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Press releases Saturday 9 February 2008

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(1) Acupuncture can improve IVF success rates
(2) Depression among trainee doctors linked to medication errors
(3) One in five hospital patients are malnourished
(4) Changing parental behaviour key to tackling cot deaths
(5) Government targets to cut smoking in pregnancy "unrealistic"

(1) Acupuncture can improve IVF success rates
(Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis)
http://www.bmj.com/cgi/content/short/bmj.39471.430451.BEv1

Preliminary results published on bmj.com today suggest that acupuncture given with embryo transfer can improve rates of pregnancy and live birth among women undergoing in vitro fertilisation.

Some 10 to 15% of couples have difficulty conceiving at some point in their reproductive lives and seek specialist fertility treatment. A commonly used option is in vitro fertilisation, which involves retrieving a woman's egg, fertilising the egg in the laboratory, and then transferring the embryo back into the woman's womb.

In 2000, approximately 200,000 babies worldwide were conceived through in vitro fertilisation.

Because each cycle is expensive, lengthy, and stressful, new drugs and technologies have been developed to improve success rates, but progress has been limited.

However, acupuncture has been used in China for centuries to regulate the female reproductive system. So researchers at the University of Maryland School of Medicine and the VU University Amsterdam set out to determine whether acupuncture given with embryo transfer improves the rates of pregnancy and live birth among women undergoing in vitro fertilisation.

They reviewed seven trials involving 1,366 women undergoing in vitro fertilisation. The trials compared acupuncture, administered within one day of the embryo transfer procedure, with sham acupuncture or no additional treatment.

The overall quality of the trials was good and included a broad selection of women at various ages and with different causes and durations of infertility.

Complementing the embryo transfer process with acupuncture increased the odds of pregnancy by 65% compared to sham acupuncture or no additional treatment. In absolute terms, this means that 10 women would need to be treated with acupuncture to bring about one additional pregnancy.

In trials where the baseline pregnancy rates were already high, the benefit of acupuncture was smaller and non-significant.

Although still somewhat preliminary, this review suggests that acupuncture given with embryo transfer can improve rates of pregnancy and live birth among women undergoing in vitro fertilisation, say the authors.

In vitro fertilisation is an expensive procedure, costing an average of $12,400 per cycle in the United States, they add. So, even if the increased likelihood of success with acupuncture was small, it may still be cost-effective.

They call for further studies to confirm these preliminary findings and to investigate the relation between baseline rate of pregnancy and the effectiveness of additional acupuncture.

Contact:
Eric Manheimer, Research Associate, Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, USA
Email: emanheimer@compmed.umm.edu

(2) Depression among trainee doctors linked to medication errors
(Rates of medication errors among depressed and burned out residents: a prospective cohort study)
http://www.bmj.com/cgi/content/short/bmj.39469.763218.BEv1
(Editorial: Medication errors caused by junior doctors)
http://www.bmj.com/cgi/content/short/bmj.39475.402650.80v1

Doctors in training who are depressed are more than six times as likely to make medication errors as their non-depressed colleagues, finds a US study published on bmj.com today.

Depression and burnout are highly prevalent among doctors in training in the US. Studies have found rates of burnout to be between 41 and 76%, while rates of depression range from 7 to 56%.

Medication errors are also very common. In the US, up to 98,000 patients die each year due to medication errors, while in the UK, adverse events occur in more than 10% of hospital admissions, half of which may be preventable.

The stress of resident training, including sleep deprivation and lack of leisure time, are the most commonly cited explanations, yet few studies have sought to quantify the relationship with patient safety.

So researchers set out to determine the prevalence of depression and burnout among 123 paediatric residents at three children’s hospitals in the United States and to establish if a relationship exists between these disorders and medication errors.

One in five (20%) of the participating residents were depressed and almost three quarters (74%) were burned out, according to recognised criteria.

During the survey period, a total of 45 medication errors were made by participants. Those who were depressed made 6.2 times as many medication errors as their non-depressed colleagues.

