Press releases Monday 27 September to Friday 1 October 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) Swine flu patients benefited from taking Tamiflu, says study
• (2) Poor kidney function linked to future heart and brain problems
• (3) New strategy could reduce twin rate after IVF
• (4) Drugs for low libido raise concerns over industry "construction" of new diseases
• (5) Should athletes undergo mandatory ECG screening?

(1) Swine flu patients benefited from taking Tamiflu, says study
(Research: Effectiveness of oseltamivir on disease progression and viral RNA shedding in patients with mild pandemic 2009 influenza A H1N1: opportunistic retrospective study of medical charts in China)
http://www.bmj.com/cgi/doi/10.1136/bmj.c4779

Healthy people who caught swine flu during the 2009 pandemic may have been protected against developing radiographically (x-ray) confirmed pneumonia by taking the antiviral drug oseltamivir (Tamiflu), concludes a study of cases in China published on bmj.com today.

The researchers also show that oseltamivir treatment was associated with shorter duration of fever and viral RNA shedding (the period when a virus is contagious), although they stress that their findings should be interpreted with caution.

In 2009, pandemic influenza A (H1N1) virus spread rapidly, resulting in millions of cases and over 18,000 deaths in over 200 countries.

Trials carried out on seasonal flu viruses have shown that taking antiviral drugs within 48 hours of symptom onset can reduce the severity and duration of symptoms, and possibly the risk of complications.

However, the extent to which antivirals may benefit otherwise healthy individuals with mild 2009 H1N1 infection, remains unknown.

So researchers reviewed the medical records of 1,291 patients in China with laboratory confirmed mild H1N1 infection during the 2009 pandemic.

The average age of patients was 20 years. Three quarters (76%) were treated with oseltamivir from a median of the third day of symptoms. Of 920 patients who had a chest x-ray, a minority (12%) had abnormal findings consistent with pneumonia.

No patients required intensive care unit admission or mechanical ventilation.

Using statistical modelling of the patients' data, the researchers ruled out the effects of age, sex, influenza vaccination, and treatment with antibiotics on the main study outcomes: getting pneumonia, having prolonged high fever, and viral RNA shedding. Oseltamivir treatment was then identified as a significant protective factor against subsequent development of pneumonia, confirmed by a chest x-ray. This protective effect was seen in all patients including those who started treatment more than two days after onset of symptoms.

Oseltamivir treatment started within two days of symptom onset also reduced the duration of fever and viral RNA shedding, they add. They also found that 2009 H1N1 might be shed longer than seasonal influenza virus.

These findings are consistent with patients with the 2009 H1N1 benefiting from use of oseltamivir, conclude the authors. However, they stress that their finding that oseltamivir treatment protected against subsequent radiographic pneumonia should be interpreted with caution, given the retrospective design of this work and the fact that not all patients underwent a chest x-ray.

They call for continued investigation into the effectiveness of antiviral treatment to allow for improvement both in clinical treatment and public health guidance.

Contacts:

Weizhong Yang, Chinese Centre for Disease Control and Prevention, Beijing, People's Republic of China
Email: yangwz@chinacdc.cn

(2) Poor kidney function linked to future heart and brain problems
(Research: Low glomerular filtration rate and stroke risk: a meta-analysis)
http://www.bmj.com/cgi/doi/10.1136/bmj.c4249
(Research: Chronic kidney disease and risk of major cardiovascular disease and non-vascular mortality: prospective population based cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.c4986
(Editorial: Glomerular filtration rate and the risk of stroke)
http://www.bmj.com/cgi/doi/10.1136/bmj.c4390

People with impaired kidney function are at a higher risk of future stroke than people with normal kidney function, concludes a study published on bmj.com today.

A second study, also published today, finds that even the earliest stages of chronic kidney disease are linked to a higher risk of coronary heart disease.

This study suggests that considering signs of early kidney disease, in addition to routinely measured risk factors such as blood pressure and blood cholesterol, modestly improves the identification of people at high risk of cardiovascular disease. It provides about half as much predictive gain as did history of diabetes or about a sixth as much as did history of smoking.

Doctors already know that chronic kidney disease and cardiovascular disease are linked. However, kidney disease often goes undiagnosed, because it is largely without symptoms, and the impact of kidney function on stroke is still unclear.

So, in the first study, researchers from Taiwan and the USA investigated the link between low glomerular filtration rate or GFR (the flow rate of fluid filtering through the kidneys) and risk of future stroke.

They analysed the results of 33 studies involving over 280,000 individuals and found that people with an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.73m2 (the normal range is 100-130 ml/min/1.73m2) had a 43% greater risk of future stroke than people with a normal eGFR.

They also found that Asian people with a low eGFR were at higher risk of future stroke than their non-Asian counterparts.

Based on these findings, they conclude that a low eGFR should be seen as a marker for increased stroke risk, prompting doctors to start risk reduction strategies, such as blood pressure control and use of cholesterol lowering drugs, to avert future strokes, particularly in people of Asian race.

In the second study, UK and Icelandic researchers tracked 16,958 people living in Reykjavik over 24 years and found that even the earliest stages of chronic kidney disease were at increased risk of developing coronary heart disease.

