Press releases Monday 26 October to Friday 30 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) Advances in screening have offset an increase in Down's syndrome
(1) Study reveals high death rates and short life expectancy among the homeless and marginally housed
(3) Migraine with aura doubles the risk of stroke
(4) BMJ raises concerns over "outlawed" gagging clauses in NHS contracts
(5) Swine flu vaccine must be free and safe for high uptake
(6) Lie back and think of babies
(7) Around one in five pregnant smokers go undetected each year

(1) Advances in screening have offset an increase in Down's syndrome
(Research: Trends in Down's syndrome live births and antenatal diagnoses in England and Wales from 1989 to 2008: analysis of data from the National Down Syndrome Cytogenetic Register)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3794

The number of diagnoses of Down's syndrome has increased by almost three quarters (71%) from 1989/90 to 2007/08, largely due to the considerable increase in the number of older mothers over this period. However, the number of babies born with this condition during the same period fell by 1% because of antenatal screening and subsequent terminations, finds research published on bmj.com today.

Researchers from Barts and The London Medical School analysed data held on the National Down Syndrome Cytogenetic Register (NDSCR) since it was set up in January 1989. The register currently holds anonymous data on over 26,000 cases of Down's syndrome diagnosed antenatal or postnatally in England and Wales, this is around 93% of all diagnosed Down's births and pregnancy terminations in both countries.

Their results show that while there has been a stark increase in the proportion of younger women (below the age of 37) opting for screening (3% to 43%), the proportion of older women deciding to be screened has stayed constant at around 70%, despite improved tests.

And for all women with an antenatal diagnosis of Down's syndrome, the proportion who decided to terminate the pregnancy has also remained constant at around 9 in 10 (92%).

Lead author, Professor Joan Morris, says that, given older women have a far greater chance of having a baby with Down's (the risk for a 40 year old mother is 16 times that for a 25 year old mother), more research is needed to find out why around 30% of older women decide not to be tested. "It is important to ascertain whether the decision is an informed one and, if not, to address the lack of information," she says.

The authors conclude that as more women are having children later in life and a significant proportion of these mothers are deciding against screening "a large number of births with Down's syndrome are still likely, and that monitoring of the numbers of babies born with Down's syndrome is essential to ensure adequate provision for their needs."

Contact:
Professor Joan Morris, Professor of Medical Statistics, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
Email: j.k.morris@qmul.ac.uk

Homeless and marginally housed people have much higher mortality and shorter life expectancy than could be expected on the basis of low income alone, concludes a study from Canada published on bmj.com today. as a marker of socioeconomic disadvantage.

Previous studies have found high levels of excess mortality among the homeless compared with the general population, but little information is available on death rates among homeless and marginally housed people living in low-cost collective dwellings, such as rooming houses and hotels. as a marker of socioeconomic disadvantage.

So, researchers at St Michael's Hospital in Toronto and Statistics Canada compared death rates and life expectancy among a representative sample of homeless and marginally housed people with rates in the poorest and richest income sectors of the general population. as a marker of socioeconomic disadvantage.

Using data from the 1991-2001 Canadian census, they tracked 15,000 homeless and marginally housed people across Canada for 11 years. as a marker of socioeconomic disadvantage.

Mortality rates among homeless and marginally housed people were substantially higher than rates in the poorest income groups, with the highest rates seen at younger ages. as a marker of socioeconomic disadvantage.

Among those who were homeless and marginally housed, the probability of survival to age 75 was 32% in men and 60% in women. This compared to 51% and 72% among men and women in the lowest income group in the general population. as a marker of socioeconomic disadvantage.

For men, this equates to about the same chance of surviving to age 75 as men in the general population of Canada in 1921 or men in Laos in 2006. For women, this equates to about the same chance of surviving to age 75 as women in the general population of Canada in 1956 or women in Guatemala in 2006. as a marker of socioeconomic disadvantage.

Remaining life expectancy at age 25 among homeless and marginally housed men was 42 years - 10 years lower than the general population and six years lower than the poorest income group. as a marker of socioeconomic disadvantage.

