Press releases Monday 11 May to Friday 15 May 2009
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(1) Mandatory folic acid fortification reduces heart defects at birth
(2) Virtual reality simulators improve surgical skills
(1) Swine flu: Keeping doctors fully informed
(Research: Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1673
(Editorial: Folic acid fortification and congenital heart disease
http://www.bmj.com/cgi/doi/10.1136/bmj.b1144
The number of babies born with severe congenital heart defects has decreased after mandatory fortification of grain products with folic acid in Canada, concludes a large study published on bmj.com today.
It is widely known that taking folic acid before conception and in early pregnancy reduces the risk of neural tube defects such as spina bifida. Some studies suggest that folic acid may also decrease the birth prevalence of congenital heart disease, the most common of all birth defects, but the evidence is still inconclusive.
So researchers assessed the impact of folic acid fortification policies on the birth prevalence of severe congenital heart defects in Quebec, Canada, where fortification of flour and pasta products with folic acid has been mandatory since 1998.
Mandatory food fortification has not been adopted in Europe.
Using administrative databases, they identified all infants (live and stillborn) with severe congenital heart defects in Quebec over a 16 year period (1990 to 2005). Data were analysed in two time periods (before and after fortification) to estimate the change in prevalence of severe heart defects within the population.
During the study period there were 1.3 million births in Quebec and 2,083 infants born with severe heart defects, corresponding to an average birth prevalence of 1.57 per 1,000 births.
The time trend analysis showed no change in the birth prevalence of severe heart defects in the nine years before fortification, while in the seven years after fortification there was a significant 6% decrease per year.
Further analysis made little difference to the results, suggesting that the decreasing trend after fortification did not occur by chance, and supporting the theory that intake of folic acid around conception reduces the risk of severe congenital heart defects.
The authors suggest the results were not likely caused by chance because the timing of the observed effect coincided exactly with the timing of the fortification; there is biological plausibility for this association, and most other factors that are known to increase the birth prevalence of severe congenital heart defects, such as older maternal age, medication use, or obesity, have gradually increased over the study period in Quebec.
An average 6% drop per year may seem modest, say the authors. But, given that treatment for heart defects in infancy is highly complex and is associated with high infant mortality rates, even a small reduction in the overall risk will significantly reduce the costs associated with the medical care of these patients and the psychological burden on patients and their families.
They also suggest that their results may have underestimated the true impact of folic acid on the birth prevalence of severe congenital heart defects, and call for further population-based studies to confirm these findings.
Such studies raise important questions about whether food fortification is an effective strategy, say two heart experts in an accompanying editorial. For example, are the current levels of fortification sufficient to significantly reduce the rates of congenital malformations, and is food fortification harmful to some people?
As the population becomes more obese, rates of type 2 diabetes increase and nutritional habits remain poor, the prevalence of congenital heart disease may increase, they write. So, rather than considering fortification targeted at populations, should we find more effective interventions to target women of child bearing age?
Contacts:
Research: Louise Pilote, Professor of Medicine, McGill University, Montreal, Canada
Email: louise.pilote@mcgill.ca
Or
Raluca Ionescu-Ittu, PhD candidate, McGill University, Montreal, Canada
Email: raluca.ionescu-ittu@mail.mcgill.ca
Editorial: Dr Helena Gardiner, Senior Lecturer and Director of Perinatal Cardiology, Faculty of Medicine, Imperial College at Queen Charlotte's and Chelsea and the Royal Brompton Hospitals, London, UK
Email: louise.pilote@mcgill.ca
Using virtual reality simulators to train surgeons improves performance and reduces operating time, finds a study published on bmj.com today.
Surgery is traditionally learnt by repeated practice on patients but, in recent years, targets and reductions in working time have cut training opportunities for young doctors, while ethical factors sometimes make it unacceptable for novices to learn on patients.
Although simulation based training has been explored since the 1970s, high quality evidence to support its widespread adoption is still sparse. So a team of researchers based in Denmark set out to assess the effect of virtual reality training on surgical performance within the training curriculum.
The study took place from September 2006 to August 2007 and involved 24 junior registrars training in obstetrics and gynaecology with no clinical experience of laparoscopic (keyhole) surgery.
Participants were randomly allocated to either virtual reality simulator training or to traditional clinical training. The simulator group received seven hours of training. After training, the registrars performed their first laparoscopic operation on a patient (under senior supervision) and were scored according to their technical performance by two independent assessors. Their operation time was also recorded.
The simulator trained group scored an average of 33 points, equivalent to the experience gained in 20-50 laparoscopic procedures (intermediate level performance). The control group scored an average of 23 points, equivalent to the experience gained in less than five procedures (novice level performance).
Operating time was 12 minutes in the simulator group compared with 24 minutes in the control group.
The authors stress that surgical performance also involves non-technical skills, such as communication, teamwork and decision-making and therefore simulator training should only be considered as a supplement to real operations.
However, these findings clearly show that skills in laparoscopic surgery can be increased in a clinically relevant manner by virtual reality simulator training, they say. The performance level of novices was increased to the level of intermediately experienced laparoscopists and the operation time was reduced by half.
Simulator training should be incorporated into the curriculum for all surgical trainees before they embark on patient procedures, they conclude. This can potentially improve patient safety and improve operation room efficiency.
This study makes an important contribution to our understanding, but the strength of simulation is as an adjunct rather than an alternative to clinical experience, suggest two surgeons from Imperial College London in an accompanying editorial.
A key challenge is to integrate simulation within existing curricular structures to ensure that practice takes place within a robust educational framework, they say. Simulation is costly in terms of equipment and teaching facilities. However, the establishment of simulation centres at key sites can enable trainees to participate in regular practice sessions which align with and reinforce their clinical training, they conclude.
Contacts:
Research: Christian Rifbjerg Larsen, Clinical Research Fellow, Department of Gynaecology, The Juliane Marie Centre (for Children, Women and Reproduction), Copenhagen University Hospital, Denmark
Email: crl@rh.regionh.dk
Editorial: Roger Kneebone, Reader in Surgical Education, Department of Biosurgery and Surgical Technology, Imperial college London, UK
Email: r.kneebone@imperial.ac.uk
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