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Press releases Monday 10 to Friday 14 November 2008

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(1) Doctors must look after their health too
(2) Radical changes needed to increase number of sperm donors in the UK
(3) ECG tests no better than routine clinical assessment at predicting future heart disease
(3) Soluble fibre, antispasmodics and peppermint oil should be used to treat IBS
(3) World leaders must be more open about their health

(1) Doctors must look after their health too
(Research paper: Counselling for burnout in Norwegian doctors: one year cohort study)
http://www.bmj.com/cgi/content/full/337/nov11_3/a2004

Short term counselling followed by a modest cut in work hours may help reduce emotional exhaustion (burnout) and sick leave in doctors, according to a study published on bmj.com today.

It is well known that doctors have higher rates of depression and suicide than the general population and are less likely to seek help. There have been calls for early intervention programmes to help doctors with mental distress and burnout before their problems interfere with the welfare of patients.

Although such programmes have been shown to reduce stress and exhaustion, it is not clear what type of intervention is best suited to which individual or personal characteristics, or which factors contribute to positive changes.

Dr Karin Rø and colleagues from Norway examined levels of burnout and predictors of reduction in emotional exhaustion after one year, in 227 stressed doctors who participated in voluntary counselling.

Initially, 187 doctors attended a one day individual session, and 40 a one week group based course. Of the 185 doctors who completed follow-up assessments, 70 returned for an additional intervention during the follow-up year, 51 to a one week course and 19 to an individual session.

They completed self report assessments in the four weeks before and the three weeks after the counselling, and a follow-up questionnaire after one year. The data was compared with data obtained from a representative sample of Norwegian doctors in 2003.

One year after a counselling intervention stressed doctors reported a reduction in emotional exhaustion and job stress similar to the level found in a representative sample of Norwegian doctors.

The researchers also found that the number of doctors on full time sick leave had reduced substantially in the year after counselling (35% to 6%), and that the use of psychotherapy also substantially increased from 20% to 53% in the follow-up year.

Interestingly, they found that reduction in work hours after the intervention was also associated with a reduction in emotional exhaustion.

"Our findings indicate that seeking a counselling intervention could be conducive to reduction of burnout among doctors. Considering doctors' reluctance to seek help - it is important to offer interventions that facilitate access," conclude the authors.

Contact:
Karin Rø, Research Institute, Modum Bad, Vikersund, Norway.
Email: Karin.roe@modum-bad.no

(2) Radical changes needed to increase number of sperm donors in the UK
(Editorial: Sperm donation in the UK)
http://www.bmj.com/cgi/content/short/337/nov11_3/a2318

A radical overhaul of sperm donation services is needed to address the critical shortage of sperm donors in the UK, say two fertility experts in an editorial on bmj.com today.

Mark Hamilton, Chairman of the British Fertility Society, and Allan Pacey, Secretary of the British Fertility Society, say that the UK is struggling to meet the demand for donated sperm and many clinics have long waiting lists or have been forced to stop providing services altogether.

They believe that the removal of donor anonymity in 2005 may have contributed to the current shortage of donors. With around 4000 UK patients requiring donor sperm each year, and the UK legal limit of 10 pregnancies from a single donor, a minimum of 500 new donors are needed every year to meet demand. But in 2006 there were only 307 new registrations. The authors say increasing the number of families that can be created from a single donor should be considered. To prevent siblings born from donation later inadvertently having children together, UK law limits the number of families that can be created from any one donor to 10. But Hamilton and Pacey argue that this figure is arbitrary and not evidence based, and a more flexible approach is needed.

They point out that the size of the UK population is enough for a large safety margin to already exist. Interestingly, in the Netherlands, which has a smaller population than the UK, the upper limit is 25 offspring per donor, while in France it is five.

The British Fertility Society has called for major changes in the organisation of recruitment services to increase the number of new donors. Possible changes that Hamilton and Pacey describe include implementing a new national service framework for sperm donation with large regional centres providing the bulk of donor management and smaller local centres providing services for recipients. Currently, up to 35% of potential donors are lost after their first enquiry and never assessed. Making services more accessible and efficient may reduce this figure and encourage more men to participate. According to the authors, another option would be the introduction of sperm sharing schemes that would work along the same lines as egg sharing programmes that are already in place in the UK, whereby fertile male partners of women who need IVF could become donors and have their fertility treatment partly funded by sperm donation.

