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Press releases Saturday 30 June 2007

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(1) New cervical cancer test increases the detection rate of abnormal cells

(2) Doctors call for opt-out approach to HIV testing

(3) Probiotic drinks can help reduce diarrhoea associated with antibiotics

(4) Many people with early dementia can drive safely, say experts

(5) BMJ Editor condemns scare mongering over bird flu

(1) New cervical cancer test increases the detection rate of abnormal cells
(More histological high-grade cervical disease is detected by the ThinPrep Imager than by conventional cytology: a prospective study)
BMJ Online First

A new computerised screening test for cervical cancer detects more abnormalities than the traditional smear test, according to a study published on bmj.com today.

It could also lead to fewer women needing to be re-tested and might allow for longer intervals in-between testing, says Elizabeth Davey and her colleagues.

The manual screening of conventional pap smears for cervical cancer has been around for decades but liquid-based cytology (LBC) is now replacing it in many countries.

Conventional smears are made by transferring material, taken from the cervix by a collection instrument, directly onto a glass slide. LBC slides are made by rinsing the collection instrument in liquid to produce a suspension, which is processed in a laboratory to produce a single layer of cells.

A recent study published by Guglielmo Ronco in the BMJ found that LBC did not significantly increase the ability to detect moderate (CIN2) or severe abnormalities (CIN3) compared to the conventional smear when both slides were evaluated manually by a cytologist.

In the study published today by Dr Davey, researchers used a computerised reading system, known as a Thin Prep Imager (TPI) to evaluate LBC slides. The programme would highlight any slides which needed further examination. These were looked at by a cytologist.

Samples were taken from 55,164 Australian women. From each single collection, a conventional cytology (CC) sample was made first, followed by a TPI sample.

The most important finding of the study is that the ThinPrep Imager detected 1.3 more cases of high-grade cervical abnormalities per 1,000 women screened than the conventional cytology test.

In Australia, 7.7 cases per 1,000 women screened are currently detected each year through a biennial Pap test screening programme using conventional cytology. Based on the results of this study, introducing the ThinPrep Imager would increase detection to 9.0 cases per 1,000 women screened.

Furthermore, fewer slides were found to be unsatisfactory using TPI ± 1.78% compared to 3.09% with CC. Therefore, fewer women might be recalled for repeat smears than currently occurs if the ThinPrep Imager were introduced into population screening programmes.

The use of the TPI also increased detection of low-grade cell lesions and the researchers conclude this could result in higher rates of further testing. On the other hand, they say, together with the finding of improved detection of moderate and severe changes (CIN2 and CIN3), it does raise the possibility that the increased detection of abnormalities by TPI might allow longer intervals in between screening.

Contacts:
Contact: Elizabeth Davey, Research Fellow, School of Public Health, Building A27, University of Sydney, NSW, Australia
Email: daveye@health.usyd.edu.au

(2) Doctors call for opt-out approach to HIV testing
(Time to move towards opt-out testing for HIV in the UK
http://www.bmj.com/cgi/content/short/334/7608/1352
(Routine testing to reduce late HIV diagnosis in France
http://www.bmj.com/cgi/content/short/334/7608/1352
(Editorial: Reducing the length of time between HIV infection and diagnosis
http://www.bmj.com/cgi/content/short/334/7608/1329

In this week±s BMJ, two groups of public health doctors argue for routine opt-out HIV testing in healthcare settings such as general practice surgeries, accident and emergency departments and hospital wards.

In the first article, Professor Harold Jaffe and colleagues say that a third of people in the UK with HIV do not know they have the virus, yet UK guidelines recommend opt-out testing only for pregnant women and people attending genitourinary (GUM) clinics.

They argue that routine opt-out testing would not only give a more accurate picture of how many people have HIV, but would cut infection rates, lessen the stigma surrounding testing and reduce the number of people being diagnosed in the later stages of HIV.

They point to America where guidelines from the Centres for Disease Control and Prevention now recommend voluntary opt-out testing as the standard of care for people aged 13-64 years, unless the prevalence of HIV is less than 0.1% of the population.

