A stressful job doubles the likelihood of stroke – but only for men

job-stressA study published in Annals of Internal Medicine has found that men with a stressful job are twice as likely to have a stroke than are men with less demanding jobs.  Interestingly, there was no correlation between job stress and incidence of stroke among women.

A stroke occurs when the blood supply to the brain is cut off, for example when a clot blocks one of the blood vessels supplying the brain.  Stroke can cause permanent neurological damage and even death, and has been linked to stress for quite some time.

Tsutsumi et al. interviewed 3,190 Japanese men and 3,363 Japanese women from a variety of job backgrounds, including managers, professionals, technicians, clerks, salespeople, farmers, craftsmen and labourers.  The level of occupational stress experienced by these workers was evaluated and participants were placed into four stress categories: high strain (high job demand + low job control); active job (high job demand + high job control); low strain (low job demand + high job control); and passive job (low job demand + low job control).

Over the next 11 years, 91 men and 56 women experienced a stroke.  Men under high job strain – i.e. those with lots of demands on their shoulders and with little control of their workload – were twice as likely to experience a stroke than were men under low strain.  In women, however, the incidence of stroke was the similar among those with a stressful job and those under less strain.

Among men, the association between job stress and stroke lessened somewhat when other risk factors for stroke, such as obesity and high blood pressure, were taken into account, suggesting that pre-existing chronic diseases and an unhealthy lifestyle up the chance of stroke in stressed out employees.

The authors of the study suggest that that the difference between the sexes could be because women approach stressful jobs differently to men or because more women than men work part-time.
Akizumi Tsutsumi, Kazunori Kayaba, Kazuomi Kario, and Shizukiyo Ishikawa (2009) Prospective Study on Occupational Stress and Risk of Stroke Arch Intern Med 169 (1): 56-61

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Here it is, your heart

The British Heart Foundation has launched a new advertising campaign that features an amazing real-time simulation of a beating heart.

The campaign confronts viewers with the perhaps gory but nevertheless fascinating reality of the most vital of vital organs, and challenges them to think about heart and circulatory disease – Britain’s biggest killer.

British Heart Foundation Director of Policy and Communications, Betty McBride, said, “We wanted to confront people with the reality of what a working heart looks like. This is a rare chance for people to see in incredible detail how it works. We expect people to react in lots of different ways – whether it’s amazed, squeamish or disturbed. It’s vital that we get people to take time to think about their heart health.”

The Virtual Heart Simulator was developed in a collaboration between specialists at The Heart Hospital in London and design agency Glassworks. The British Heart Foundation boasts that this fantastic video represents “the biggest technical advancement since Leonardo da Vinci sketched the heart 500 years ago.”

The campaign advertises the guidance and advice that the British Heart Foundation provides, not least through its Heart Helpline, where cardiac nurses and information officers are on hand 9am-10pm, seven days a week, to provide free confidential information on heart health issues.

The campaign website also features a helpful A-Z of the heart, which explains in plain english cardiology terms such as ‘supraventricular tachycardia’ and ‘cardiomyopathy’.

  • You can call the Heart Helpline on 0300 333 1 333, or alternatively peruse the British Heart Foundation website www.bhf.org.uk for stacks of information on heart health
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One in five children with cancer receive wrong chemotherapy doses

ChemotherapyA study of nearly 1,400 adult and pediatric cancer patients published in the Journal of Clinical Oncology has found that 19% of children taking chemotherapy drugs in outpatient clinics or at home were subject to some sort of medication error.  In addition, 7% of adult cancer outpatients also were on the receiving end of chemotherapy mistakes.

Alarmingly, approximately 40% medication errors in children had the potential to cause harm, and four children were actually injured.

“As cancer care shifts from the hospital to the outpatient setting, adults and children with cancer receive more complicated, potentially toxic medication regimens in the clinic and home,” said Dr Kathleen Walsh, study leader and assistant professor of pediatrics at the University of Massachusetts Medical School.  Given that outpatients are essentially required to administer these complex regimens themselves without any medical guidance, errors in medication are, therefore, quite likely.

In this study, the authors retrospectively examined medical records from outpatient visits at three adult and one pediatric oncology clinic.  In total, 1,262 adult patient visits involving 10,995 medications and 117 pediatric visits involving 913 medications were assessed.

Of the adult visits, 90 were associated with a medication error, whereas 22 pediatric visits involved a chemotherapy mistake. More than 70% of the errors in children occurred at home, whereas in adults chemotherapy errors were much more likely in the clinic (>50% of cases).

