Press releases Monday 5 October to Friday 9 October 2009
Please remember to credit the BMJas 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) Seasonal vaccine offers some protection against swine flu
(1) Common mental disorders may be linked to an increased risk of obesity
(3) Four out of 10 back pain sufferers will recover within a year
(4) Including boys in HPV vaccination programmes would not offer value for money
(5) Screening all patients for MRSA "unethical" says expert
(6) Collaborative requesting does not increase consent for organ donation
(7) Four out of 10 back pain sufferers will recover within a year
(1) Seasonal vaccine offers some protection against swine flu
(Research: Partial protection of seasonal trivalent inactivated vaccine against novel pandemic influenza A/H1N1 2009: case-control study in Mexico City)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3928
(Editorial: The future of influenza vaccines)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4014
The 2008-2009 seasonal flu vaccine (trivalent inactivated vaccine, TIV) provides some protection against swine flu, particularly the most severe forms of the disease, according to preliminary research published today on BMJ.com.
However, the authors emphasise that the results should be considered cautiously "and in no way indicate that seasonal vaccine should replace vaccination against pandemic influenza A/H1N1 2009."
In June 2009, the emergence of this new flu virus led the World Health Organisation to raise the level of influenza pandemic alert from phase three to phase six. By July 2009, 122 countries reported almost 100,000 confirmed cases of swine flu.
This study, led by Dr Jose Luis Valdespino from Mexico, investigated the link between the 2008-9 seasonal flu vaccine with cases of influenza A/H1N1 during the epidemic in a speciality hospital in Mexico City.
The authors say the reason the seasonal vaccine offers some protection is because it boosts existing antibodies in individuals who have previously been exposed to a similar flu virus, either by infection or vaccination.
Valdespino and colleagues compared the health outcomes (hospitalisation, mechanical ventilation and death) of 60 patients with swine flu and 180 control patients with other diseases. Both groups of patients informed the authors directly, by telephone or via a close relative whether they had received the 2008-9 seasonal flu vaccine.
The results show that the uninfected participants were significantly more likely to have received the seasonal flu vaccine and suggest that it protected them against particularly severe forms of swine flu. However the authors say the results must be taken in context and argue that given the small sample size "it will be key to conduct similar studies in other settings to confirm or refute our results."
In an accompanying editorial, Dr Menno de Jong from the Academic Medical Centre of the University of Amsterdam concurs with Dr Valdespino that the results do not mean that there is no need for a specific vaccine against swine flu.
Dr de Jong also raises the issue of vaccine production and says that vaccines may not be available in time, even in countries that have procured sufficient quantities, so that "vaccinated people may be protected only after the peak of the pandemic has passed." He added that "to protect against seasonal and pandemic strains, vaccines and vaccine production need to improve."
Contacts:
Research: Jose Luis Valdespino, Director of Research Development and Quality Assurance, Laboratories de Biológicos y Reactivos de México (BIRMEX)
Email: jvaldespinog@birmex.gob.mx
Or
Elizabeth Loder, Clinical Editor, BMJ
Email: eloder@bmj.com
Editorial: Menno de Jong, Professor of Clinical Virology, Academic Medical Centre of the University of Amsterdam, Netherlands
Email: m.d.dejong@amc.nl
(2) Common mental disorders may be linked to an increased risk of obesity
(Research: Common mental disorder and obesity - insight from four repeat measures over 19 years: prospective Whitehall II cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3765
(Editorial: Obesity and depression or anxiety)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3868
People with common mental disorders such as depression and anxiety are at increased risk of becoming obese, according to new research published on bmj.com today.
The findings also show that individuals with chronic or repeat episodes of common mental disorders are particularly at risk, say the authors.
Previous studies report contradictory results and it remains unclear if common mental disorders lead to an increased risk of obesity, or if obesity is a risk factor for future mental disorders. Understanding the connection between these common conditions is vital because they have a significant impact on health care systems and could aid effective treatment and prevention.
To provide more evidence, researchers led by Mika Kivimäki from University College London, investigated the direction and possible dose-response nature of the link between common mental disorder and obesity.
Their findings are based on four medical screenings of 4,363 British civil servants aged between 35 and 55 years old, over a 19 year period between 1985 and 2004. Each screening included a standardised assessment of common mental disorder (General Health Questionnaire) and measurement of height and weight from which body mass index (BMI) was calculated.
After adjusting for several factors, including use of medicines for mental disorders, weight gain was more common among individuals with common mental disorder symptoms at the start of the study than among those who were symptom free.