They say "programmes for routine screening have been instituted in emergency departments and urgent care centres at several US hospitals and yielded relatively high rates of previously undiagnosed HIV infection".

About 20,000 UK residents between the ages of 15 and 59 were living with undiagnosed HIV infection in 2005.

Surveys of gay men attending GUM clinics in the same year showed the prevalence of undiagnosed HIV was 3.2%. In women of childbearing age that prevalence was much lower (0.09%), but was highest in women from sub-Saharan Africa (2.4%).

The authors therefore call for surveys to be carried out in areas of known increased HIV prevalence and in facilities that are known to serve people at increased risk of infection. This would provide the necessary data to inform a discussion of expanding opt-out HIV testing.

"In view of the clear advantages of early diagnosis of HIV infection for public and individual health, we believe the effectiveness and feasibility of expanded opt-out testing should be seriously assessed," they conclude.

In the second article, researchers look at the situation in France, where the rate of HIV testing is among the highest in Europe, but 40% of people are still not diagnosed until the disease is advanced, either with AIDS or with a low CD4 cell count. Therefore, of the estimated 7,000 people newly diagnosed with HIV in France in 2004, 3,000 may have advanced disease.

This has a major impact on death rates and the spread of infection, say Cyrille Delpierre and colleagues. Each year, one fifth of HIV infected patients' deaths were patients who had discovered their infection in the year before their deaths.

While the current policy in France successfully targets at risk groups, they say it fails to reach low risk groups, who tend to be older, mainly men, heterosexual, with a partner and children. Low risk groups are the most likely to test late.

They say late testing could play an important role in the spread of the infection. Studies suggest that if someone knows they are infected they are more likely to use preventative measures, such as using a condom.

Late testing could also be associated with greater costs in hospital care and the management of opportunistic infections. Catching these people earlier could, they say, lead to a reduction of 31% a year in the number of new sexually transmitted infections.

They therefore recommend expanding routine voluntary HIV testing to all primary health care settings.

An accompanying editorial argues that a more precise goal for any changes in policy should be to reduce the average time between infection and diagnosis.

Contacts:
Professor Harold Jaffe, Department of Public Health, University of Oxford, UK Email: Harold.jaffe@dphpc.ox.ac.uk

Cyrille Delpierre, Epidemiologist, Toulouse, France Email: cyrildelpierre@yahoo.fr

(3) Probiotic drinks can help reduce diarrhoea associated with antibiotics
(Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with of antibiotics: randomised double blind placebo controlled trial)
BMJ Online First

Drinks containing probiotic bacteria can help reduce diarrhoea among older people, which may reduce length of stay in hospital and save the NHS money, say Imperial College researchers at Hammersmith Hospital in a study published on bmj.com today.

Between 5% and 25% of patients experience diarrhoea, including Clostridium difficile associated diarrhoea, as a complication of treatment with antibiotics.

Researchers set out to find whether probiotic drinks, which contain live micro-organisms, are helpful in reducing diarrhoea related to antibiotic use.

They identified 135 people from three London hospitals who were all aged over 50 and receiving antibiotics for various reasons, such as for respiratory infection.

The patients were split at random into two groups. One was given a commercially available probiotic yoghurt drink while the other received a longlife, sterile milkshake. Neither group knew which drink they received.

Drinks were given twice a day, within 48 hours of the people starting antibiotic therapy and continued for one week after the antibiotics were stopped. The people were also contacted for follow up four weeks later.

Nursing staff monitored bowel movements and when there was evidence of diarrhoea, samples were taken for analysis.

Of the 113 patients who were able to be contacted for follow-up, results showed the group taking probiotic drinks fared much better. Only 12% of those people developed antibiotic-associated diarrhoea, compared to 34% of the other group.

Of the probiotic group of patients, none developed C.difficile associated diarrhoea, compared to 17% of people in the other group.

Apart from the health benefits, the researchers say that considerable savings may be made from greater use of probiotic drinks.

The researchers estimate cost of supplying the probiotic drink to prevent one case of C.difficile associated diarrhoea to be ±60. Previous published research suggests that treating one case of C.difficile can cost on average ±4,000 because of increased length of stay and use of drugs.

