages reported being sexually active in the past six months, compared with 43% to 76% of women, and men were significantly more likely to report being interested in sex than were women (66% versus 53% among those aged aged 25-74 and 62% versus 21% in those aged 57-85). These gender differences increased with age and were greatest in people aged 75-85 years: 38.9% of men compared with 16.8% of women were sexually active.

On the other hand, overall, sexual satisfaction was similar in the two genders: among sexually active respondents, about two thirds of men and women reported a good quality sex life. These proportions also changed as women aged though, so that only half women aged 57-85 who were sexually active reported a good quality sex life compared with nearly three quarters of men.

A novel aspect of this study was the use of a new measure devised by the authors called “sexually active life expectancy” – that is, the average number of remaining years a person could expect to remain sexually active.

At the age of 30, men had a sexually active life expectancy of 34.7 years (i.e., to within 10 years of the average life expectancy of 74.8 years) and women had 30.7 years (to 20 years less than their life expectancy of 80.6 years). This means that men spend 78% of their lives sexually active, compared with 61% for women. At 55, these figures changed to 14.9 remaining years for men and 10.6 years for women.

For me the most interesting finding was the link between good health and good sex. Men aged 25-74 who were in very good or excellent health were more than twice as likely to be sexually active than their less healthy counterparts, whereas women of the same age were 60% more likely to be sexually active.

Of those people who were sexually active, men and women who were in very good or excellent health were 70% more likely to report having a good quality sex life than those who were in less good shape, and were 40-80% more likely to be interested in sex.

Good health also increased how long people would remain sexually active compared with people reporting fair or poor health: men in very good health at age 55 were projected to gain on average 5-7 years of life as sexually active, whereas women were projected to gain 3-6 years.

It seems like good health keeps people keeping on in more way than one…
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Lindau S & Gavrilova N (2010) Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ 340 (mar09 2). DOI: 10.1136/bmj.c810

Arts, Cancer

A picture is worth a thousand words: comic books for medical and patient education

March 13, 2010 No Comments

The BMJ has just published an interesting feature about comics in medicine – the history, the approaches, and their use in medical and patient education.

The authors Michael J Green and Kimberly R Myers call such comics “graphic pathographies”: illness narratives in graphic form. “These graphic pathographies can be helpful to patients wanting to learn more about their illness and find a community of similarly affected people,” they say. “Graphic pathographies also provide doctors with new insights into the personal experience of illness and misconceptions about disease and treatment that could affect compliance and prognosis.”

The two examples they discuss are Marisa Acocella Marchetto’s Cancer Vixen, in which Marchetto describes her experiences as “a shoe-crazy, lipstick-obsessed, wine-swilling, pasta-slurping, fashion-fanatic big-city girl cartoonist” with breast cancer, and Brain Fies’ Mom’s Cancer, which documents Fies’ mother’s metastatic lung cancer. Both provide actually quite moving and at times subtle personal accounts of illness, and in a more succinct and engaging way than the same tale in prose form.

Medical comics are proving particularly useful in patient education, both to promote public awareness and to help patients and their families understand what to expect from a disease. Apparently, combining pictures and text enhances understanding because reading and viewing activate different information processing systems within the brain. “This combination also fosters connections between new information and existing knowledge,” say the authors, “thereby increasing recall of health information, especially among those with low literacy.”

The series Medikidz is a prime example of the latter approach. Medikidz comics provide quite complex medical information for kids about a variety of different diseases, such as osteosarcoma, scoliosis, and type 1 diabetes.

The “Medikidz” are a group of five larger-than-life superheroes who journey around Mediland, a planet shaped like the human body. These heroes battle against villainous characters representing aspects of disease. For example, Chi is the Medikidz lungs specialist whose secret power is hypnotic relaxation, whereas her nemesis is Anna Phalaxis.

Comics can also be used to educate medical students and doctors. For example, personal patient stories in comic book form could reinforce to junior doctors that fact that healing a patient entails more than treating a body. Also, as the authors point out, “In keeping with research in medical education showing that visual art improves students’ diagnostic skills, reading graphic stories may likewise enhance students’ observational and interpretive abilities.”

I find these comic fun to read, and they certainly seem a novel and creative way to communicate patients experiences and information about diseases.

Otolaryngology

Regular use of common painkillers is associated with hearing loss in middle aged men

March 9, 2010 No Comments

A study has found that regular use of common painkillers – such aspirin, paracetamol, and ibuprofen – increases the risk of hearing loss in men aged 40-74 years.

Using aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, or paracetamol twice a week or more over a 20 year period increased the risk of hearing loss by 12%, 21%, and 22%, respectively.

Nearly a quarter (22%) of American men aged 45-64 years use aspirin weekly, largely because it prevents blood clots and is thought to ward off heart attacks in healthy people. Furthermore, 16% of American middle aged men use paracetamol weekly, whereas 13% use ibuprofen this regularly.

