Press releases Monday 12 April to Friday 16 April 2010

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) Weight loss surgery lowers risk of pregnancy complications in obese women
(2) Questions remain over existence of “new syndrome” in autistic children
(3) Banning trans fats would save lives, say doctors
(4) Commissioning in the English NHS should be abandoned

(1) Weight loss surgery lowers risk of pregnancy complications in obese women
(Research: Impact of bariatric surgery on hypertensive disorders in pregnancy: retrospective analysis of insurance claims data)
http://www.bmj.com/cgi/content/full/340/apr13_1/c1662

Obese women who undergo bariatric surgery before having a baby have a much lower risk of developing serious health problems during pregnancy, finds a study published on bmj.com today.

Obesity, especially extreme obesity, is a risk factor for hypertensive disorders in pregnancy. These include serious conditions such as pre-eclampsia, where abnormally high blood pressure and other disturbances develop during pregnancy. They are a common cause of pregnancy complications and infant death and affect about 7% of all pregnancies in the United States.

Bariatric surgery is an effective weight loss intervention for women with a body mass index (BMI) of 40 or more, or a BMI of 35-40 with associated conditions like diabetes. But little is known about the impact of surgery on hypertensive disorders in pregnancy.

So researchers from Johns Hopkins University in the United States set out to test the theory that women who had a delivery after bariatric surgery would have lower rates of hypertensive disorders in pregnancy compared with women who had a delivery before surgery.

Using insurance data from 2002-2006, they identified 585 obese women aged 16-45 years who had undergone bariatric surgery, had at least one pregnancy and delivery, and had continuous medical insurance coverage during pregnancy plus two weeks after delivery.

Of these women, 269 had surgery before delivery and 316 had surgery after delivery.

Compared with women who delivered before surgery, women who delivered after surgery had substantially lower rates (75%) of hypertensive disorders, even after adjusting for factors such as age at delivery, multiple pregnancy, surgical procedure, pre-existing diabetes, and insurance plan.

These results have important clinical, public health, and policy implications, say the authors. For example, bariatric surgery could be considered in women of childbearing age who wish to start a family, and have a BMI of 40 or more, or a BMI of 35-40 with associated conditions.

Future research should also address long term maternal and child health after pregnancies and deliveries following bariatric surgery in terms of weight management, nutritional status, and burden of long term chronic disease, they conclude.

Contacts:
Stephanie Desmon, Senior Media Relations Representative, Johns Hopkins Medicine, Baltimore, MD, USA
Email: sdesmon1@jhmi.edu

This week, the BMJ questions the existence of a new bowel condition in autistic children dubbed "autistic enterocolitis" by Dr Andrew Wakefield and colleagues in a now infamous and recently retracted paper published by the Lancet in 1998.

In a special report, journalist Brian Deer tries to unravel the journey of the biopsy reports that formed the basis of the study, while an accompanying editorial asks does autistic enterocolitis exist at all?

In 1996, Dr Andrew Wakefield was hired by a solicitor to help launch a speculative lawsuit against drug companies that manufactured MMR vaccine to find what he called at the time "a new syndrome" of bowel and brain disease caused by vaccines.

Deer reveals that biopsy reports from the Royal Free Hospital's pathology service on 11 children included in the Lancet study showed that eight out of 11 were interpreted as being largely normal. But in the paper, 11 of the 12 children were said to have "non-specific colitis": a clinically significant inflammation of the large bowel.

So how did the mismatches occur?

Apparently, the biopsies were first reported on by Dr Susan Davies, a consultant histopathologist and co-author on the study, but they were also seen and interpreted by three other co-authors before final publication.

When Dr Davies was cross examined before the General Medical Council she said that she had initially been concerned about the use of the term "colitis" in the Lancet paper because she herself had found nothing abnormal in the biopsy sections. But she was reassured, she said, by the "formalised review" of the biopsies by her three colleagues.

This apparent concurrence of four pathologists gave strength to the finding of a new bowel disease, writes Deer. But there is no suggestion in the paper that the second assessment caused findings to be substituted or changed.

How many peer reviewers would have felt comfortable approving the paper if they had known that the hospital pathology service reported biopsy specimens as largely normal, but they were then subjected to an unplanned second look and reinterpreted, he asks?

Professor David Candy, paediatric gastroenterologist at St Richard's Hospital, Chichester, who reviewed the paper in 1997, said "no": he wouldn't have felt comfortable. "That's an example of really naughty doing - to exclude the original pathology findings."

So what should we make of all this, asks Deer? The biopsy slides are no longer available, and cannot be re-assessed. All we have are Dr Davies' pathology reports, and independent specialists seem to agree that she regarded what they showed as largely unremarkable.

Professor Tom MacDonald, dean of research at Barts and the London School of Medicine and co-author of Immunology and Diseases of the Gut said: "If I was the referee and the routine pathologists reported that 8/11 were within normal limits, or had trivial changes, but this was then revised by other people to 11/12 having non-specific colitis, then I would just tell the editor to reject the paper."

