Press releases Monday 8 June to Friday 12 June 2009
Please remember to credit the BMJ
as source when publicising an article and to tell your readers that they can
read its full text on the journal's website (http://www.bmj.com).
(1) New test could help diagnose early dementia
(2) Individuals with family history of genetic disease at risk of discrimination
(3) Label for first homoeopathic product may be illegal, warns senior scientist
(4) Study calls for urgent review of NHS and independent birth care
(5) Rear facing car seats safest for children under 4 years old
(1)New test could help diagnose early dementia
(Research: Self administered cognitive screening test (TYM) for detection of Alzheimer's disease: cross sectional study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2030
(Editorial: Diagnosis of dementia)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1176
A new cognitive test for detecting Alzheimer's disease is quicker and more accurate than many current tests, and could help diagnose early dementia, concludes a study published on bmj.com today.
An estimated 24 million people throughout the world have dementia and the number affected will double every 20 years. Early diagnosis is crucial to effective treatment, but there is no available short cognitive test that is quick to use, examines various skills, and is sensitive to Alzheimer's disease.
So researchers at Addenbrooke's Hospital in Cambridge designed and evaluated a new cognitive test, the TYM ("test your memory"), in the detection of Alzheimer's disease.
The TYM is a series of 10 tasks including ability to copy a sentence, semantic knowledge, calculation, verbal fluency and recall ability. The ability to do the test is also scored. Each task carries a score with a maximum score of 50 points available. The test is designed to use minimal operator time and to be suitable for non-specialist use.
The test was completed by 540 healthy individuals (controls) aged 18 to 95 years of age with no history of neurological disease, memory problems or brain injury. A further 139 patients with diagnosed Alzheimer's or mild cognitive impairment were also tested.
The test was compared with two commonly used bedside cognitive tests - the mini-mental state examination and the Addenbrooke's cognitive examination.
The mini-mental state examination has been the standard short cognitive test for 30 years and is the main test chosen by the National Institute for Health and Clinical Excellence (NICE) for deciding which patients should receive drugs and for monitoring their response to treatment.
Controls completed the test in an average time of five minutes and gained an average score of 47 out of 50. Patients with Alzheimer's disease performed much poorer than controls with an average score of 33 out of 50. Patients with mild cognitive impairment scored an average of 45 out of 50.
The average TYM score remained constant between the ages of 18 and 70 years, with a small decline in performance after this age. Scores did not differ between men and women or by geographical background, suggesting that education and social class would have only mild effects on the TYM score.
The TYM detected 93% of patients with Alzheimer's disease, while the mini-mental state examination detected only 52% of patients, suggesting that the TYM test is a much more sensitive tool for detecting mild Alzheimer's disease. Compared to the mini-mental state examination, the TYM also takes less time to administer and tests a wider range of cognitive domains.
The Addenbrooke's cognitive examination tests a similar number of cognitive domains to the TYM and is sensitive to mild Alzheimer's disease, but it takes 20 minutes to administer and score.
The TYM is a powerful and valid screening test for the detection of Alzheimer's disease, conclude the authors.
The usefulness of screening tests varies according to the clinical setting, says consultant physician Claire Nicholl in an accompanying editorial.
If the test your memory test is to be adopted more widely it must be validated in a range of settings and different populations, she writes. Until then, the most important message is that clinicians should identify a test that suits their clinical setting, and develop experience in its use to improve the identification of patients with early dementia.
Contact:
Research: Jeremy Brown, Consultant Neurologist, Addenbrooke's Hospital, Cambridge Tel: (via James Woodman, press office)
Email: james.woodman@addenbrookes.nhs.uk
Editorial: Claire Nicholl, Consultant Physician, Medicine for the Elderly, Addenbrooke's Hospital, Cambridge, UK
Email: claire.nicholl@addenbrookes.nhs.uk
People with a family history of genetic disease are often discriminated against by insurance companies and their relatives and friends, according to research published on bmj.com today.
Advances in genetic testing have meant that many individuals have been able to tailor treatment and inform reproductive decisions. However, these powerful new technologies have also caused fear about the misuse of genetic information including discrimination, say the authors.
Such fear led the US Government to pass legislation preventing health insurance companies and employers using genetic information.
The lead authors, Drs Yvonne Bombard and Michael Hayden based at the University of British Columbia, say the scale of genetic discrimination is largely unknown and this is the first study to focus on this issue in a genetically tested and untested population.
The authors surveyed 233 individuals in Canada who were at risk of developing Huntington's disease. None of the group had symptoms of the disease, 167 of them underwent testing (83 had the Huntington's disease mutation, 84 did not) and 66 chose not be tested.
Huntington's disease is an inherited neurodegenerative psychiatric disorder for which there is no treatment or cure. The disease usually manifests itself in mid-life and individuals suffer from mood and personality changes, chorea (involuntary movements) and cognitive decline. The disease ends in death, usually 15 to 20 years after diagnosis.