However, just this week the Journal of the American Medical Association published research showing that aspirin doesn’t reduce “vascular events” – such as angina or stroke – in people who don’t have any clinical cardiovascular disease.

As such, the jury is still out on the benefits versus risks of using regular doses of aspirin to avoid cardiovascular disease, and this new research on hearing loss seems to add to the “against” pile.

This study, published in the American Journal of Medicine, assessed 26,917 male healthcare professionals who were aged 40-74 years in 1986. These men were quizzed every two years on their use of painkillers and whether they had been professionally diagnosed with hearing loss.

Men who used paracetamol at least twice a week were 22% more likely to be diagnosed with hearing loss than people who took it less, whereas regular users of NSAIDs were 21% more likely. On the other hand, the risk was only 12% higher in men who regularly used aspirin.

For NSAIDs and acetaminophen, the risk of hearing loss increased with duration of regular use. Men who used NSAIDs or paracetemol regularly for 4 or more years were 33% more likely to develop hearing loss than those who did not use these drugs as regularly.

The risk of hearing loss varied with age and was greatest in men under 60 years of age. For aspirin, regular users aged less than 50 years and those aged 50-59 years were 33% more likely to have hearing loss than were nonregular users. Interestingly, there was no association between regular aspirin use and hearing loss in men aged 60 years or older.

For NSAIDs, men aged less than 50 years were most strongly affected: regular users aged less than 50 years were 61% more likely develop hearing loss than nonregular users. Those aged 50-59 years were 32% more likely to be diagnosed with hearing loss and those aged 60 years or older were 16% more likely.

There was a similar graded change with age for paracetamol: regular users aged under 50 years were, astoundingly, 99% more likely to have hearing loss than men who used the drug less regularly, whereas those aged 50-59 years were 38% more likely and those aged 60 years and older were 16% more likely.

The authors suggest that the age differential effect might be because hearing loss itself increases with age independently of painkiller use – after the age of 60 hearing thresholds worsen by 1 decibel a year on average. “The relative contribution of regular analgesic use to hearing loss may be greater in younger individuals before the cumulative effects of age and other factors have accrued,” they say.

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Curhan S et al. (2010) Analgesic Use and the Risk of Hearing Loss in Men. The American Journal of Medicine 123 (3): 231-237. DOI: 10.1016/j.amjmed.2009.08.006

Mental health, Psychology

Talking therapies for depression are overrated thanks to publication bias

March 5, 2010 5 Comments

An analysis of studies into counseling therapies for depression – such as cognitive-behavioural therapy – has found that the effect of such approaches has been overestimated because studies that show a strong effect of the treatments are getting published over studies with more modest results.

In 117 studies, “talking therapies” had an average effect of 0.67 on symptoms of depression, with zero being “no effect,” whereas once publication bias was taken into account this effect dropped to 0.42.

Publication bias is “the tendency for increased publication rates among studies that show a statistically significant effect of treatment.” Think about it – patients, researchers and editors are going to be more interested in studies showing that a treatment has a considerable effect on a condition than those showing that the treatment has only a negligible effect. As a result, those studies showing a strong effect either way – that a treatment is really good or really useless – are more likely to get published and the effect of a therapy gets overestimated.

Publication bias is known to affect studies on the effects of antidepressant medications: trials showing that a drug works are more likely to get published than those showing that it doesn’t work. This is due in no small part to the pharmaceutical companies that fund drug research wanting to promote the most positive outcome possible for the medications that they sell.

Now a new analysis by Cuijpers et al. has found a similar effect among studies about psychotherapy for depression – only the most dramatic findings are getting out there and as such the effects of “talking therapies” are being “talked up.”

The authors looked at published studies on psychological treatments for depression – either approaches where verbal communication between a therapist and a client was the core element or in which a patient independently worked through a treatment book with some kind of personal support from a therapist.

They found a total of 117 studies that compared 175 treatment conditions with a control condition. When they calculated the effect of treatment in each study and analysed all these numbers together, the mean treatment effect for psychotherapy compared with control was 0.67, with zero being “no effect.”

The authors then undertook several types of statistical tests to determine whether the studies in their analysis were subject to publication bias.

The mean effect dropped to 0.42 once all the data had been adjusted for publication bias, and the various tests all pointed strongly to bias. The authors point out that effect sizes of 0.80 can be assumed to be large, effect sizes of 0.50 are moderate, and effect sizes of 0.20 are small.

Interestingly, no indication of publication bias was found for studies examining interpersonal psychotherapy, which targets how the patient interacts with other people, or for studies examining psychotherapy for women with postpartum depression.

