NHS

New research has mapped the way that MRSA “superbug” bacteria spread, BBC News has reported. The results suggest that antibiotic-resistant bacteria may often spread from large, inner-city hospitals to smaller regional ones when patients are transferred.

The way that superbugs spread has been researched as part of an intricate study conducted by Scottish researchers, who looked at samples taken across the UK over 53 years. The researchers used genetic techniques to scan patterns and mutations within the various samples and to build up a “family tree” showing how a particular strain (called EMRSA-16) has spread between different hospitals across the country. They found that EMRSA-16 has generally spread by transmission from hospitals in large population centres in London and Glasgow to regional healthcare settings. The researchers suggested that patients’ referrals are an important cause of the spread of this bug across the country.

This type of study can provide useful estimates of transmission routes of MRSA, although there is still a need for further research incorporating a larger number of sampled hospitals to determine the wider UK pattern.

MRSA can be prevented through effective hand washing and screening before hospital admission. Find out more about preventing MRSA.

 

Where did the story come from?

The study was carried out by researchers from the University of Edinburgh and was funded by various research grants, as well as US governmental organisations including the National Institute of Allergy and Infectious Diseases, the National Institutes of Health and the Department of Health and Human Services. The study was published in the peer-reviewed journal Proceedings of the National Academy of Sciences USA (PNAS).

The story was covered accurately by BBC News.

 

What kind of research was this?

This study used genetic analysis of bacteria samples to map the way a particular form of MRSA spread between patients and hospitals across the UK. It collected information from infected patients in the UK over 53 years and looked at the emergence and transmission of EMRSA-16, a major clone (type) of MRSA. The study identified genetic elements and mutations of EMRSA-16 that allowed it to spread between patients and hospitals across the county.

MRSA (meticillin-resistant staphylococcus aureus) is a type of bacterial infection that is resistant to a number of widely used antibiotics. It is often referred to as a “superbug”. MRSA infections are more common in hospitals because patients often have an entry point, such as a surgical site, which allows the bacteria to enter the body. Also, bacteria can easily spread through direct contact with other patients and staff or contaminated surfaces.

Proper hand washing and screening are effective methods used to prevent MRSA infections from occurring. Rates of MRSA have fallen in recent years because of increased awareness of infection by both medical staff and the general public. However, it still places a considerable strain on the health system as it is more difficult to treat than other types of bacterial infection. Currently, all patients who go to hospital for a planned procedure are offered a swab test to see whether they are carrying MRSA bacteria.

 

What did the research involve?

Researchers looked at the genetic make-up of more than 80 variations of a major clone of MRSA called EMRSA-16 found in hospitals. Samples were collected from infected patients during a 53-year period. The EMRSA-16 clone of MRSA predominantly occurs in hospitals, and the researchers estimated that it has been present in UK hospitals for about 35 years. Researchers then identified genetic elements and mutations in the bug and tracked how these spread between patients and hospitals across the country.

Researchers used a specialist approach to map part of the genetic make-up of each sample, looking for changes and patterns in its genetics. In effect, this allowed them to build up a “family tree” showing how different strains had developed.

 

What were the basic results?

The key finding of this study was that EMRSA-16 has spread within the UK by transmission from central hospitals serving large populations to smaller, regional healthcare settings. It found that Glasgow in west Scotland was a hub for transmission to 16 surrounding regions in the north and east of Scotland. Similarly, in London EMRSA-16 spread from large city hospitals to smaller surrounding hospitals in south and southeast England.

 

How did the researchers interpret the results?

Study lead Dr Ross Fitzgerald reported that “our findings suggest the referral of patients to different hospitals is a major cause of MRSA transmission around the country.” He also said that “variants of MRSA circulating in regional hospitals probably originated in large city hospitals.”

The researchers concluded that these findings could help prevent the spread of drug-resistant infections such as MRSA.

 

Conclusion

This study estimates how a strain of MRSA (EMRSA-16) may spread from hospitals in major UK cities to smaller regional healthcare settings. Findings from this study are supported by findings of a recent US study, which estimated high transmission routes from large hospitals to long-term care facilities.

The researchers note that the dataset used is limited by the relatively small number of hospitals sampled. Despite its interesting findings, further research is required that incorporates a larger number of sampled hospitals to determine the pattern of spread elsewhere in the UK.

Collecting data on the prevalence and spread of superbugs such as MRSA (medically known as surveillance) plays an important role in containing and eradicating potentially harmful bacteria in medical settings, and ultimately reducing the number and severity of hospital-acquired infections. When used strategically, data of this type, along with simple but effective measures such as thorough hand washing, can make a difference to the spread of infections, as illustrated by the recent fall in MRSA in NHS hospitals.