Some options that the British Fertility Society decided not to recommend, due to concerns over safety standards, include increasing the age limit of donors from the present 40 years and lowering the acceptable levels of semen quality. Both Hamilton and Pacey conclude that all these proposals need to be evaluated, so future decisions and policies can be based on clear evidence.

Contacts:
Mark Hamilton, Chairman of the British Fertility Society, University of Aberdeen, Aberdeen, Scotland
Email: m.hamilton@abdn.ac.uk 

Allan Pacey, Secretary of the British Fertility Society, University of Sheffield, Sheffield, UK
Email: a.pacey@sheffield.ac.uk 

(3) ECG tests no better than routine clinical assessment at predicting future heart disease
(Research paper: Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina)
http://www.bmj.com/cgi/content/full/337/nov13_2/a2240
(Editorial: Prognostic value of electrocardiography in suspected angina)
http://www.bmj.com/cgi/content/short/337/nov13_2/a2340

ECG (electrocardiogram) tests commonly given to people with suspected angina to predict the likelihood future of heart disease have limited accuracy, according to a study published today on bmj.com.

Alternative tests which add predictive value to that obtained from the patient's clinical history are needed to improve the chances of detecting people at higher risk of future heart disease and heart attacks, say the authors.

Angina is the most common symptom of coronary artery disease and is experienced by about 2 in every 100 people in the UK. Patients are assessed at rapid access chest pain clinics, designed to ensure that people who develop new symptoms of suspected angina can be assessed by a specialist within two weeks of referral.

Prompt assessment using ECG while patients are resting and when they are exercising is the most commonly performed non-invasive test used in suspected angina patients, but its ability to predict future heart disease is unknown.

A team of researchers led by the London Chest Hospital studied 8 176 patients with suspected angina and no prior diagnosis of heart disease, who were referred by their doctor to one of six chest pain clinics.

All the patients were clinically assessed (studying data such as age, sex, ethnicity, duration of symptoms, description of chest pain, smoking status, history of hypertension, medications) as well as having an ECG done while they were resting.

4 873 (60%) of the patients had an exercise ECG performed and were split into two groups, one comprising 4 848 patients with a "summary" result recorded, and the other with 1 422 patients who additionally had "detailed" exercise ECG data recorded. All patients were followed up for the next few years.

The researchers found that almost half (47%) of all coronary ‘events' that happened to people during the follow up period occurred in patients who had had a negative exercise ECG that did not indicate any heart problems.

This suggests that exercise ECGs are limited in how accurately they predict the risk of future heart disease, say the authors.

They found that a routine clinical assessment provided almost as much predictive information about future heart problems as having a ECG. The resting ECG showed no additional benefit to the information obtained from the history and examination.

The authors conclude that ECG tests are of limited value in identifying potential future coronary problems in patients with suspected angina and no prior diagnosis of heart disease, adding little to routine clinical assessment including the patient's history and an examination.

The researchers say: "The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients."

These findings are a reminder of "the importance of taking a detailed history and making a thorough physical examination, and that additional information from the ECG is helpful in some patients but does not predict risk in everyone," says Beth Abramson, Director of St Michael's Hospital in Toronto in an accompanying editorial.

Contact:
Adam Timmis, London Chest Hospital, Barts and The London NHS Trust, London
Email: adamtimmis@mac.com 

(4) Soluble fibre, antispasmodics and peppermint oil should be used to treat IBS
(Research paper: Effect of fibre, antispasmodics, and peppermint oil in irritable bowel syndrome: systematic review and meta-analysis)
http://www.bmj.com/cgi/content/full/337/nov13_2/a2313
(Editorial: Treatment of irritable bowel syndrome in primary care )
http://www.bmj.com/cgi/content/extract/337/nov13_3/a2213

Fibre, antispasmodics and peppermint oil are all effective therapies for irritable bowel syndrome (IBS) and should become first-line treatments, according to a study on bmj.com today.

National guidelines on the management of IBS should be updated in light of this evidence, say the authors.

IBS is characterised by abdominal pain and an irregular bowel habit, and affects between 5% and 20% of the population. Because the exact cause of IBS is unknown it is difficult to treat. A wide range of therapies are currently used including fibre supplements, probiotics, antidepressants, hypnotherapy and laxatives.