One of the key types of medication error recorded in adults was administration of an incorrect dose due to confusion over conflicting instructions. In some cases, medication orders for several months of chemotherapy would be written at the beginning of treatment, and doses would then be adjusted as needed at each clinic visit. Patients thus had an initial set of orders and a modified set instructions written on the day of the outpatient visit, causing much bewilderment when it came to the time of administration.

A considerable proportion of the medication errors in children were due to parents’ confusion about instructions, which resulted in the child receiving the wrong dose or the wrong number of doses per day.

“Requiring that medication orders be written on the day of administration, following review of lab results, may be a simple strategy for preventing errors among adults, while most of the errors involving children may have been avoided by better communication and support for parents of children who use chemotherapy medications at home,” said Dr Walsh.

In addition, information technology such as computer order entry, electronic medication administration records and bar-coding – which have proved effective in hospitals – might also help prevent medication errors in an outpatient setting.


Walsh KE et al. (2008) Medication Errors Among Adults and Children With Cancer in the Outpatient Setting. Journal of Clinical Oncology DOI: 10.1200/JCO.2008.18.6072

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Government to tackle obesity with Change4Life campaign

Change 4 LifeI recently blogged about the alarming rates of obesity among children in England, with one in four 4-5 year old children and one in three 10-11 year olds in this country obese or overweight. The Foresight report, published in 2007, ominously predicts that by 2050 90% of British children will be overweight or obese.

The British Government has now responded to this issue by launching a huge campaign to persuade the population to switch to a healthier lifestyle. The Change4Life strategy will promote the message “eat well, move more, live longer” on TV, in the press, on billboards and online initially for 3 months, and will continue over 3 years.  The initiative will be supported by £200m of advertising and marketing donated by food companies such as Tesco, Mars, Nestlé and Flora.

Dawn Primarolo, minister for public health, said today: “We are trying to create a lifestyle revolution on a grand scale. There are very serious health consequences with allowing dangerous quantities of fat to build up in our bodies. This is not just an ad campaign – we are calling it a lifestyle revolution – it is a long-running concerted effort to change behavior.”

The television campaign launches on Saturday 3rd January with adverts designed by Aardman Animations, the people behind the much loved plasticine duo Wallace and Gromit.  The engaging clip is designed to warn viewers of the health risks associated with being overweight and is targeted at helping young families change their lifestyle for good.

Change4Life is the biggest Government campaign ever launched and is expected to follow in the success of similar cross-media anti-smoking initiatives.  Unlike anti-smoking public awareness strategies though, this campaign steers away from shock tactics and instead offers practical advice.

Critics have been quick to point out that the involvement of food companies in the campaign is a way for such corporations to cast their brand in a healthy light without actually changing the salt or fat content of their food.  Tam Fry of the National Obesity Forum warned that junk food companies were donating millions to the campaign as a way of heading off the “regulation they fear”.

The Telegraph notes that “neither the leaflets nor the screen advertisements use the word obesity”, preferring instead to state that children could grow up to have “dangerous levels of fat in their body”.  The campaign is designed to avoid pointing the finger at any one group, however, specifically avoiding talking about ‘fat bodies’ and blaming modern life rather than parents.

Let’s hope that the more kindly, blame-free approach of Change4Life gets the people of the UK off the sofa and helps to avert our obesity timebomb.

  • If you’re skeptical, the Big Question in The Independent casts a critical eye over the Change4Life campaign, asking whether the Government can really make us eat less.
  • On the other hand, it you want to get serious about improving your lifestyle there is stacks of information on how to eat better, move more and live longer on the Change4Life website.
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Can text messages be used to monitor health?

text-messageMobile phones are possibly one of the most ubiquitous pieces of technology in the 21st century.  In 2003 the Office of National Statistics reported that 75% of all adults in the UK owned or used a mobile phone, and Wikipedia estimates that the UK now has more mobile phones than people.

Text messaging has been the surprise success of mobile phones – who would have thought that people would prefer to write out a message to their friends rather than simply give them a quick call?  The latest statistics record that 4.7 million messages are being sent every hour in Britain, with 72% of women and 70% of men texting regularly.  These days, however, text messages are being put to much worthier use than simply catching up on last night’s gossip.

Earlier this month the BMJ reported that the ability to send a text message was a sure sign of recovery from a faint or a panic attack.  The authors of the study had spent several years working for the charity Festival Medical Services, helping out in the first aid tents at large British music festivals.  They noticed that teenagers who were brought in for medical attention would send a text message to their friends as soon as they were feeling better.  Given that sending a text message requires “a Glasgow coma scale score of 15 (fully conscious), an adequately functioning ‘executive system’ in the frontal lobes, and a high degree of manual dexterity and psychomotor coordination”, they concluded that this ability was reasonable grounds for discharge and successfully employed ‘the text test’ during busy times at this year’s Reading Festival.