They found that assessment of chronic kidney disease in addition to conventional risk factors modestly improved coronary heart disease risk prediction. It provided about half as much predictive gain as did history of diabetes or about a sixth as much as did history of smoking.

The researchers also found a suggestive association between chronic kidney disease and increased risk of death from causes other than cardiovascular disease or cancer, recommending the need for further studies to investigate this link in more detail.

These findings are supported in an accompanying editorial, which says that the presence of chronic kidney disease should act as a "red flag" that triggers cardiovascular risk assessment and implementation of appropriate preventive strategies already shown to be effective in the general population.

Contacts:

Research paper 1: Bruce Ovbiagele, Associate Professor, Stroke Center and Department of Neurology, University of California, Los Angeles, California, USA
Email: ovibes@mednet.ucla.edu
Research paper 2: Emanuele Di Angelantonio, University Lecturer, Department of Public Health and Primary Care, University of Cambridge, UK
Email: emanuele.diangelantonio@phpc.cam.ac.uk
Editorial: Vlado Perkovic, Executive Director, George Institute for Global Health, Sydney, Australia
Email: rgunning@georgeinstitute.org.au

(3) New strategy could reduce twin rate after IVF
(Patient empowerment for prevention of twins after in vitro fertilisation: randomised controlled trial)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2501
(Editorial: Encouraging single embryo transfer during IVF)
http://www.bmj.com/cgi/doi/10.1136/bmj.c4754

A strategy to encourage single embryo transfer after in vitro fertilisation (IVF) could be an important tool to prevent multiple pregnancies and their associated complications, finds a study published on bmj.com today.

Deciding how many embryos should be transferred after IVF is a complex problem. The transfer of only one embryo will prevent a multiple pregnancy and the risk of complications for mother and baby, but could require more cycles to achieve pregnancy.

Although professionals and policy makers have launched initiatives to encourage the use of single embryo transfer, in 2004 it was used in only 19% of in vitro fertilisation cycles in Europe. The effect of patient empowerment on decision making is also still being debated.

So a team of researchers in the Netherlands set out to evaluate the effects of a multifaceted patient empowerment strategy aimed at helping couples decide how many embryos should be transferred after IVF.

The study involved 308 couples on the waiting list for a first IVF cycle at five clinics in the Netherlands. Couples were randomly selected to receive either the intervention strategy or standard IVF care.

The strategy consisted of a decision aid, support from an IVF nurse, and the offer of an extra IVF cycle if single embryo transfer was unsuccessful.

The results show that, after the first IVF cycle, 43% of couples in the intervention group chose single embryo transfer compared with 32% in the control group. After the second IVF cycle, single embryo transfer was used by 26% of couples in the intervention group compared with 16% in the control group.

Neither of these findings were statistically significant, which means that the results could be simply down to chance. And there were no differences between the couples' levels of anxiety or depression compared with those receiving standard care. However, couples receiving the strategy had significantly higher empowerment and knowledge levels.

The average savings compared with standard IVF care were 169.75 (146.77; $219.12) per couple. If these savings were extrapolated to the Dutch national level, with 7,500 new couples per year, this reduction would add up to 1,273,125 annually, say the authors.

It seems that patients are willing and able to make complex decisions, if they are empowered to do so, conclude the authors.

They add: This study illustrates that a multifaceted empowerment strategy can effectively encourage the use of single embryo transfer in clinical IVF practice. The strategy increases patient knowledge and has no substantial effect on levels of anxiety or depression. The strategy reduces costs as well, and could therefore be an important tool to reduce the twin rate after in vitro fertilisation, within a setting with patient autonomy.

An accompanying editorial says that supporting patients with reliable information is key to empowerment.

Contact:

Arno van Peperstraten, PhD researcher, Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Netherlands
Email: G.vanHerwijnen@cs.umcn.nl

(4) Drugs for low libido raise concerns over industry "construction" of new diseases
(Feature: Merging of marketing and medical science: female sexual dysfunction)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5050
(Commentary: Female sexual dysfunction is a real but complex problem)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5336

Drug companies have not only sponsored the science of a new condition known as female sexual dysfunction, they have helped to construct it, in order to build global markets for new drugs, reveals an article in this weeks BMJ.

Researching his new book Sex, Lies and Pharmaceuticals Ray Moynihan, journalist and lecturer at the University of Newcastle in Australia, discovered that drug industry employees have worked with paid key opinion leaders to help develop the disease entity; they have run surveys to portray it as widespread; and they helped design diagnostic tools to persuade women that their sexual difficulties deserve a medical label and treatment.

He believes that drug marketing is merging with medical science in a fascinating and frightening way and he asks whether we need a fresh approach to defining disease.

He quotes a company employee saying that her company was interested in expediting the development of a disease and he reveals how companies are funding surveys that portray sexual problems as widespread and creating tools to assess women for "hypoactive sexual desire disorder."

Many of the researchers involved in these activities were drug company employees or had financial ties to the industry, writes Moynihan. Meanwhile, scientific studies conducted without industry funding were questioning whether a widespread disorder of low desire really existed.