However, burnout did not appear to be associated with higher rates of medication errors.

These findings indicate that mental health may be a more important contributor to patient safety than previously suspected, say the authors. The high burnout rate in this study, which is consistent with other studies, also raises questions about whether current methods of doctors’ training generate avoidable stress that is detrimental to the health of residents, they add.

The authors acknowledge several study limitations, including the fact that they collected their data before the implementation of work hour limits for residents in the US. However, recent studies suggest that work hour changes significantly decreased burnout scores but did not alter rates for depression.

Our results highlight the need for better research on the mental health of doctors, write the authors. Further efforts to study and improve the working conditions and mental health of doctors should be a priority, they conclude.

Although the suggestion that medication errors may be linked to depression and burnout seems reasonable, these results are far from conclusive, warn researchers from the University of Aberdeen in an accompanying editorial. Large, prospective, and appropriately designed studies are needed to clarify the roles of individual factors involved in error generation, they say.

Contacts:
Paper: Amy Fahrenkopf, Instructor of Pediatrics, Harvard Medical School Department of Medicine, Children's Hospital Boston, MA, USA
Email: amy.fahrenkopf@tch.harvard.edu
Editorial: James McLay, Senior Lecturer in Medicine and Therapeutics, Department of Medicine and Therapeutics, University of Aberdeen, Scotland
Email: j.mclay@abdn.ac.uk

(3) One in five hospital patients are malnourished
(Malnutrition in hospitals)
http://www.bmj.com/cgi/content/short/336/7637/290

About 20% of patients in general hospitals are malnourished, or thin and losing weight, or both, warn experts in this week's BMJ.

And up to 80% of these patients enter and leave hospital without any action being taken to treat their malnutrition because screening tools are underused and poorly enforced, they add.

Malnutrition is a common cause and consequence of illness particularly in older people, write Professors Mike Lean and Martin Wiseman. The number of malnourished people leaving NHS hospitals in England has risen by 85% over the past 10 years and is still rising.

Malnutrition affects the function and recovery of every organ system, increases the risk of infection, extends hospital stay, and makes readmission more likely. So clinicians need to be able to identify patients who have malnutrition or are at risk of malnutrition.

So how can this be achieved, they ask?

Several scoring systems that allow health professionals to identify and refer adults at risk of malnutrition exist, but they need to be validated before use in the community and hospital settings.

In 2006, the National Institute for Health and Clinical Excellence (NICE) recommended that all patients in hospital should be screened and monitored regularly for malnutrition, but these standards are weakly policed and are probably insufficient to stop many elderly people becoming malnourished if the quality of food is poor and there is a lack of staff to feed people.

Nutritional support is an important part of medical treatment, say the authors, yet hospital food is still provided by caterers who lack validated training in nutrition. Malnutrition is also often overlooked in residential care homes.

They believe the final solution to malnutrition in hospitals probably lies in recognising human nutrition as a discrete discipline, in which all medical graduates should reach a minimum level of competence, and some will specialise.

As such, they call for a basic understanding of human nutrition to be part of medical training and formal course in nutrition to be a requirement for higher training in medical specialties such as cardiology, diabetes, and public health.

Contacts:
Mike Lean, Professor of Human Nutrition, Faculty of Medicine, University of Glasgow, Royal Infirmary, Glasgow, Scotland
Email: lean@clinmed.gla.ac.uk 

(4) Changing parental behaviour key to tackling cot deaths
(Does cot death still exist?)
http://www.bmj.com/cgi/content/short/336/7639/290

Getting parents to stop smoking during pregnancy and to follow safe sleeping advice is key to tackling sudden unexplained infant deaths, according to an article in this week's BMJ.

The term sudden infant death syndrome (SIDS) was introduced in 1969 as a recognised category of natural death that carried no implication of blame for bereaved parents.

Since then, however, a lot has been learnt about risk factors, such as smoking and the role of parenting in cot death, undermining the popular myth that cot death is a bolt from the blue that can strike any child from any family.