Text messages have also been employed by heathcare trusts to monitor the medical status of patients.  Oxfordshire and Buckinghamshire Mental Health and Oxford University’s Department of Psychiatry have been using a daily text message to monitor the mood of mental health patients.  Patients receive a text message every morning and  respond with a letter in the range of A to E, which corresponds with mood on a scale from depression and euphoria.  This technique allows doctors to to plot mood swings in real time, monitor medication efficacy and assess whether a face-to-face appointment is needed, and removes the need for unreliable retrospective assessments.  The system is current being used with 150 patients and is due to be rolled out across Oxfordshire and Buckinghamshire in the new year.

In a similar vein, London’s Hammersmith & Fulham Primary Care Trust has been using text messages to establish the current smoking status of patients and, accordingly, their risk of developing cardiovascular disease.  As many as 49% of patients responded to texts enquiring whether they were active smokers, a much higher response rate than other methods of communication previously used.  Doctors were then able to quickly and efficiently update medical records.  The system that the Trust used, iPlato, began as a means of reducing missed GP appointments within the NHS and has now been adopted across 40 NHS organisations, including 36 Primary Care Trusts.  As well as monitoring smoking status, iPlato also uses text messages to establish methadone compliance, keep tabs on patients on weight management plans and helps patients stay up to date with prescriptions.

And it’s not just in the UK that healthcare providers are exploiting text messages to monitor patients.  The Infectious Disease Clinic at the University of Virginia is piloting a text messaging system to improve contact with HIV patients living in rural parts of the state. In the programme, patients are given a mobile phone that only receives texts about medication regimens and pending medical appointments, and can only call emergency and medical contacts.  Organizers hope that this initiative will help patients adhere to their treatment for longer than 6 months, the current drop off point.

Stanford University in California and the Centers for Disease Control and Prevention even held a conference on text messages and healthcare in February this year – Texting 4 Health.  The event “showcased applications, ideas, and insights on using mobile text messaging to improve personal and public health”.  Speakers from as far afield as Denmark and Scotland presented the text messaging strategies that are currently in use in their regions – HandyMentor for asthma self management and SweetTalk for diabetes reminders if you’re wondering – and techniques to provide health information and instigate healthy lifestyles via text messaging were presented (the full conference program and slides can be found here).

Given the widespread use of mobile phones, text messages could certainly be a cheap and far reaching way to monitor patients and disseminate public health information.  What do you think?  Are text messages the future of health management?  Are text messaging programmes going to be widely adopted for public health purposes in 2009?  Or are text messages good only for personal affairs and not for important medical information?

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Busting the fake online pharmacies

which-is-realAn orchestrated raid in ten countries has led to the arrest of several individuals behind online pharmacies that illegally sell unlicensed or prescription-only medicines.  Dozens of residential and commercial addresses in Australia, Canada, Germany, Ireland, Israel, New Zealand, Singapore, Switzerland, the UK and the USA were searched by investigators and countless counterfeit drugs were seized, including those purported to treat conditions such as diabetes, impotency, obesity, hair loss and the side effects of steroid abuse.

The operation, codenamed Pangea, was undertaken by the international police agency Interpol, the World Health Organisation’s (WHO) International Medical Products Anti-Counterfeiting Taskforce (IMPACT), and the Permanent Forum on International Pharmaceutical Crime.

Federal agencies in the US conducted an intensive one-day inspection of international mail in Dallas, Chicago, Seattle and New York.  In total approximately 635 international mail parcels were examined and 18 containing counterfeit Viagra, Cialis, steroids and Xanax were seized.

In the UK, the Medicines and Healthcare products Regulatory Agency visited 12 residential and commercial addresses relating to seven websites thought to be selling unlicensed agents or prescription-only medicines.  Over a thousand packs of pharmaceuticals were seized, as well as several computers and reams of documentation.

Over 50% of medicines bought from illegal websites that conceal their physical address are counterfeit – i.e. they are deliberately mislabelled with respect to their identity or source. The quality of such drugs is unpredictable, as many contain the wrong amount of active ingredients, wrong ingredients or no active ingredients at all.

Jean-Michel Louboutin, Executive Director of Interpol’s Police Services, said, “Buying medicines from illegal and unregulated websites poses significant risks, not least that the buyer is putting their health in danger by taking drugs which have no guarantee of safety, quality or effectiveness”.

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Drinkers don’t take their medications often enough

alcoholA recent study by Bryson et al. has found that moderate to severe alcohol misuse increases the likelihood that patients won’t take their medication properly.