Industry is also taking a leading role in educating both professionals and the public about this controversial condition, he adds.

For example, a Pfizer funded course designed for doctors across the United States claimed that up to 63% of women had sexual dysfunction and that testosterone and sildenafil (Viagra) may be helpful, along with behavioural therapy. And he points out that German drug company Boehringer Ingelheims educational activities went into overdrive as the planned 2010 launch of its desire drug, flibanserin, approached.

In June, flibanserin was rejected by advisors to the US Food and Drug Administration and Pfizers sildenafil was also pulled after studies showed virtually no difference from placebo. But although the drugs have so far failed, Moynihan warns that the edifice of scientific evidence about the condition remains in place creating the impression that there is a massive unmet need for treatment.

And with more experimental drugs in the pipeline, the drug industry shows no signs of abandoning plans to meet the unmet need it has helped to manufacturer, he says.

Perhaps its time to reassess the way in which the medical establishment defines common conditions and recommends how to treat them, he suggests.

Perhaps it is time to develop new panels to take responsibility for defining treatable illness, made up of people without financial ties to those with vested interests in the outcomes of their deliberations and much more broadly representative of the wider public and start the slow process of untangling the marketing from the medical science. he concludes.

"Faced with a woman in tears whose libido has disappeared and who is terrified of losing her partner, doctors can feel immense pressure to provide an immediate, effective solution," says Dr Sandy Goldbeck-Wood, a specialist in psychosexual medicine, in an accompanying commentary.

She says Moynihans research clarifies both the conflicts of interest at work and the relative paucity of good quality evidence for pharmacological solutions to womens sexual problems. However, she argues: "his argument that female sexual dysfunction is an illness constructed by pathologising doctors under the influence of drug companies will fail to convince clinicians who see women with sexual dysfunction, or their patients."

Women who have struggled to overcome the psychological and cultural barriers to requesting help with their sexual difficulties will not welcome the argument that they are to be left alone, she writes.

She believes the problem is one of oversimplification and believes that more studies are needed that reflect the complexity of sexual life. "It's time to invest in more research into the most realistic, respectful and evidence based treatments, rather than narrow biological ones founded on poor evidence," she says.

The BMJ is hosting an event in London on 4 October 2010 about female sexual dysfunction and the pharmaceutical industry.

Click here for more information: http://resources.bmj.com/bmj/about-bmj/bmj-spotlight-on-female-sexual-dysfunction

Journalists wishing to attend should contact Emma Dickinson on +44 (0)20 7383 6529.

Contacts:

Feature: Ray Moynihan, Conjoint Lecturer, University of Newcastle, Newcastle, Australia
Email: ray.moynihan@newcastle.edu.au
Commentary: Sandy Goldbeck-Wood, Associate Specialist in Psychosexual Medicine, Camden and Islington Mental Health Trust and Specialty Doctor in Obstetrics and Gynaecology, Ipswich Hospital, UK
Email: goldbeckwood@doctors.org.uk

(5) Should athletes undergo mandatory ECG screening?
(Head to Head: Can electrocardiographic screening prevent sudden death in athletes?)
Yes: http://www.bmj.com/cgi/doi/10.1136/bmj.c4923
No: http://www.bmj.com/cgi/doi/10.1136/bmj.c4914

Should athletes have to undergo mandatory electrocardiographic screening (also known as ECG or heart trace) before competing? Doctors debate the issue in this week's BMJ.

Antonio Pelliccia and Domenico Corrado argue that screening athletes for silent heart problems would save lives. They say the best evidence of the efficacy of ECG screening on mortality in athletes comes from Italy, the only country where it is required by law, and where a mass screening programme has been in place for almost 30 years.

The incidence of sudden deaths before and after implementation of the programme fell by 89%, and no deaths were reported among athletes disqualified from competition because of hypertrophic cardiomyopathy. They say this supports the idea that timely identification of affected athletes offers the possibility to improve survival.

Cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds they argue.

But in an opposing piece, Dr Roald Bahr argues that the diagnostic accuracy of ECG screening varies, that false positives can be as high as 40%, and that some conditions, such as coronary atherosclerosis, are likely to remain undetected.

The conditions that cause cardiac death differ substantially between populations, he says. He argues that a screening programme that has successfully identified cardiomyopathies in Italy will not necessarily be effective in, for example, Norway, where this seems to be a rare cause of sudden death.

He argues that because diagnostic accuracy is low, and depends on which cardiac conditions are the main causes of sudden death, ECG screening for athletes would fail public health criteria.

Screening of hundreds of thousands of athletes to save possibly one life a year, cannot be justified, he concludes.

Contacts:

Antonio Pelliccia, Scientific Director, Institute of Sports Medicine and Science, Italian National Olympic Committee, Rome, Italy
Email: ant.pelliccia@libero.it
Roald Bahr, Professor in Sports Medicine, Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
Email: roald.bahr@nih.no

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)
http://intranet.bmj.com/departments/dept-bmj/bmj-team-resources/web-team-resources/General_blogging_principles.doc