The authors then looked specifically at the much vaunted approach cognitive-behavioural therapy, where therapist focuses on the impact a patient’s present dysfunctional thoughts have on current behaviour and future functioning. The overall effect size of the 89 comparisons between cognitive-behavioural therapy and a control condition was 0.69, but this value was reduced to 0.49 after adjustment for publication bias.

The authors conclude that research on psychotherapy for adult depression does not seem to be any freer from publication bias than research on medication treatment. As they say, “Pharmaceutical companies have clear financial reasons to inflate research findings, and psychological investigators have both personal and professional reasons for doing the same.”

The implications for this analysis are pretty messy – the research suggests that one of the two most important treatments for adult depression is not as effective as assumed, bad news given that “talking therapies” are generally thought to work better than pharmaceutical approaches, the other top therapy.
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Cuijpers P at el. (2010) Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias. The British Journal of Psychiatry 196 (3): 173-178. DOI: 10.1192/bjp.bp.109.066001

Children

Keep your eyes on your kids in the laundry room – for the sake of theirs

March 3, 2010 No Comments

Don’t leave your young kids unsupervised with your laundry. Not just because they might start mixing with your carefully separated piles of whites and darks, but because they might injure their eyes playing with the brightly coloured liquid detergent capsules.

A letter to the BMJ, ophthalmologists at the Western Eye Hospital in London have highlighted a “wave of paediatric eye injuries” from liquid capsules for fabric detergents. These capsules were responsible for 40% of chemical eye injuries in children under the age of 5 last year at the hospital.

The majority of the 13 children who presented to the hospital with such injuries were girls. In 12 cases the kids were fine after treatment, but one child only had their eyes washed on arrival and sustained permanent burns on both their eyes.

Furthermore, the Poisons Unit at Guy’s and St Thomas’ hospital, also in London, received 192 enquires related to the capsules during 2007-8 and 225 calls during 2006-7, a fifth of which related to ocular exposure.

Liquid detergent capsules, also known as liquitabs, were first introduced in 2001 and are composed of an alkaline solution contained in a water soluble membrane that dissolves when in contact with moist hands or the mouth. Alkali injuries are the most severe form of chemical eye injury and can cause irreversible damage.

The authors advise that concentrated cleaning products like liquitabs should be kept out of the reach of children. If an accident occurs, parents should immediately wash their child’s eyes to reduce the chance that their child will suffer permanent eye damage.

Children, Education, Psychology

Hot housed Chinese schoolkids are getting ill from the stress

March 2, 2010 No Comments

A third of Chinese children experience high levels of school-related stress, and these kids are about five times more likely to have the physical symptoms of stress – that is, headache or abdominal pain – then their less frazzled peers.

Thanks to the combination of China’s recent economic growth – with the increased opportunities for upward mobility – and the vast numbers of people competing for each university place and job, Chinese children are under pressure to do well right from the start of primary school.

A cross-sectional study published in Archives of Disease in Childhood has now shown the negative effects this relentless pressure can have on children’s health.

The study was carried out on more than 2,00 children aged 9-12 years in nine schools in urban and rural areas of Zhejiang, a relatively wealthy coastal province in the east of China.

Nearly a fifth said they rarely enjoyed school, with boys less likely to enjoy school than girls. A total of 81% said they worried “a lot” about exams, and 78% felt under pressure to perform well at school “all the time.”

In particular, the punitive nature of school in China comes across in this study: 44% of children were always afraid of being punished by their teachers. Furthermore, 71% said they were physically punished by their parents at least sometimes. No wonder these kids were so worried about doing well.

When it came to the psychosomatic symptoms of stress, 67% of boys and 66% of girls reported headache at least once a week, whereas 60% of boys and 78% of girls has stomach ache that often.

As a comparison, a study of school stress in Swedish 10-13 year olds reported that 21% of boys and 30% of girls experienced headache and 17% of boys and 28% of girls experienced abdominal pain at least once per week.

Children who were the most stressed on all the measures looked at were 5.6 times more likely to experience headache and 4.9 times more likely to report abdominal pain than kids who were the least stressed. Being bullied was the individual stressor that was most strongly associated with psychosomatic symptoms.

The authors believe that their findings “reflect the high value placed on education in Chinese society, urban and rural, and the widespread belief in the possibility for upward social mobility through education.”

Piling so much stress onto such young children could be storing up problems for the future. Studies have shown that children who have high levels of anxiety and depression are likely to have psychological problems into adolescence and adulthood.

According to the authors, “Much of the stress in Chinese schools is unnecessary and has simply become incorporated into the system.” They recommend reducing the frequency of exams and the sheer volume of homework to make life a little less intense for kids.

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Hesketh T et al. (2010) Stress and psychosomatic symptoms in Chinese school children: cross-sectional survey. Archives of Disease in Childhood 95 (2): 136-140. DOI: 10.1136/adc.2009.171660

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