Many patients do not take their medications as often as they should – i.e. on at least 80% of the days they are supposed to.  In fact, a recent study found that over the space of a year, 40% of patients taking cardiovascular or diabetes medications didn’t take their medications often enough.  Such ‘medication nonadherence’ is associated with worsening of disease, increased health care costs, and even death.

Bryson et al. looked at more than 20,000 patients who were receiving treatment for high blood pressure, high cholesterol levels, or diabetes.  All participants undertook a three-point questionnaire to evaluate their alcohol use on the basis of frequency and typical quantity of drinking during the past year, and the frequency of heavy episodic drinking (at least 6 drinks per occasion).  Medication adherence over the space of a year was measured by how often patients went back to their pharmacy for a refill.

Among patients taking medication for high blood pressure or high cholesterol levels, nonadherence increased as the severity of alcohol misuse increased.  Compared with patients who did not drink, the proportion of patients who did not stick to their cardiovascular medications was significantly higher among those who moderately or severely misused alcohol.  Interestingly, there was no difference in adherence to diabetes medications between diabetic patients who did not drink and those who did.

This research might seem like it’s straight from the department of the obvious: “Of course people with alcohol problems don’t take their medications properly!”  There are a couple of key findings that are important to bear in mind though.  For one, the authors were able to assess alcohol consumption with a brief questionnaire , unlike previous studies on this subject that used lengthy, time consuming interviews.  Thus the approach used in this study could be used easily in clinical practice.

In addition, a fair few studies have examined the problem of medication nonadherence, but most have found that the factors responsible for nonadherence are ones that would be very difficult to modify, such as older age (over 80 years old) or low socioeconomic status.  The study by Bryson et al. is important because it identifies a modifiable factor responsible for medication nonadherence.  Counsel a patient to cut their drinking and, in theory, they should be more likely to take their medication properly, which would keep their condition in check and enable them to get on with their life unhindered.

Bryson CL et al. (2008) Alcohol screening scores and medication nonadherence. Ann Intern Med 149 (11): 795-803. PMID: 19047026

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More than 20% of English primary school children are obese or overweight

obesechild460One in four 4-5 year old children and one in three 10-11 year olds in England are obese or overweight, according to data from the 2007/08 National Child Measurement Program published by the NHS Information Centre.  The North East, the West Midlands and London are particular obesity blackspots, and boys are more likely to be obese than girls.

The National Child Measurement Program, established in 2005, weighs and measures school children in Reception (3-4 years old) and Year 6 (10-11 years old) to assess the level of overweight and obesity among kids in England. Almost a million primary school children were measured in the 2007/08 survey, representing 88% of those eligible.

The 2007/08 survey found that 22.6% of 3-4 year old children and 32.6% of 10-11 year olds were overweight or obese.  Almost twice as many Year 6 children were obese compared with Reception-age kids (18.3% vs 9.6%), and boys were significantly more likely to be obese than were girls.

The prevalence of obesity among primary school kids in both age groups was significantly higher than the national average in the North East, West Midlands and London.  In addition, there was a high prevalence of obesity in Reception-age children in the North West and Year 6 children in Yorkshire and Humber.  The South East Coast, South Central, South West and East Midlands regions, on the other hand, had lower-than-average rates of obesity among schoolchildren.

Obesity rates in 2007/08 seem similar to those in the 2006/07 survey (9.9% among Reception-age children and 17.5% in Year 6 children); however, the National Child Measurement Program report cautions that the prevalence of obesity among Year 6 children might have been underestimated by as much as 1.3% in 2006/07 due to children opting out of being measured.

The British Heart Foundation responded to these results by calling for several measures to tackle childhood obesity, including tighter regulation of junk food marketing, consistent and simple food labelling, and more funding to help children get involved in physical activities.  Saranjit Sihota, Head of Public Policy at Diabetes UK, likewise called for more action to tackle the epidemic – remarking that “This new data confirms the shocking state of children’s health in this country” – and pointed out that said that there is a clear link between obesity and Type 2 diabetes.

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Festive funnies in the BMJ Christmas issue

Christmas treeEvery year the British Medical Journal team get in the festive spirit with their Christmas issue, publishing zany or amusing research.  This year is no exception, with a host of genuine research papers and rigorous scientific analyses guaranteed to make you giggle.

Research articles in this week’s issue of BMJ include:

  • Head bangers: stuck between rock and a hard bass
  • Head banging to heavy metal is a popular dance form, but it increases the risk of head and neck injury. The effects may be lessened with reduced head and neck motion, head banging to lower tempo songs or to every second beat, and using protective equipment such as neck braces, say Australian researchers Declan Patton and Andrew McIntosh.