Around 40% of respondents said they experienced discrimination, primarily by insurance companies (1 in 3), their family and in social settings (1 in 5). Interestingly, there were not many reports of discrimination in employment, health care or public sector settings.
The findings show that it is family history that appears to be the major cause of genetic discrimination not participation in genetic testing. The authors conclude that "clearly, there is a need to shift the current focus of genetic discrimination as a genetic testing issue to one that equally highlights the role family history plays in people's lives."
The authors maintain that many individuals and families fear being unable to cope with the predictive test results, especially given no treatment exists to slow or prevent Huntington's disease. They add that the decision to test can become a "litmus test by which relatives judge each other's loyalty to the family" and that testing often causes disruption within the family.
In conclusion the authors say that "ultimately asymptomatic individuals at genetic risk are at similar risk for discrimination because their label of having a family history of disease."
In an accompanying editorial, Professor Aad Tibben from Leiden University in the Netherlands advocates the benefits of genetic testing and says it "gives a person at risk the opportunity to take more responsibility and control over their life, their health and their future. In general, the test brings relief from uncertainty and more control over people's future life, and no serious adverse consequences have been reported."
Tibben is intrigued by the study's findings related to genetic discrimination within the family and social relationships and believes more insight is needed into the dynamics in these fields.
Contact:
Research: Yvonne Bombard, Doctoral Candidate, Centre for Molecular Medicine and Therapeutics (CMMT). Current: Postdoctoral Fellow, Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
Email: yvonne.bombard@utoronto.ca
Or
Michael Hayden, Canada Research chair in Human Genetics and Molecular Medicine, Department of Medical Genetics, University of British Columbia, Vancouver, Canada
Email: mrh@cmmt.ubc.ca
(3) Label for first homoeopathic product may be illegal, warns senior scientist
(Letters: Homoeopathic product licence)
http://press.psprings.co.uk/bmj/june/colquhoun.doc
http://press.psprings.co.uk/bmj/june/evans.doc
http://press.psprings.co.uk/bmj/june/moore.doc
The labelling for the first homoeopathic product to get a licence from the UK Medicines and Healthcare Products Regulatory Agency (MHRA) should be illegal, because they breach Unfair Trading regulations, argues a senior scientist today.
In a letter published in this week's BMJ, Professor David Colquhoun from University College London says the MHRA "has made a mockery of its own aims" by allowing Arnica 30C pills to be labelled "a homoeopathic medicinal product used with the homoeopathic tradition for the symptomatic relief of sprains, muscular aches, and bruising or swelling after contusions."
This label should be illegal, he says, because the pills contain no trace of the ingredient on the label, but this deceit has been allowed through a legal loophole for a long time now. He points out that if you sold strawberry jam that contained not a trace of strawberry you'd be in trouble.
But he can see no such loophole that allows manufacturers of Arnica 30C to evade the consumer protection laws which ban "falsely claiming that a product is able to cure illnesses" and which apply to the way that "the average consumer" will interpret the label.
The average consumer is unlikely to know that "used with the homoeopathic tradition" is a form of weasel words that actually means "there isn't a jot of evidence that the medicine works," he writes.
Since there is not the slightest evidence that Arnica 30C pills provide symptomatic relief of sprains, etc, the labelling that the MHRA has approved seems to be illegal, he concludes.
In a second letter, Professor Stephen Evans from the London School of Hygiene and Tropical Medicine believes that the MHRA could have resisted granting a licence because there is "good evidence against any efficacy."
This fiasco, he says, takes us back to the days before drug regulation was introduced, partly to prevent hazards of snake oil-type remedies. And he warns that this product "may have major indirect harms ... not only in individual patients who may not get benefit from the other effective remedies but also in a general sense by undermining the rational basis for medicine."
In a final letter, Nicholas Moore, a clinical pharmacologist at the University of Bordeaux, says that "giving homoeopathy credit for any kind of demonstrable efficacy is ludicrous."
But he suggests that homoeopathy might be useful as "a truly inactive placebo" for over-treated illnesses such as the common cold and insomnia. This "will not alter the course of the disease. But the patient will feel better, which is one of the aims of medicine's art, if not its science," he writes.
Contact:
David Colquhoun, Research Professor, University College London, UK
Email: d.colquhoun@ucl.ac.uk
Stephen Evans, Professor of Pharmacoepidemiology, London School of Hygiene and Tropical Medicine, UK [Please note, Professor Evans is not in the UK between Tuesday and Thursday and will not be easily available on the phone. You can attempt to reach him on mobile: +44 (0)7979 600 702 Tues before 11.30hrs UK time or after 18:00hrs; Wed after 17:00hrs; Thurs after 19:00hrs]
Nicholas Moore, Clinical Pharmacologist, University of Bordeaux, France
Email: nicholas.moore@pharmaco.u-bordeaux2.fr
There is an urgent need to review certain aspects of care for women giving birth using an independent midwife and those using NHS services, concludes a study published on bmj.com today.
Patient choice is a key aspect of government health policy in the UK and hospitals are urged to support low risk women who want to give birth at home.