For homeless and marginally housed women, remaining life expectancy at age 25 was 52 years - seven years lower than the general population, and five years lower than the poorest income group. as a marker of socioeconomic disadvantage.

A large part of this premature mortality is potentially avoidable, say the authors. Many excess deaths were attributable to alcohol and smoking-related diseases and to violence and injuries, much of which might have been related to substance abuse. as a marker of socioeconomic disadvantage.

There were also many excess deaths related to mental disorders and suicides. as a marker of socioeconomic disadvantage.

This study shows that homeless and marginally housed people living in shelters, rooming houses, and hotels have much higher mortality and shorter life expectancy than could be expected on the basis of low income alone, they conclude. These findings emphasise the importance of considering housing situation as a marker of socioeconomic disadvantage.

Contacts:
Julie Saccone, Senior Public Relations Specialist, St Michael's Hospital, Toronto, Ontario, Canada
Email: sacconej@smh.toronto.on.ca

Dr Stephen Hwang, Research Scientist, Centre for Research on Inner City Health, St Michael's Hospital, Toronto, Ontario, Canada
Email: wangs@smh.toronto.on.ca

Migraine with aura (temporary visual or sensory disturbances before or during a migraine headache) is associated with a twofold increased risk of stroke, finds a study published on bmj.com today. Further risk factors for stroke among patients with migraine are being a woman, being young, being a smoker, and using oestrogen containing contraceptives.

The risk was highest among young women with migraine with aura who smoke and use oestrogen containing contraceptives.

Migraine is a common, chronic disorder that affects up to 20% of the population. Women are affected up to four times more often than men. Up to one third of sufferers also experience an aura prior to or during a migraine headache (often described as the perception of a strange light, an unpleasant smell or confusing thoughts or experiences).

Doctors have long suspected a connection between migraine and vascular events such as stroke. So to investigate this further, an international team of researchers analysed the results of nine studies on the association between any migraine (with and without aura) and cardiovascular disease. Differences in study design and quality were taken into account to minimise bias.

They show that migraine with aura is associated with a twofold increased risk of ischemic stroke. This risk is further increased by being female, age less than 45 years, smoking, and oestrogen containing contraceptive use.

There was no association between migraine and heart attack or death due to cardiovascular disease.

In light of these findings, the authors recommend that young women who have migraine with aura should be strongly advised to stop smoking, and methods of birth control other than oestrogen containing contraceptives should be considered. They also call for additional research to investigate the association between migraine and cardiovascular disease in more detail.

The absolute risk of stroke for most migraine patients is low, so a doubling of risk is not cause for panic, explains Elizabeth Loder from Brigham and Women's Hospital, Boston, in an accompanying editorial. However, at a population level, this risk deserves attention because the prevalence of migraine is so high.

She suggests that patients who have migraine with aura should be followed closely and treated aggressively for modifiable cardiovascular risk factors.

Contacts:
Research: Kevin Myron, Manager, Media Relations, Brigham and Women's Hospital, Office of Public Affairs, Boston, MA, USA
Email: kmyron@partners.org

Editorial: Elizabeth Loder, Chief, Division of Headache and Pain, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Email: eloder@partners.org

Despite government outlawing of gagging clauses in NHS contracts, new evidence published on bmj.com today reveals how some trusts have continued to use them.

The first case relates to a dispute between Liverpool Women's NHS Foundation Trust and Peter Bousfield, a long serving consultant, who was offered early retirement and a termination payment after he had raised a series of concerns about patient safety.

Documents have come to light showing that not only was a non-disclosure clause incorporated into the compromise agreement at the behest of the trust, contrary to NHS guidance, but the trust's solicitors also threatened Mr Bousfield with a court injunction if he tried to bring matters to the attention of local members of parliament.

The second case highlights issues surrounding doctors who leave trusts "under a cloud" with gagging clauses made in their favour, making it difficult for future employers to find out what went wrong and leaving them free to repeat their behaviour. The BMJ hears how a concerned medical colleague who tried to report a consultant to the General Medical Council got into trouble for breaching the gagging clause.