Individuals with a common mental disorder at all three preceding screenings were twice as likely to be obese at the final screening compared to symptom free individuals at all previous screenings.
In addition, clear evidence of a dose-response relationship was found, showing that those who experienced more incidences of a common mental disorder had a greater risk of weight gain and obesity.
Interestingly, contrary to some previous research, there was little evidence that obesity leads to common mental disorders in people with no pre-existing mental disorder.
"In this population of British middle-aged adults common mental disorder is predictive of subsequent weight gain and obesity," say the authors, and they call for more research to verify the generalisability of the findings to wider populations.
They conclude by saying that if their observed associations are causal, their findings will have important implications for prevention and treatment.
Although Kivimäki and colleagues found little evidence that obesity predicts depression or anxiety, clinicians should be aware that this association can occur in both directions, say researchers from the University of Adelaide in an accompanying editorial.
They suggest that further research on how best to deliver lifestyle interventions is needed along with government action on taxes, tariffs, and trade laws to encourage the supply and consumption of healthy food and physical activity choices.
Contacts:
Research: Mika Kivimäki, Professor of Social Epidemiology, University College London, London, UK
Email: m.kivimaki@ucl.ac.uk
Editorial: Evan Atlantis, Early Career Research Fellow, School of Medicine, University of Adelaide, Australia
Email: evan.atlantis@adelaide.edu.au
(3) Four out of 10 back pain sufferers will recover within a year
(Research: Prognosis for patients with chronic low back pain: inception cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3829
(Editorial: Prognosis of low back pain in primary care)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3694
Over a third (35%) of patients will recover from chronic low back pain within nine months and four out of 10 (41%) will do so within a year, according to research published on bmj.com today.
This is the first study of its kind and the results go against the common view that recovery from an episode of chronic low back pain is unlikely.
The lead author, Dr Luciola Menezes Costa, from the University of Sydney, says individuals with previous sick leave due to low back pain, high disability levels, low levels of education and being born overseas were more likely to have delayed recovery.
Chronic low back pain is a major health problem, say the authors, and places a huge social and economic burden on society. They also argue that there is currently considerable uncertainty associated with recovery rates.
The participants were drawn from a larger group of 973 patients who attended primary care clinics in Sydney with a new episode of low back pain. These patients had visited their health care provider with acute low back pain (ie. the episode had lasted for more than 24 hours but less than two weeks). Patients with serious spinal health problems such as cancer, infection, fractures or inflammatory arthritis were excluded from the study. Those who had not recovered by 90 days were considered to have chronic non-specific low back pain and joined the current study.
The researchers followed up 400 patients with chronic non-specific low back pain with a telephone interview assessing pain and disability levels and work status nine and 12 months later. The results reveal that a reasonable number of participants had complete recovery within a year of first developing chronic low back pain (35% by nine months, 41% by one year).
In conclusion, Dr Menezes Costa says that this study is important as it demonstrates that the rate of recovery from chronic low back pain is higher than previously reported and that the findings suggest that the prognosis is not uniformly poor for patients with chronic low back pain.
The authors add that the results should be reassuring for patients as they show that recovery from a new episode of chronic non-specific low back pain is possible.
However, in an accompanying editorial, two senior researchers from Keele University point out that, for a condition like low back pain, which for many people lasts a lifetime, research on what happens to patients over much longer time scales is needed.
Only then can we improve our understanding about how different patterns emerge and in what order, why some people recover whereas others have episodic pain for years or develop long term constant pain, they write.
Contacts:
Research: Professor Chris Maher and Luciola Menezes Costa, The George Institute for International Health, The University of Sydney, Australia
Email: cmaher@george.org.au; lmenezes@george.org.au
Editorial: Elaine Hay, Professor of Community Rheumatology, Arthritis Research Campaign National Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
Email: e.m.hay@keele.ac.uk
(4) Including boys in HPV vaccination programmes would not offer value for money
(Research: Cost-effectiveness analysis of including boys in a human papillomavirus (HPV) vaccination programme in the United States)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3884
(Editorial: Should HPV vaccination be given to men?)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4127
Including boys in human papillomavirus (HPV) vaccination programmes of pre-adolescent girls would not be cost-effective if there is high vaccine coverage and efficacy in girls, as it is likely that the costs of vaccinating boys will outweigh the added health benefits, finds new research published on bmj.com today.