Analysis by Bazian

Links To The Headlines

Large city hospitals 'breed and spread' MRSA. BBC News, May 15 2012

MRSA outbreaks start at major city hospitals. Daily Express, May 15 2012

Links To Science

McAdam PR, Templeton KE, Edwards GF et al. Molecular tracing of the emergence, adaptation, and transmission of hospital-associated methicillin-resistant Staphylococcus aureus. PNAS, Published online before print May 14 2012

“Overweight mothers-to-be could be condemning their unborn children to decades of ill health,” the Daily Mail reported.

The news is based on the results of large, long-term research that examined mothers’ body mass index (BMI) before and during pregnancy and how this was linked to various indicators of their children’s health when their children reached 32 years of age. These indicators included BMI, waist size and levels of fat and sugar in the blood, which are associated with the risk of conditions such as diabetes and heart disease.

Researchers found that higher maternal BMI before pregnancy was associated with increased BMI in children, as well as larger waistlines, raised blood pressure and increased blood levels of insulin and fat. Greater maternal weight gain during pregnancy was also associated with increased BMI, waist size and levels of fat in the blood.

This study adds to a growing body of evidence that mothers’ weight before and during pregnancy may affect a range of health-related factors in their children, perhaps even in the long-term. That said, this study’s design means that on its own it cannot prove that a mother’s weight or weight gain during pregnancy are responsible for the health effects seen in their grown-up children. For example, many complex environmental, social and genetic influences are known to determine who develops obesity.

Although the long-term effects of maternal weight are unclear from this study, excess weight is known to increase the risk of complications during birth, as well as making it harder to conceive in the first place. This study highlights the importance of maintaining a healthy weight for these reasons, rather than the potential long-term ones.

The Daily Mail also reported that “concern about the issue is so high that British doctors have started to medicate babies in the womb.” The newspaper appears to be referring to ongoing research into treating women for high blood sugar during pregnancy. This valuable study primarily aims to treat mothers, rather than their unborn babies, to cut potentially dangerous complications, rather than to improve their children’s long-term health.

 

Where did the story come from?

The study was carried out by researchers from the Hebrew University-Hadassah in Israel and the University of Washington in the US. It was funded by the US National Institutes of Health and the Israeli Science Foundation. The study was published in the peer-reviewed medical journal Circulation.

The story was accurately covered by the Daily Mail. However, it should be noted that this study measured factors that can contribute to various diseases, but did not determine the rates of negative health outcomes such as heart attacks, diabetes and strokes mentioned in the news coverage.

 

What kind of research was this?

This cohort study examined how mothers’ BMI and weight changes during pregnancy were associated with various markers of disease in their children once they reached adulthood. The disease markers of interest were waist circumference, BMI, blood pressure and levels of glucose, insulin, fats and lipoproteins in the blood. These were measured once the children reached 32 years of age. Maternal BMI and weight changes during pregnancy were reported by mothers in interviews conducted by nurses while they were in hospital after having their baby.

This is the ideal study design to examine a possible association between maternal weight and children’s health. The study’s strengths also included its large size and long follow-up. However, this type of study can only find associations between factors, and cannot prove a cause-and-effect link. This is because researchers cannot exclude the possibility that another factor is responsible for the association seen.

 

What did the research involve?

This research drew on data from a large, long-running study called the Jerusalem Perinatal Study. The research collected the following information on births in Jerusalem between 1974 and 1976:

• demographic and socioeconomic information
• medical conditions of the mother during current and previous pregnancies and gynaecological history
• smoking status of the mother
• height, pre-pregnancy weight and end-of-pregnancy weight of the mother
• child’s birth weight and gestational age

This information was obtained from maternity ward logbooks, birth certificates and interviews with mothers while they were hospitalised after having their baby.

In this study, a sample of 1,400 individuals born during this period was interviewed and examined again between 2007 and 2009 (when they reached 32 years of age). Individuals who had been born as part of a multiple birth, who were premature or who had congenital malformations were excluded. The researchers collected data on:

• height
• body weight
• waist circumference
• blood pressure
• levels of glucose, insulin and fats in the blood

The researchers looked at associations between maternal pre-pregnancy BMI and weight gain during pregnancy and children’s outcomes at 32 years of age. During their calculations, they accounted for gender, ethnicity and other factors that could explain any relationship seen, including:

• how many previous pregnancies a mother had had
• the mother’s age at the birth
• maternal smoking, and smoking status of the children as adults
• socioeconomic status
• maternal education, and education of the children
• maternal medical condition
• the children’s birth weight and gestational age
• physical activity of the children 

 

What were the basic results?

