Press releases Monday 26 April to Friday 30 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) Students who have difficulties at medical school more likely to face professional misconduct hearings
(2) It' s not what politicians say but what we hear
(3) HPV test detects more pre-cancerous cells than conventional smear test
(4) Babies of mothers exposed to lower ambient sunshine during pregnancy at greater risk of developing MS
(5) Threefold increase for very severe morning sickness in women whose mothers suffered from the illness
(6) Doctors in the Netherlands urge NHS not to follow Dutch "two-tier healthcare system"

(1) Students who have difficulties at medical school more likely to face professional misconduct hearings
(Research: Risk factors at medical school for subsequent professional misconduct: a multicentre retrospective case-control study)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2040
(Editorial: Identifying medical students at risk of subsequent misconduct)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2169

Doctors who are male, from lower income groups and have experienced academic difficulties at medical school are more likely to find themselves in front of the General Medical Council (GMC) for professional misconduct, according to research published on bmj.com today.

The authors, Janet Yates and David James from the University of Nottingham Medical School, emphasise that this is a small study and that "the findings are preliminary and should be interpreted with caution."

While only a relatively small number of doctors are found guilty of serious complaints, a number of high profile cases have led to significant media coverage and public concern about doctors who fail to maintain adequate professional standards. It is important, says the study, that research into this area is ongoing in order "to protect the integrity of the professional and maintain the public confidence."

The authors compared the applications and medical school progress of 59 GMC misconduct cases with 236 individuals who had not been referred to the GMC. The personal details of all participants were fully anonymised before their student progress files were sent to the authors for analysis. The majority of individuals (69%) had completed their medical courses between 1968 and 1987.

The results show that GMC misconduct cases were more likely to be male and from lower social class groups and they were more likely to have failed exams, repeated parts of their courses or had a lower overall performance than their peers. The misconduct cases were also possibly less likely to have achieved Consultant status or to be on the GP Register.

The authors argue that "this small preliminary study provides the first evidence in the UK that male students and those who perform poorly in the early years of the course ... might be at slightly increased risk of subsequent professional misconduct. Lower social class background (as estimated from the father' s occupation at course entry) was also an independent risk factor in this retrospective study."

The authors say that the "lower social class background is a sensitive finding" and one that they cannot explain. However, they stress that they are not suggesting "that such students should be viewed differently to any others because we have demonstrated only a relative risk, and the absolute risk for an individual from any background is small." The majority of individuals potentially at risk will not actually have any problems.

They maintain that the data must be viewed in context, saying: "86% of the doctors in our study graduated at least 20 years ago when life at medical school and in the profession may have been different. Also social class is both notoriously difficult to define and subject to frequent re-evaluation."

The authors conclude that poorly performing students should receive additional support and mentoring and that more detailed research in this area needs to be carried out.

In an accompanying editorial, Alison Reid from the New South Wales Medical Board in Australia, says that Yates' research is important as "it is derived from the United Kingdom' s system of medical training and regulation, which is also well recognised in Commonwealth and ex-Commonwealth countries."

Reid argues that "attempts to identify medical students who are at risk of subsequent professional misconduct should be encouraged because this offers the opportunity for support and remediation if possible, or if not, redirection of the student into a more suitable area of study. This is not just a matter of public protection; students deserve support and assistance and must have realistic career expectations."

Contacts:
Research: David James, Foundation Director of Medical Education, The University of Nottingham Medical School, Nottingham, UK
Email: david.james@nottingham.ac.uk
Or
Philip Castle, Investigator, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
Email: ncipressofficers@mail.nih.gov

Lindsay Brooke, Media Relations Manager, The University of Nottingham, UK
Email: lindsay.brooke@nottingham.ac.uk

Editorial: Alison Reid, Medical Director, New South Wales Medical Board, Australia
Email: alison.reid@nswmb.org.au

(2) It' s not what politicians say but what we hear
(Editorial: How cognitive biases affect our interpretation of political messages)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2276

There is increasing evidence that individuals interpret the same election message in different ways, according to their personal political views, say experts on bmj.com today.

Martin McKee, from the London School of Hygiene and Tropical Medicine, and David Stuckler from the University of Oxford argue that "it is possible for two well-informed groups of people faced with the same evidence to reach completely different conclusions about what should be done."

They highlight a recent American study where three groups who described themselves as either Democrats, Republicans or Independents were randomly given four versions of an authoritative news story about diabetes. The stories were exactly the same apart from how they described the causes of diabetes - one said nothing while the other three alluded to genetic factors, individual lifestyle choices and social determinants such as economic status.

Interestingly, the Democrats and Independents were far more likely to agree with the social determinants explanation but this had no effect on the Republicans. Furthermore, the Democrats were significantly more likely than the Republicans to support action to tackle diabetes, such as restrictions on junk food.