Previous studies have consistently shown that HPV vaccination of pre-adolescent (12 year-old) girls provides good value for money. Recent data from clinical trials also suggest that HPV vaccination in males has high efficacy against vaccine-type infections and genital lesions. Because HPV infections are sexually transmitted, vaccinating boys will likely provide direct health benefits to the boys themselves as well as indirect health benefits to their sexual partners by reducing HPV transmission. Whether or not these benefits are worth their investment is unclear.
To provide more evidence, researchers from The Harvard School of Public Health in Boston conducted a cost-effectiveness analysis to compare HPV vaccination of pre-adolescent girls alone with vaccination of both pre-adolescent girls and boys in the US.
The study used models that take into account the dynamics of HPV infection and cervical cancer screening strategies to predict the health benefits and economic costs of programmes by combining epidemiological, clinical, and demographic information from the US population.
The researchers also examined how alternative scenarios might impact on cost-effectiveness, varying assumptions regarding screening practice, vaccine efficacy in boys, duration of vaccine protection, and long-term impact on health outcomes not yet observed in clinical trials (e.g. anal and oral cancers).
Interventions were considered good value for money if they were less than cost-effectiveness values ranging from $50,000 to $100,000 per quality-adjusted life year (QALY).
Findings showed that HPV vaccination of pre-adolescent girls (with continued screening in adulthood) is good value for money. Assuming 75% vaccination coverage and lifelong vaccine protection, routine vaccination of 12-year-old girls was consistently found to be less than $50,000 per QALY gained, compared with screening alone.
However, including boys in the routine vaccination programme generally surpassed the higher cost-effectiveness threshold of $100,000 per QALY, even when assuming high vaccine protection and health benefits.
The authors predicted that vaccinating both boys and girls would only fall below the cost-effectiveness threshold of $100,000 per QALY under conditions of high, lifelong vaccine efficacy against all potential health benefits (including other anogenital and oral cancers, genital warts, and juvenile onset recurrent respiratory papillomatosis), or under assumptions of lower efficacy with lower coverage or vaccine costs.
"Our results suggest that if vaccine coverage and efficacy are high among pre-adolescent girls, including boys in an HPV programme is unlikely to provide comparatively good value for resources," say the authors.
They conclude: "As new data become available and new information emerges, assumptions and analyses will need to be iteratively revised to continue to inform policies with respect to HPV vaccination."
The health economic implications are clear - good coverage of females obviates the need to vaccinate boys, say two US researchers in an accompanying editorial.
They also point out that more than 80% of the 500,000 annual cases of cervical cancer occur in low resource settings and developing countries, which cannot afford or access HPV vaccines. Targeting young women in these populations for HPV vaccination and screening older women would therefore have a bigger effect on reducing the burden of cervical cancer than widespread HPV vaccination of young men from resource rich areas, they write.
The best policy is to ensure that preadolescent females are vaccinated worldwide, they conclude.
Contacts:
Research: Jane Kim, Assistant Professor, Harvard School of Public Health, Boston, USA
Email: jkim@hsph.harvard.edu
Editorial: Philip E Castle, Investigator, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
Email: castlep@mail.nih.gov
(5) Screening all patients for MRSA ‘unethical' says expert
(Analysis: Should we screen low risk patients for meticillin resistant Staphylococcus aureus)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4035
Mandatory MRSA screening for all patients admitted to English hospitals is unethical and should be reconsidered, says Dr Michael Millar in an editorial published on BMJ.com today.
Testing all patients for MRSA began in April 2009 but Dr Millar, a microbiologist from Barts and the London NHS Trust, questions the validity of consent for screening when the levels of risk is not adequately explained to patients.
He says that consent is not genuine as patients are not told that mandatory screening results in high numbers of false positives, patients being placed in isolation and delays in treatment. He argues that "patients placed in isolation can suffer psychological and physical harms, partly as a result of the reduced contact with healthcare workers and others."
The author says there is little evidence that screening all patients for MRSA reduces infection rates and that this policy "runs contrary to current UK guidelines for the control of MRSA, which emphasise selective screening, and to US guidelines, which do not support legislation to mandate MRSA screening."
While MRSA rates have fallen by more than half from 2003 to 2009, says Millar, the overall number of healthcare associated infections have been rising substantially, which raises questions about the focus on MRSA, he says.
Dr Millar concludes that asymptomatic MRSA patients present a low risk of transmission and the focus should be aimed at patients with active infection and tackling poor staff hand hygiene. He says "it is generally agreed that MRSA is spread in hospitals on the hands of healthcare staff and that the determinants of transmission include microbial load and degree of contact with healthcare workers."