The researchers found that greater maternal BMI before pregnancy was associated with the following factors in grown-up children at the age of 32:

• increased BMI
• increased waist circumference
• increased blood pressure
• increased blood levels of insulin and fat 
• lower levels of high-density lipoprotein cholesterol

These associations were independent of weight gain during pregnancy (i.e. were evident regardless of how much weight a mother gained during pregnancy).

Greater weight gain during pregnancy was associated with:

• increased BMI
• increased waist circumference
• increased blood levels of fat 

When calculating these various associations, the researchers split mothers into four evenly sized groups, based on their pre-pregnancy BMI. They found that, on average, the adult children of women in the group with the greatest BMI (maternal BMI more than 26.4kg/m2) went on to have a BMI of  five units (kg/m2) higher than the children of mothers in the lowest quarter (maternal BMI less than 21.0kg/m2).

 

How did the researchers interpret the results?

The researchers concluded that “maternal size both before and during pregnancy is associated with cardiometabolic risk factors in young adult offspring.”  In other words, mothers who have a high BMI before pregnancy or who gain a lot of weight during pregnancy are more likely to have children who have risk factors for various metabolic and heart-related health problems in adulthood.

The researchers added that these associations appear to be driven mainly by children’s body fat during adulthood.

 

Conclusion

The link between pregnant women’s weight and the health of their children has been in the public eye several times in recent months, with high-profile news stories questioning whether our mothers can “programme us to be fat” and the need to “treat babies for obesity while still in the womb”.

This latest study analysed potential links between mothers’ excess weight around the time of pregnancy and “cardiometabolic risk factors” in their children decades later. Cardiometabolic risk factors are factors such as raised BMI and blood sugar, which signal that a person has a higher risk of conditions such as diabetes and heart disease.

The study found a long-term relationship, with higher maternal weight (assessed using BMI) and greater weight gain during pregnancy associated with a number of factors in the mothers' children at the age of 32. These included increased BMI, waist circumference, blood pressure and blood levels of insulin and fats, and decreased levels of high-density lipoproteins (“good cholesterol”) in children. As the authors state, this study “adds to and extends accumulating evidence” of this relationship, as similar findings have been reported in other studies.

This study has shown associations between maternal weight and children’s later health, but it cannot show cause and effect. This is because it cannot rule out the possibility that another factor is responsible for the association seen. Also, both pre-pregnancy weight and weight gain were not directly measured but were reported by mothers in interviews conducted by nurses after delivery. This may have led to some inaccuracy in the calculation of BMI and makes the results less reliable.

The average pre-pregnancy BMI of women in this study was 24kg/m2 (within the healthy range) in mid-1970s Jerusalem. This population may not be typical of pregnant women in the UK today.

In addition, the exact mechanism by which maternal pre-pregnancy weight and weight gain during pregnancy might cause increased levels of cardiometabolic risk factors in children remains to be determined. Several mechanisms, including shared genetic and environmental characteristics or changes caused by exposures in the womb, have been proposed, although none is completely clear.

Analysis by Bazian

Links To The Headlines

Obesity legacy of mums-to-be: Carrying too many pounds in pregnancy can give your baby a life of weight problems. Daily Mail, May 15 2012

Links To Science

Hochner H, Friedlander Y, Calderon-Margalit R et al. Associations of maternal prepregnancy body mass index and gestational weight gain with adult offspring cardiometabolic risk factors/clinical perspective : The Jerusalem perinatal family follow-up study. Circulation, February 17 2012, 2012;125:1381-1389 (published online before print)

Women concerned about PIP breast implants can find all the latest NHS information about the issue in our Health A-Z section on PIP implants.

Worries about the implants have emerged since news of a major investigation into them in France was widely covered in the media in December 2011.

Initially it was thought that around 40,000 women in the UK had the implants but on March 15 the Department of Health said new evidence meant a further 7,000 women in the UK might have them. About 95% of the implants were provided privately for purely cosmetic reasons.

The French implants caused global concern after it was revealed they contained industrial silicone rather than medical-grade fillers and that they may be more prone to rupture and leakage than other implants.

Initially reports also linked the implants to a rare form of cancer known as ALCL. This cancer link has been now been firmly discounted by medical experts here and in Europe.

 

What type of implants are involved?

The implants involved are called Poly Implant Prosthèse (PIP) and were made by a French company of the same name.