So, in a special report, freelance journalist Jonathan Gornall asks whether it is time to stop classifying unexplained infant deaths as SIDS and instead focus on reducing the risks that we now know account for most sudden infant deaths.

In October, Britain's leading SIDS research team concluded that maternal smoking during pregnancy - already a recognised factor in 90% of cot death cases - was directly responsible for 60% of such deaths.

The Foundation for the Study of Infant Death endorsed this, saying: "If no women smoked in pregnancy, about 60% of cot deaths could be avoided, reducing the number of deaths in the UK from around 300 to 120 a year."

Heeding advice on sleeping position has also had an impact. Since the 1991 Back to Sleep campaign, the number of cases in the UK has fallen by 75%. However, a 2006 study found that the proportion of SIDS babies who died while co-sleeping with their parents had risen from 12% in 1984 to 50% in 2003.

However many SIDS cases there are, the fact that by the foundation's own estimation most are now attributable to modifiable parental behaviour suggests the need for a fundamental rethink, writes Gornall.

Can the foundation continue to justify funding the hunt for the elusive "cause" of SIDS when even scientists can’t agree on where to look for an answer, he asks?

Attitudes must change, he says. Efforts must focus on educating women who smoke throughout their pregnancies and those parents who continue to endanger their infants with other unsafe parenting practices, whether through ignorance or carelessness.

SIDS campaigners, many of them cot death parents whose children died before key risk factors were as well understood as they are today, have worked hard to ensure that parents do not suffer the additional burdens of suspicion and stigma, he writes.

Yet the flip side of this coin is the need to confront the hard truths about cot death if the "reduce the risk" message is to be brought home to those parents who remain the hardest to reach and whose children are most at risk.

Contact:
Jonathan Gornall, freelance journalist, London, UK
Email: jgornall@mac.com 

(5) Government targets to cut smoking in pregnancy "unrealistic"
(Personal View: We need better data on smoking in pregnancy)
http://www.bmj.com/cgi/content/short/336/7639/330

National targets to reduce smoking in pregnancy are unreliable and unrealistic because they are based on incomplete data, argues a midwife in this week's BMJ.

The initial national target was to reduce smoking in pregnancy from 23% in 1995 to 18% by 2005 and now to 15% by 2010. An additional requirement is to reduce the rate of mothers who are smoking at delivery by 1% year on year, specifically focusing on disadvantaged women to tackle inequalities in infant mortality.

Yet, according to Department of Health figures published in June, only a quarter of Primary Care Trusts achieved this target in 2005-7.

Carmel O'Gorman, a midwife specialising in smoking cessation at the Good Hope Hospital in Birmingham, is concerned by how realistic this target is and whether it is achievable within the required timescale.

The quality of current smoking data makes it difficult to set local targets and baselines and to monitor progress, she warns.

The latest infant feeding survey shows marked variations in smoking in pregnancy by mother's social class and age. But this survey is only undertaken every five years and cannot provide local information.

To provide a more timely and regional breakdown of the number of mothers smoking at delivery, she believes that all hospital trusts with maternity services should collect data on smoking, though she acknowledges there are problems with data recording.

Another weakness is that the data are based on self-reporting and should be interpreted with caution, she warns. She suggests measuring cotinine levels (a by-product of nicotine) during pregnancy and at delivery to help increase the trustworthiness of data and clarify the true scale of the problem.

Given these problems, her view is that the resultant targets are unreliable and unrealistic, which can be demotivating and cause needless stress for those involved.

Collecting quality data isn't just about meeting targets, she says, it is key to knowing whether our interventions are improving health.

She describes successfully working with women and their partners to prevent postnatal relapse back to smoking, but points out that not all of these may be measurable in the target driven NHS.

Contact:
Mr Michael Moloney, Consultant Obstetrician & Gynaecologist, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
Email: michael.moloney@heartofengland.nhs.uk 

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