Contacts:
Press Office, Barts and The London NHS Trust, London, UK
Angela Boon, email: angela.boon@bartsandthelondon.nhs.uk
or
Dan Wheelahan, email: dan.wheelahan@bartsandthelondon.nhs.uk k
Editorial: Philip E Castle, Investigator, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
Email: castlep@mail.nih.gov
(6) Treatment for miscarriage does not affect long term fertility
(Research: Incidence of pregnancy after expectant, medical or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3827
The type of treatment a woman receives after an early miscarriage does not affect subsequent fertility, with around 80% of women having a live birth within five years of their miscarriage, concludes a study published on bmj.com today.
Fifteen per cent of pregnancies end in early miscarriage. For decades the standard management of early miscarriage was surgical evacuation of retained products of conception. But this was increasingly questioned and now women are usually offered expectant (watch and wait) and medical management as well.
Previous studies, including the largest published trial (the MIST trial), have suggested that all three methods are probably equivalent in terms of gynaecological infection, but their long term effects on fertility are not known.
So researchers based in the South West of England compared fertility rates for the three management methods (expectant, medical or surgical).
They surveyed 762 women who had taken part in the original MIST study, and who had randomly received surgical, medical or expectant management for an early miscarriage (less than 13 weeks gestation).
These women completed a questionnaire about subsequent pregnancies and live births after this miscarriage. The effects of age, previous miscarriage and previous birth history were taken into account.
Among the survey respondents, 83.6% reported a subsequent pregnancy, with 82% having a live birth.
Time to subsequently giving birth was very similar in the three management groups: 79% of those randomised to expectant management, 78.7% of the medical group and 81.7% of the surgical group all had a live birth five years after their miscarriage.
However, older women and those suffering three or more miscarriages were significantly less likely to subsequently give birth.
The authors conclude that method of miscarriage management does not affect subsequent pregnancy rates, with around four in five women having a live birth within five years of a miscarriage.
"Women can be reassured that long term fertility concerns need not affect their choice of miscarriage, management method," they say.
Contact:
Lindsay Smith, GP Research Lead, East Somerset Research Consortium, Westlake Surgery, Somerset, UK
Email: research@esrec.nhs.uk
(7) Collaborative requesting does not increase consent for organ donation
(Research: Effect of "collaborative requesting" on consent rate for organ donation: randomised controlled trial (ACRE trial))
http://www.bmj.com/cgi/doi/10.1136/bmj.b3911
Collaborative requesting - a request for organ donation made jointly by the patient's clinician and a donor transplant coordinator - does not increase consent rates compared with routine requesting by the patient's clinician, finds research published on bmj.com today.
The technique is advocated by the UK's Organ Donation Task Force, but its effectiveness has never been rigorously tested.
One of the biggest barriers to increased donor rates is the refusal of consent by relatives. A recent audit of 341 deaths in intensive care units in the UK revealed that 41% of relatives of potential donors denied consent. In an interview study a third of relatives who had refused donation said that they would not refuse again, whereas only a few of people who had given consent regretted their decision.
There may therefore be factors in the way the request for donation is made that could affect the decision.
So a research team, led by Dr Duncan Young from John Radcliffe Hospital in Oxford, carried out the first randomised controlled trial to compare collaborative requesting with routing testing.
The study involved 201 relatives of patients meeting brain stem death criteria in 79 UK intensive care units. Relatives were randomly assigned to either collaborative requesting by the patient's clinician and a donor transplant coordinator or routine requesting by the patient's clinician alone.
Sixty one per cent of relatives in the routine requesting group consented to organ donation and 57% consented in the collaborative requesting group.
The conversion rate (donors with consent from whom any organs were retrieved) was 91.9% in the routine requesting group and 78.9% in the collaborative requesting group.
This study provides clear evidence that there is no increase in the relatives' consent rates for organ donation when collaborative requesting is used in place of routine requesting by the patient's clinician, say the authors.
These findings also have implications for UK policy, as the UK Department of Health Organ Donation Task Force report recommends the use of collaborative requesting by donor transplant coordinators in all hospitals in the UK, they write.
In light of these results, they suggest it may be more effective to focus on other strategies to increase consent rates, such as the ‘long contact' technique where donor transplant coordinator is involved with the family before an approach is made.
Contacts:
Dr Duncan Young, Consultant in Critical Care, John Radcliffe Hospital, Oxford, UK
Email: duncan.young@nda.ox.ac.uk
FOR ACCREDITED JOURNALISTS
For more information please contact:
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Tel: +44 (0)20 7383 6254
Email: rdavies@bma.org.uk
Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
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and from:
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