Gagging clauses have been specifically prohibited in NHS employment contracts since before the Public Interest Disclosure Act was passed in 1998, and this position was reinforced in August 1999 when the Department of Health issued guidance on whistleblowing. The British Medical Association (BMA) also has whistleblowing guidance and a helpline for hospital staff.

Yet despite this, there is some suggestion that these are not isolated cases. For example, Public Concern at Work says: "We are hearing anecdotally that these compromise agreements are being done with quite blatant clauses in them, whereby people are being paid a specific amount extra not to say anything."

And at a recent House of Commons debate, William Cash, MP said: "There are whistleblowers, but they are terrified to come forward. The reality is that devices are being employed by certain hospitals and hospital authorities to bypass the 1998 Act."

In an accompanying commentary, Dr Mark Porter, Chairman of the BMA Consultants' Committee says: "Our fundamental responsibility is to provide care of the highest possible quality to our patients and do all we can to guarantee their safety - no matter what obligations we have to any other parties, including our employers."

According to a recent BMA survey, around 1 in 7 hospital doctors in England and Wales who reported concerns said that their trusts had indicated that by speaking up, their employment could be negatively affected.

"To say there are no circumstances in which a concern for patient safety can be raised outside the organisation, or to attempt to enforce silence through a contractual mechanism, is appalling," he writes.

Contacts:
Andrew Bousfield, The Centre for Investigative Journalism, London, UK (www.tcij.org)
Email: andrew@tcij.org

Dr Mark Porter, Chairman, BMA Consultants' Committee, London, UK
Email: pressoffice@bma.org.uk

Almost half of adults surveyed in Summer 2009 in Hong Kong (45%) say they would take up free swine flu vaccination. However, this figure drops to around 1 in 7 (15%) if the price they have to pay for the vaccine reaches $HK200 (£16; Euro 17; $26). In the absence of proved efficacy and safety, the figure decreases to less than 1 in 20 (5%), according to one of the first studies on behavioural intentions and A/H1N1 vaccination, published on bmj.com today.

The authors, led by Professor Lau at the Chinese University of Hong Kong, conclude that uptake of swine flu vaccination among the general population is unlikely to be high and would be sensitive to price and safety of the vaccine.

The results of the study also reveal that more than 6 out of 10 (63%) people mistakenly believe that the efficacy of the vaccine had been confirmed by clinical trials and around one in six (16%) believe it is necessary for all Hong Kong people to be vaccinated against swine flu.

In September 2009, there were over 22,000 confirmed swine flu cases in Hong Kong resulting in 15 associated deaths. The Hong Kong government has proposed to purchase 5 million shots of the vaccine and said it would initially be offered to 2 million high risk groups. The government also estimated that 500,000 people could voluntarily pay for vaccination; however pricing has still not been agreed.

Lau and colleagues used a telephone questionnaire to interview a random sample of 301 adults between 2-8 July, after the announcement of A/H1N1 as a pandemic on 11 June. Telephone numbers were randomly selected from current telephone directories (over 95% of households in Hong Kong have a telephone line installed), and at least three calls were made before the number was considered invalid. Interviews were done in the evening (from 6.30pm to 10pm) to avoid over-representation of people not working.

The response rate was 80%. Respondents were between 18 and 60 years of age, 55% were female and 47% were below 40 years old.

Participants were also asked about their knowledge of the vaccine, the seriousness of the pandemic and their perception of risk. A third (30%) mistakenly believed that more than 1% of those who contracted swine flu would die and around one in ten considered that they, their family or the general population had a high or very high chance of contracting the disease.

In conclusion, Professor Lau, says that from the results "it seems that free or low cost vaccination needs to be provided to achieve a high rate of vaccination against A/H1N1. More importantly, the general public has to be convinced about the vaccine's efficacy and safety as misconceptions may exist about what the scientific data show."