The authors also refer to a study on brain activity in Democrat and Republican research participants who were exposed to contradicting messages from both parties. They say: "Whereas those registered as Republicans clearly identified the contradictions voiced by Democrat politicians, they saw minimal contradiction in the statements by Republicans, and vice versa."

They conclude: "Politicians are often criticised for being all things to all people and for making promises that they then fail to keep. However - the problem may be less what the politicians are actually saying but rather how their words are heard and interpreted."

Contacts:
Martin McKee, Professor of European Public Health, London School of Hygiene and Tropical Medicine, London, UK
Email: martin.mckee@lshtm.ac.uk

(3) HPV test detects more pre-cancerous cells than conventional smear test
(Research: Cervical cancer and rate of severe intraepithelial neoplasia in primary HPV-DNA screening with cytology triage: randomised study within organised screening programme)
http://www.bmj.com/cgi/doi/10.1136/bmj.c1804

Human papillomavirus (HPV) screening detects more cervical severe pre-cancerous lesions than conventional cervical screening, finds a study published on bmj.com today.

This is the first study to include the HPV test in an established cervical screening programme and the findings are important for cervical cancer prevention, says Dr Ahti Anttila at the Finnish Cancer Registry, who led the research.

HPV is a common sexually transmitted infection seen most often in young women and adolescents. There are more than 100 types of HPV - some cause only genital warts, but others cause cancers including cervical cancer.

The study involved 58,282 women aged 30-60 years who were invited to participate in the routine cervical screening programme in Southern Finland between 2003 and 2005.

Women were randomly allocated to either an HPV test, with further screening if the test was positive, or to conventional cytology screening (the smear test or Pap test). Women were then tracked for a maximum of five years.

The results show that HPV screening was more sensitive than conventional cytology screening in detecting severe pre-cancerous lesions on the surface of the cervix (known as cervical intraepithelial neoplasia or CIN III+).

Although the overall number of cervical cancer cases detected was small, the authors conclude that "considering the high probability of progression of CIN III lesions in women aged 35 years or more, our results are important for prevention of cervical cancer."

Contact:
Dr Ahti Anttila, Research Director, Mass Screening Registry of the Finnish Cancer Registry Helsinki, Finland
Email: ahti.anttila@cancer.fi

(4) Babies of mothers exposed to lower ambient sunshine during pregnancy at greater risk of developing MS
(Research: Low maternal exposure to ultraviolet radiation in pregnancy, month of birth, and risk of multiple sclerosis in offspring: longitudinal analysis)
http://www.bmj.com/cgi/doi/10.1136/bmj.c1640

The risk of developing multiple sclerosis later in life is higher for children born in November-December compared with those born May-June, according to a new Australian study published on bmj.com today.

These results, found by researchers at Murdoch Childrens Research Institute and The Australian National University, are consistent with previous research that found a reciprocal pattern in the northern hemisphere, where there were more cases of multiple sclerosis among people born in May and fewer in those born in November.

Low vitamin D levels have been linked with a higher risk of multiple sclerosis and the researchers suspect that variations in a woman' s exposure to sunlight (the main source of vitamin D) during pregnancy may influence the development of the central nervous system or immune system and therefore determine the risk for this disease in adult life.

The research team analysed data on the number of patients with multiple sclerosis born in Australia compared to other births for each birth month of every year from 1920 to 1950 by sex and region of birth.

They then used the large regional and seasonal variation in ambient ultraviolet radiation in Australia to explore the relation between a mother' s exposure to ambient ultraviolet radiation during pregnancy and subsequent risk of multiple sclerosis in their offspring.

They found that the risk of multiple sclerosis was around 30% higher for those born in the early summer months of November and December compared to the months of May and June.

No association between daily ultraviolet radiation levels at the time of birth (or one to four months before birth) and subsequent risk of multiple sclerosis was found. However, maternal exposure to low ultraviolet radiation levels between five and nine months before birth (first to early second trimesters) predicted a higher risk of multiple sclerosis.

This effect persisted after adjustment for region of birth and appeared more important than the month of birth.

Region of birth was also related to risk, suggesting that offspring postnatal exposure to sunlight during childhood and early adulthood is also important.

These findings clearly show that region of birth and low maternal exposure to ultraviolet radiation in the first trimester are independently associated with subsequent risk of multiple sclerosis in offspring in Australia, say the authors. The team also indicates that vitamin D supplementation during pregnancy needs to be evaluated to help prevent multiple sclerosis.