Because of a lack of suitable drug treatments, international and national guidelines promote the use of complementary and alternative treatments, including the recently published National Institute of Health and Clinical Excellence (NICE) guidelines on the management of IBS.

Fibre, antispasmodics and peppermint oil are used to treat IBS, but evidence of their effectiveness is unclear because of conflicting conclusions and errors in previous studies.

In an attempt to resolve this uncertainty, Dr Alex Ford and colleagues performed a systematic review and meta-analysis of randomised trials comparing fibre, antispasmodics and peppermint oil with placebo or no treatment in more than 2500 adult patients with IBS..

Fibre, antispasmodics and peppermint oil were all found to be effective treatments for IBS. The number needed to treat to prevent IBS symptoms in one patient was 11 for fibre, 5 for antispasmodics, and 2.5 for peppermint oil. None of the treatments had serious adverse effects.

The researchers analysed 12 studies which compared fibre with placebo or no treatment involving 591 patients. Interestingly, insoluble fibre such as bran was not beneficial, only isphaghula husk (soluble fibre) significantly reduced symptoms.

They identified 22 studies comparing various antispasmodics with placebo in 1778 patients. Hyoscine was the most successful at preventing symptoms of IBS. The authors suggest that hyoscine, which is extracted from the cork wood tree, be used as the first-line antispasmodic therapy in primary care.

Peppermint oil seemed to be the most effective treatment of the three, based on four trials involving 392 patients.

These treatments have been overlooked because of the introduction of newer more expensive drugs which were withdrawn due to lack of efficacy and safety concerns, say the authors. All three treatments have been shown to be potentially effective therapies for IBS and current national and international guidelines need to be revised to include this new evidence, they add.

The results of this study should "reawaken interest in the pharmacotherapy of irritable bowel syndrome and stimulate further research," says Professor Roger Jones from King's College London.

However, he cautions that this new evidence must not detract from the need to make a holistic diagnosis and integrated approach to the treatment of IBS which takes account of the physical, psychological, and social factors involved.

Contacts:
Alex Ford, McMaster University, Health Sciences Centre, Ontario, Canada
Email: alexf12399@yahoo.com 

Roger Jones, King's College London, London, UK
Email: roger.jones@kcl.ac.uk 

(5) World leaders must be more open about their health
(Personal View: Open the medical records of future world leaders)
http://www.bmj.com/cgi/content/short/337/nov07_3/a2486

Anyone who runs for Prime Minister or President should have an independent health examination to ensure their ability to govern, argues a doctor on bmj.com today.

Lord David Owen, a trained doctor and member of the House of Lords, says that millions of people are affected by the decisions of people in high public office, and these leaders have an obligation to the general public to ensure that their decision making is not impaired by physical or mental illness.

No one has to stand for high public office he says, "if potential candidates knew they faced independent assessment and that they had a health problem then they would either not stand or they would make it public of their own volition."

According to Owen, many heads of governments and their personal doctors do not tell the truth about their illness and have received inferior medical treatment as a result of this secrecy. For example, when François Mitterrand was President of France he kept his cancer of the prostate and secondaries in the bone secret for 11 years, even though his personal doctor made monthly public statements about his health with no mention of his true medical condition.

More recently, despite happily revealing his medical records from Vietnam, in the run-up to the US elections, Senator McCain was not so open about his malignant melanoma diagnosis.

When in office, leaders should be obliged to have an annual independent health check to ensure that they are fit for office and are able to step down temporarily or permanently if their illness is affecting their capacity to do the job, writes Owen.

In 1998, the Prime Minister of Norway suffered a severe depressive reaction and offered to resign. But, after discussion with the Foreign Minister, he publicly announced that he was suffering from depression, and after four weeks of treatment and adapting his working practices he returned to work. His actions commanded great respect from the Norwegian public and helped lessen the stigma surrounding mental health.

According to Owen, this example illustrates the lessening prejudice and much greater public understanding of illness. A greater openness would not necessarily preclude someone with an illness from convincing their party and the public that they are fit for office, he concludes.

Contacts:
Lord David Owen, trained doctor and member of the House of Lords, UK
Email: lordowen@gotadsl.co.uk 

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