Contacts:
Professor Joseph Lau, Associate Director, School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong
Email: jlau@cuhk.edu.hk
Or
Nelson Yeung, Research Assistant, School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong
Email: nelsonyeung@cuhk.edu.hk

Women who lie on their backs for 15 minutes after artificial insemination have a "significantly higher" chance of getting pregnant than women who move around straight after treatment, according to research published on bmj.com today.

The authors, led by Dr Inge Custers from the Academic Medical Centre in Amsterdam, are now calling for all women undergoing intrauterine insemination to be offered 15 minutes of immobilisation after the procedure.

Intrauterine insemination with or without ovarian hyperstimulation is one of the most common methods of fertility treatment provided globally. While some small scale studies have investigated links between immobilisation and the success of intrauterine insemination, this is the first large scale trial to do so.

Almost 400 couples participated in the study - around half were asked to lie down for 15 minutes after intrauterine insemination and the other half were allowed to move around immediately after the procedure. The results show that "the ongoing pregnancy rate was significantly higher in the immobilisation group: 27% (54) v 18% (34)."

The authors say it is not clear why immobilisation improves the success of intrauterine insemination but they speculate that moving around after treatment might cause leakage.

Dr Custers argues that all women undergoing intrauterine insemination should be allowed to lie down for 15 minutes after treatment and that “Although immobilisation takes more time and occupies more space in busy rooms, the intervention will be economic in the long run, as pregnant patients will not return in subsequent cycles."

In an accompanying editorial, Professor William Ledger from the University of Sheffield, says that while Custers' research shows promise, further studies are needed. He suggests that units should carry out their own evaluation to test the hypothesis in the "real world" and that "if successful, more couples could be spared the rigorous and costly process of in vitro fertilisation."

Contacts:
Dr Inge Custers, PhD Student and Registrar, Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, The Netherlands
Email: i.m.custers@amc.uva.nl
Or
Frank van den Bosch, Press Officer, Academic Medical Centre, Amsterdam, The Netherlands
Email: f.r.vandenbosch@amc.nl

Self-reported smoking during pregnancy underestimates the true number of pregnant smokers in Scotland by 17%, and results in a failure to detect 2400 pregnant smokers each year, finds new research published on bmj.com today.

This results in thousands of smokers not being identified or offered smoking cessation services, say the authors.

It is well known that self reported smoking during pregnancy is an inaccurate way to identify smokers. Yet it is still used widely by antenatal clinics to determine the smoking status of pregnant women and to refer them to smoking cessation services. The Scottish Government also relies on self-reported smoking figures to set targets and measure the success of smoking cessation services.

To address this issue, a team of researchers from Scotland assessed whether self-reported smoking during pregnancy is an accurate way of setting targets and identifying pregnant smokers in order to offer them smoking cessation services.

The study involved a random sample (3475) of pregnant women from the West of Scotland and compared their self-reported smoking status at maternity booking with results of blood cotinine testing (to detect recent nicotine exposure) to estimate the number of undetected smokers.

In total, 24.1% (839) of pregnant women reported being smokers compared to the cotinine-validated estimate of 30.1% (1046).

Therefore, approximately a fifth (207/1046) of cotinine-validated smokers were not detected by self-report and were not offered smoking cessation services, which translates to 2400 pregnant women a year.

Importantly, the use of self-reporting in Scotland results in twice as many pregnant smokers from more deprived areas going undetected each year compared with pregnant smokers from more affluent areas.

The authors estimate that the true smoking prevalence for pregnant women in Scotland, after adjusting for area deprivation, maternal age and self-reported smoking is 28%, higher than the 23% based on self report data.

They conclude by calling for more accurate methods of identifying pregnant smokers, so that accurate data is used to inform policy and provide appropriate patient care.

Contact:
David Tappin, Director of Paediatric Epidemiology and Community Health Unit, University of Glasgow, Scotland, UK
Email: goda11@udcf.gla.ac.uk

FOR ACCREDITED JOURNALISTS

For more information please contact:

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
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