Contact:
Eszter Vasenszky, Media officer, Murdoch Childrens Research Institute, Royal Children' s Hospital, Melbourne, Australia
Email: eszter.vasenszky@mcri.edu.au

(5) Threefold increase for very severe morning sickness in women whose mothers suffered from the illness
(Research: Recurrence of hyperemesis gravidarum across generations: population based cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2050
(Editorial: Recurrence of hyperemesis across generations)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2178

If your mother suffered from hyperemesis gravidarum, an extremely serious and severe form of morning sickness, you are three times more likely to do so, according to research published today on bmj.com.

Hyperemesis is defined as nausea and vomiting in pregnancy starting before the 22nd week of gestation, which might lead to nutritional deficiencies and weight loss. It occurs in up to 2% of pregnancies and is the most common cause of hospitalisation in early pregnancy. It is associated with adverse pregnancy outcomes such as low birth weight and premature birth.

This is one of the first studies to investigate the recurrence of hyperemesis gravidarum across generations.

The authors, led by Ase Vikanes, from the Norwegian Institute of Public Health, say that hyperemesis was previously thought to be caused by psychological issues, "such as an unconscious rejection of the child or partner."

While this study demonstrates that there could be a genetic link from mothers to daughters, the authors argue that "it is possible that the risk is not genetically transmitted, but is caused by environmental factors that are shared by mothers and daughters - these can be nutritional factors, other lifestyle factors or infections." The authors say there is a need for more detailed research on this topic.

Ase Vikanes, and colleagues investigated the records of 2.3 million births from 1967-2006. The births were all registered as part of a mandatory population based study in Norway and all pregnancy complications were noted on the data.

The authors studied hyperemesis gravidarum patterns in more than 500,000 mother-and-daughter units and almost 400,000 mother-and-son units.

The results show that if a mother has hyperemesis, her daughter is three times more likely to develop the condition. However, there is no increased risk to the female partners of sons whose mothers had suffered from the illness.

The authors conclude that the study is important as it provides a new perspective about the causes of hyperemesis. They add that, in addition to this, "a better understanding of the psychological consequences of experiencing severe nausea and vomiting could be helpful for clinicians who treat and counsel women with hyperemesis gravidarum."

In an accompanying editorial, Catherine Nelson-Piercy, a consultant obstetric physician at Guy' s and St Thomas' Foundation Trust in London, agrees that "better understanding of the genetic risks of hyperemesis may help clinicians when counselling women about the risk of recurrence."

Contact:
Research: Ase Vikanes, Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
Email: ase.vigdis.vikanes@fhi.no
or
Professor Per Magnus, Norwegian Institute of Public Health and Institute of General Practice and Community Medicine, University of Oslo, Norway
Telephone: +47 21 07 82 11

Editorial: Catherine Nelson-Piercy, Consultant Obstetric Physician, Guy' s and St Thomas' Foundation Trust, London, UK
Email: catherine.nelson-piercy@gstt.nhs.uk

(6) Doctors in the Netherlands urge NHS not to follow Dutch "two-tier healthcare system"
(Personal view: A Dutch window into the development of a two tier healthcare system)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2330

Don' t follow our example of increasing private sector involvement in your health service, write two Dutch doctors on bmj.com today.

The authors, led by Dr Joe Guadagno from the VU Medical Centre in Amsterdam, urge caution for when the contracts for independent sector treatment centres in England are renegotiated.

They say that in the Netherlands, "apparent" healthy competition and private sector involvement has led to independent clinics turning away complex cases and "cream-skimming ... to ensure the quick processing of patients to yield maximum profit."

"Unsurprisingly, such providers' clinical outcomes and turnaround times can be excellent; they are likely to be heralded triumphantly for all to see how good health care can be in the private sector," they write. "Meanwhile, poor old sate funded hospitals, with no ability (or desire) to refuse patients, have far higher delays and complication rates, and the blame is attributed (usually for political purposes) to unclean hospitals and poor nursing and medical care."

They believe that the cost-effectiveness of these centres needs rigorous ongoing scrutiny, and they question the generous terms awarded to the programme.

"Although the NHS has been moving to payment by results, the independent sector has usually been awarded five year block grants on predefined levels of activity made on the basis of primary care trusts' predictions," they explain.

"The initial contracts guaranteed payments for the volumes of activity stated, but referral rates were low in the early years, so the independent sector centres were paid even though many didn' t provide the contracted volumes. Amazingly the tariffs were even more generous, being the equivalent to the NHS payments plus 15%."

They conclude that this factor "needs to be included in the contracts and tariff setting currently under discussion for the new phase 2 development of the independent sector treatment centre programme. It also has to be factored into the overall cost effectiveness of these centres to the NHS - a task urgently needed before their role is increased."

Contact:
Dr Joe Guadagno, MS Fellow, VU Medical Center, Amsterdam, Netherlands
Email: joseph.guadagno@sky.com

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)
British Medical Association
BMA House, Tavistock Square, London WC1H 9JP

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
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