Currently, around 2.5% of births occur in the home, most with NHS personnel in attendance, but a small number of women opt to employ an independent midwife, a self-employed qualified practitioner working outside the NHS.
Studies have consistently shown that, for low risk women, giving birth at home is as safe as giving birth in hospital, yet no studies have compared likely outcomes for women using an independent midwife and those using NHS services.
So a research team at the University of Dundee identified records for 8,676 women who had given birth between 2002 and 2005. Of these, 7,214 women had used NHS services and 1,462 had employed a member of the Independent Midwives' Association (IMA).
Data on socio-economic status, medical history, and previous obstetric complications were collated for each mother. Clinical outcomes, such as onset and duration of labour, delivery, use of pain relieving drugs, and infant deaths, were then compared.
There were important differences between the two groups of women. For example, IMA group mothers were more likely to have a pre-existing medical condition and previous obstetric complications than NHS group mothers. IMA mothers were also more likely to have a twin pregnancy and breech presentation.
IMA mothers were significantly more likely to start labour spontaneously and have an unassisted vaginal birth than NHS mothers. IMA mothers also used fewer pain relieving drugs and were much more likely to breastfeed successfully than NHS mothers.
IMA mothers were also more likely to experience a stillbirth or a neonatal death than NHS mothers (1.7% in the IMA group compared with 0.6% in the NHS group).
However, when 'high risk' cases were excluded from both groups, the difference was not statistically significant (0.5% in the IMA group and 0.3% in the NHS group). This suggests that it is these higher risk situations (breech birth and twin pregnancies) that account for the higher death rate, say the authors.
Although the average gestational age was very similar between the groups, birth weights in the IMA group were significantly higher than in the NHS group. NHS babies were also far more likely to be premature and admitted to a neonatal intensive care unit.
While clinical outcomes across a range of variables are much better for women using an independent midwife, the significantly higher perinatal mortality rate, particularly in higher risk women, indicates an urgent need for a full review of these cases, say the authors. The significantly higher premature birth rates and admissions to intensive care units in the NHS group also indicate an urgent need for review.
This would provide women with further evidence on which to base their decisions about pregnancy care and delivery, they conclude.
This study shows the difficulties researchers face in trying to compare outcomes between independent midwifery services and NHS care, say experts in an accompanying editorial.
Allison and Brett Shorten from the University of Wollongong and the Informed Health Choices Trust in Australia believe that mainstream maternity services "need to move beyond the rhetoric of policy documents and provide the type of services that women demand."
They conclude: "Health systems will need to cultivate models that foster open referral and consultation between professional groups and most importantly make genuine efforts to include women in decision making. Collaboration within and between disciplines will increase the likelihood of providing higher quality, safe services for women and families."
Contact:
Research: Andrew Symon, Senior Lecturer, School of Nursing & Midwifery, University of Dundee, Scotland, UK
Email: a.g.symon@dundee.ac.uk
Editorial: Allison Shorten, Senior Lecturer, School of Nursing, Midwifery and Indigenous Health, Faculty of Health and Behavioural Sciences, University of Wollongong, NSW, Australia
Email: ashorten@uow.edu.au
(5) Rear facing car seats safest for children under 4 years old
(Change Page: Advise use of rear facing child car seats for children under 4 years old)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1994
Parents should be advised to keep young children in rear facing car seats for as long as possible, state doctors in a paper published on bmj.com today.
It is common practice to switch babies to a forward facing car seat at 9kg (8 months of age for an average boy), but there is mounting evidence that it is safer for young children to travel in a rear facing seat until 4 years of age, write Drs Elizabeth Watson and Michael Monteiro.
For instance, data from Sweden where rear facing up to age 4 is common practice, has shown that children who died in accidents restrained in forward facing booster seats could have potentially survived if they had been travelling in rear facing seats.
One study used the US National Highway Traffic Safety Administration crash database to examine crashes involving 870 children between 1998 and 2003, and concluded that rear facing seats were more effective than forward facing seats in protecting children aged 0-23 months for all crash types.
Recent crash tests have also reported that rear facing seats resulted in significantly lower neck and chest injury measures compared with forward facing seats. The authors of another crash simulation study encouraged manufacturers to develop rear facing seats for children up to 4 years of age.
The authors explain that, unlike forward facing seats, rear facing car seats keep the head, neck and spine fully aligned so the crash forces are distributed over all of these body areas.
They believe part of the problem is that many parents and healthcare providers may be unaware that it is safer to leave children in rear facing seats for as long as possible, or that rear facing seats for toddlers exist.
Healthcare professionals should advise that rear facing seats are safer than forward facing seats for children under 4 years, say the authors.
They also call on manufacturers and retailers to increase the availability of rear facing seats for older children and for a change to the current weight-range labelling of European seats, which may imply that forward facing seats are as safe as rear facing seats for children over 9kg.
Contact:
Dr Elizabeth Watson, General Practice Retainer
Email: eliwat1@yahoo.co.uk
FOR ACCREDITED JOURNALISTS
For more information please contact:
Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bmj.com
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and from:
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