In an accompanying editorial, Sir Nicholas Wright also from Barts and the London points out that all histopathological interpretation is a matter of opinion, but we should always ask how reliable that opinion is.

In terms of whether autistic enterocolitis exists, several studies have shown an association between inflammatory pathology and autistic spectrum disorder, but he believes that, in view of the limited data, any firm conclusion would be inadvisable.

"We should remember, as recent experience in several fields has shown, that although science has its defects, it is a self correcting process. Time is, perhaps, the wisest counsellor of all," Wright concludes. "In the meantime, this case offers a salutary reminder for researchers and journal editors alike that coauthorship means bearing responsibility for what is written."

Contacts:
Brian Deer, Journalist, London, UK
Email: mail58@briandeer.com
Editorial: Sir Nicholas Wright, Warden, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
Email: warden@qmul.ac.uk

(3) Banning trans fats would save lives, say doctors
(Editorial: Removing industrial trans fat from foods)
http://www.bmj.com/cgi/content/full/340/apr15_1/c1826

Banning trans fats from all foods in the UK would prevent thousands of heart attacks and deaths every year, and would be a simple way to protect the public and save lives, say two senior doctors on bmj.com today.

Their views follow calls by public health specialists to eliminate the consumption of industrially-produced trans fats in the UK by next year.

Trans fats (also known as trans fatty acids) are solid fats found in margarines, biscuits, cakes, and fast food. Many studies demonstrate harmful effects of trans fats on cardiovascular risk factors.

For example, trans fats increase the amount of low density lipoprotein (LDL) or 'bad cholesterol' in the blood and reduce the amount of high density lipoprotein (HDL) or 'good cholesterol.' People with high levels of LDL cholesterol tend to have a higher risk of getting heart disease, while people with high levels of HDL cholesterol tend to have a lower risk.

A recent analysis of all the evidence recommended that people should reduce or stop their dietary intake of trans fatty acids to minimise the related risk of coronary heart disease.

The authors, from Harvard School of Public Health in the US, report that bans in Denmark and New York City effectively eliminated trans fats, without reducing food availability, taste, or affordability.

There is also no evidence that such legislation leads to harm from increased use of saturated fats.

Removing industrial trans fats is one of the most straightforward public health strategies for rapid improvements in health, they write. Based on current disease rates, a strategy to reduce consumption of trans fats by even 1% of total energy intake would be expected to prevent 11,000 heart attacks and 7,000 deaths annually in England alone.

Action by the UK might also produce larger benefits by inspiring other developed and developing countries to take similar measures to protect their citizens' health, they conclude.

Contact:
Dariush Mozaffarian, Assistant Professor of Medicine and Epidemiology, Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
Email: dmozaffa@hsph.harvard.edu

(4) Commissioning in the English NHS should be abandoned
(Editorial: Commissioning in the English NHS)
http://www.bmj.com/cgi/content/full/340/apr15_1/c1979

Commissioning in the English NHS is a failing system that needs to be abandoned, says a public policy expert in an editorial published on bmj.com today.

Professor Calum Paton from Keele University argues that since 1991, purchasing or commissioning "has mutated through a series of confusing and frequent reorganisations, involving mutually incompatible policies and high costs."

He believes this system should be dropped in favour of a more integrated approach that offers patients real choice, and can combine financial savings with quality.

Commissioning in the English NHS was born officially in 1997, when the new Labour government dropped the previous Conservative government's term "purchasing," explains Paton.

The aim was to signal that the culture of the competitive market was being replaced with collaboration between purchasers (health authorities, from 1997 to 2001) and providers (hospitals, mental health services, and community services), although the structure of the market - the split between purchaser and provider - remained. From 2002 the market was revived and commissioning became part of the new market.

According to a recent report from the House of Commons' Health Select Committee, the costs of commissioning are now 14% of the NHS budget.

Paton discusses the options recently advocated by the Nuffield Trust and King's Fund, but says they would be "complex and incur high costs. "They would also retain the purchaser-provider split, which he believes is "yesterday's dogma rather than a necessity."

Paton also challenges the widely held view that primary care trusts cannot control powerful hospitals, referrals, and admissions. And suggests that commissioning attracts a lower calibre of manager than hospitals because it is divorced from provision.

He believes that the major challenge for the NHS now is to combine financial savings with quality. But, he warns, "this cannot be achieved with commissioners who are distinct from the doctors and hospitals that provide care."

He argues that in many areas of England, "primary care trusts and hospitals seek to make financial savings at the expense of others" and says "it is ironic that many of the policy analysts who advocated the purchaser-provider split are now supporting integrated care."

Integrated health authorities (what we now call local health economies) and patient choice are perfectly compatible, he concludes, as long as such authorities are funded in line with their workload. Indeed, this removes the bureaucracy from the current choice policy in England, where the market is seen as such a high priority.

Contact:
Calum Paton, Professor of Public Policy, Keele University, Staffordshire, UK
Email: c.paton@hpm.keele.ac.uk

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

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