Contact:
Lead researcher, Dr Mary Hickson, is available for interview via Hammersmith Hospital press office, London, UK. Tel: +44 (0)20 8 383 3002; mobile: +44 (0)7825 062 049

(4) Many people with early dementia can drive safely, say experts
(Clinical Review: Driving and dementia)
http://www.bmj.com/cgi/content/short/334/7608/1365

Many people with early dementia are capable of driving safely, say researchers in this week±s BMJ.

Society±s perception of older drivers tends to be negative, write Professor Desmond O±Neill and colleagues. Yet surveys of drivers aged more than 80 consistently show prudent driving behaviours. Furthermore, stopping driving can limit access to family, friends, and services and is an independent risk factor for entry into a nursing home.

Proposed changes to UK licensing rules should therefore try to balance mobility and safety in the growing population of older drivers, they say.

They review the evidence and find that the risk of crashes in patients with dementia is acceptably low for up to three years after diagnosis.

The Driver and Vehicle Licensing Agency currently states that anyone holding a driving license must, by law, inform the agency when given a diagnosis of any medical condition that might affect safe driving. Doctors must also complete a medical report, on which the agency will base their decision on fitness to drive.

Cognitive testing, however, cannot discriminate between people with early dementia and their ability to drive safely. Evidence from Scandinavia, Australia, and the United States also suggests that mass medical screening or cognitive screening of older drivers has negative consequences on public health.

Therefore, the authors suggest that the main thrust of future measures should focus on opportunistic screening of high risk populations, such as those attending specialist memory clinics, and the refinement of effective pathways for clinicians and the licensing agency to manage mobility and safety."

Contact:
Professor Desmond O±Neill, Department of Medical Gerontology, Trinity Centre for Health Sciences, Adelaide and Meath Hospital, Dublin, Republic of Ireland
Email: arhc@indigo.ie

(5) BMJ Editor condemns scare mongering over bird flu
(Editor±s Choice: FAFfing about)
http://www.bmj.com/cgi/content/short/334/7608/0

In this week±s BMJ, Deputy Editor Tony Delamothe attacks the continued scare mongering over bird flu.

Somewhere, I imagine, there±s a small group of people proud to be counted among the Friends of Avian Flu, or FAF for short, he writes. I suspect they have a catchy mission statement, such as "Keeping the nightmare alive," and lapel badges of vaguely bird-like shape.

Their challenge is to keep bird flu forever in the public eye. This should be getting harder, as influenza H5N1 is proving particularly resistant to undergoing the killer mutation that would allow efficient human to human transmission of the virus.

Ten years after the strain first appeared in humans, it has killed just 191 people, despite millions of people and poultry living in very close proximity in South East Asia. Although these deaths are a tragedy for the victims and their families, it±s well to remember that a similar number of people die on the roads world wide every 84 minutes, he says.

Traditionally, we±ve blamed the drug companies for talking up the risks of diseases, or even inventing diseases, but this is not the case with bird flu. The track record of oseltamivir (Tamiflu) as a treatment for H5N1 is decidedly mixed. Yet FAF, he says, has incorporated this pharmaceutical failure into its story: for bird flu, The Drugs Don±t Work. Be afraid. Be very afraid.

FAF also knows that the best way to generate column inches is high profile scientific conferences with well oiled media machines, and this week±s BMJ reports some of the familiar observations from a conference, such as the inevitability of the pandemic and the possibility of drug resistance. But others, he says, were relatively new: the terminological mutation from "avian flu" to "pandemic flu," in recognition of H5N1±s failure to mutate genetically.

While H5N1 had been groomed for stardom, the story has shifted: now any influenza strain can become pandemic, with further details unknown, he says.

As influenza pandemics occurred in 1918, 1957, and 1968, another one is likely. But, he asks, why should we be any more worried in 2007 than in 1997 or 2017? Couldn±t those responsible for planning the next pandemic do their planning a little less publicly and put the frighteners on the rest of us at the appropriate time?

Contact:
Tony Delamothe, Deputy Editor, BMJ, London, UK
Email: tdelamothe@bmj.com

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