  • Rugby (the religion of Wales) and its influence on the Catholic church: should Pope Benedict XVI be worried?
  • Researcher Gareth Payne and his two colleagues from Cardiff investigate whether there is any substance to the intriguing urban legend that has arisen in Wales in recent times: “Every time Wales win the rugby grand slam, a Pope dies, except for 1978 when Wales were really good, and two Popes died.” Wales won the Grand Slam in 2008 – so should Pope Benedict XVI be worried?

  • Frankincense: systematic review
  • Edzard Ernst, the UK’s only professor of complementary medicine, systematically reviews the evidence on frankincense – a tree resin that was one of the first ever Christmas presents and is now a popular complementary remedy. He concludes that, although frankincense does not bestow supernatural instant youth or eternal life as many claims would have it, it has encouraging anti-inflammatory properties.

In the comment section, Deborah J Anderson, an author of the IgNobel-winning research on the use of coca cola as a spermicide, advises against this approach to contraception, while MA Buchanan and colleagues discuss whether modern golf clubs can cause hearing damage.

The Christmas issue also traditionally subjects prevalent medical myths to critical appraisal.  Last year Rachel Vreeman and Aaron Carroll showed that reading in low light does not damage eyesight and that turkey is not to blame for drowsiness after Christmas dinner.  This year they turn their attention to whether sugar causes hyperactivity in children and if wearing a hat reduces heat loss in cold weather, thoroughly debunking these popular beliefs.

The whole BMJ Christmas issue can be found online at www.bmj.com.  I hope you enjoy it as much as I did!

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NEJM vs the South Dakota abortion script

gavelIn the recent US election, several pieces of legislation that aimed to limit reproductive rights were voted down.  Colorado said no to the Definition of a person initiative that would have given fertilized eggs the same rights as humans, and California rejected a proposition that would have required parents to be notified when a patient under 18 has an abortion. Importantly, in South Dakota Measure 11 – which sought to ban abortion in all cases bar incest, rape and danger to the the health or life of the mother – was narrowly defeated.

Despite all this good news, one hefty piece of reproductive rights legislation slipped through the net this year.  In July, following the Planned Parenthood Minnesota vs Rounds court case, statute 34-23A-10.1 was passed.  This measure states that the physician performing an abortion must inform the pregnant mother that “the abortion will terminate the life of a whole, separate, unique, living human being”, that she “has an existing relationship with that unborn human being “, and that she is, supposedly, at “increased risk of suicide ideation and suicide”.

The New England Journal of Medicine has taken up the case of the ‘South Dakota abortion script’, which seems to have been largely ignored by the media.

The Perspective article ‘South Dakota’s Abortion Script — Threatening the Physician–Patient Relationship‘, published in November, outlines the small print of the legislation and issues at stake.  The authors write:

The law requires that doctors give pregnant women a description of medical and “statistically significant” risks of abortion, among which it includes depression and other psychological distress, suicide, danger to subsequent pregnancies, and death. Physicians must tell women the approximate gestational age of the fetus and describe its state of development … The physician must answer all the woman’s questions in writing and enter them into her medical record … Physicians who do not satisfy the statute are subject to license suspension or revocation and may be charged with a class 2 misdemeanor.

In addition, the authors state that the increased risks of psychological distress, depression, and suicide included in the script are not supported by the bulk of the scientific literature, and that the legislation should be viewed in the context of South Dakota’s repeated attempts to outlaw abortion outright, not least in 2005 and 2008.

The article also points out that in forcing doctors to parrot the state’s message as if it were their own opinion, the law violates physicians’ First Amendment rights.  The December 4 Editorial ‘Physicians and the First Amendment‘ picks up on this issue of the right of the physician to freedom of speech.  The “ideological speech” included in the script is clearly in breach of the First Amendment, which enshrines “both the right to speak freely and the right to refrain from speaking at all.”  If the state is able to dictate that doctors give emotive and partisan information about abortions, there is a precedent for the state determine the medical advice given on other contentious issues such as contraception.  The authors of the editorial call for prompt overturning of the law and boldly state:

The South Dakota ‘script law’ is an affront to the First Amendment rights of physicians and an embarrassment to the people of South Dakota.

The New England Journal of Medicine certainly has a lot of clout in the medical community and beyond, but whether they will succeed in overturning law is another matter. What is needed is for the journal and the physician community to mobilize behind this issue and either as a body or via a proxy patient take on South Dakota law the way that the landmark Roe vs Wade case took on the state of Texas. Let’s hope that this issue gets some wider publicity and that someone is willing to take on the state to protect the reproductive and constitutional rights of the people of North Dakota.

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