In a Medical Device Alert in March 2010, the Medical and Healthcare products Regulatory Agency (MHRA) said: " ... most
breast implants manufactured by the company since 2001 have been filled with a silicone gel with a composition different from that approved".

That alert was based on advice from French regulators. However, after an investigation by the MHRA, the French authorities reported in March 2012 that PIP implants made before 2001 may also contain unauthorised silicone gel.

PIP gained approval to market its silicone implants in 1997 but it is not clear when it began using a cheap type of silicone gel intended for making mattresses.

The marketing, distribution and use of the PIP implants was suspended in March 2010.

 

Do the implants have to be removed early?

About one breast implant in five needs replacing within 10 years, whatever the make, so it is unlikely that all the 7,000 women who had PIP implants before 2001 still have the same implants.

An expert committee was set up recently to examine the specific risks associated with PIP implants. It concluded that there was not enough evidence to recommend their early removal. That advice has not changed. For more details, read the expert review group's report (PDF, 159kb).

Links To The Headlines

No Routine Removal For PIP Breast Implants. Sky News, January 6 2012

NHS will remove implants free of charge for their patients but private clinics must pay for operations themselves, Government says. Daily Mail, January 6 2012

Government will pay for women who had breast implants on NHS to have them removed. The Daily Telegraph, January 6 2012

Clinics 'should remove implants'. BBC News, January 6 2012

The NHS “spends £1m a week on repeat abortions”, the Daily Mail reported. The newspaper claimed that single women are using terminations “as another form of contraceptive”, and that some will have “seven, eight or even as many as nine terminations in their lifetime”.

The Mail’s coverage seems to be a response to a request for data on repeat abortions that was made in parliament in April 2012. The article appears to draw on 2010 abortion statistics available from a Department of Health report. The annual report provides data on the number of abortions (medically termed “termination of pregnancy”) performed in the UK, and includes a section on repeat abortions.

Despite the Daily Mail's headline, the report does not provide any data or information on women’s reasons or motivations for seeking an abortion. The “abortion as contraception” claim appears to be an interpretation of the data provided by campaign groups and abortion legislation critics. Also, the data suggest that only a tiny fraction of abortions were in women who have had seven or more previous abortions – 85 procedures out of the 189,574 performed in 2010.

 

What is a repeat abortion?

Much as the term implies, a repeat abortion is an abortion in a woman who has had one or more previous abortions. The Department of Health has recorded the rate of repeat abortions for many years, and includes a section on repeat abortions in its annual report on abortion statistics.

 

How many repeat abortions are happening each year?

According to the Department of Health’s abortion statistics report, in 2010 there were 189,574 abortions in England and Wales (data are available on residents of England and Wales only). Approximately 64,445 (34%) of these were repeat abortions. The percentage of repeat abortions was found to increase with age: 8% of those under 18 years old had a repeat abortion compared with 44% of women over the age of 35. While it may initially seem puzzling why older women have more repeat abortions, a logical, cumulative effect of ageing is responsible. Put simply, the longer a woman has been alive, the greater time she has had to undergo a repeat abortion.

The Department of Health report also provides data on the percentage of abortions that are repeat abortions in women aged under 25. In 2010 in England and Wales, this figure was 24.8%, with the figure varying across difference primary care trusts (range 15% to 41%).

The Department of Health reports that “repeat unintended pregnancy and subsequent abortion is a complex issue associated with increased age”, as increasing age allows for a longer time at risk for becoming pregnant.

 

Are repeat abortions increasing?

Full sets of annual data have so far been published up to 2010, with figures for 2011 scheduled for publication in the near future. Between 2000 and 2010, there was a small rise in the number of total abortions, up from 175,542 to 189,574. The 2010 figure was, however, slightly lower than the peak number seen in 2007, when there were 198,499 abortions.

The Department of Health data also indicate that the proportion of all abortions that are considered repeat abortions has increased from 30% to 34% since 2000. In absolute terms, this was estimated to equate to 52,663 repeat abortions in 2000 and 64,445 in 2010.

 

Why have these figures come to light now?

It is not immediately clear from the Mail’s coverage why these figures are making headlines today. On April 16 2012, the Labour MP Diane Abbot asked the secretary of state for health to provide estimates on the number of repeat abortions performed in 2010, 2011 and 2012. She asked that these figures be provided based on the marital status and age of the women across each primary care trust.

However, as abortion figures are published a year in arrears, the 2012 figures will not be published until 2013. Also, the 2011 figures are not scheduled for official publication until the end of May 2012, meaning that only figures up to 2010 are available at this time. The House of Commons website also reports that the 2010 statistics provide information on the number of repeat abortions by age, but not marital status. The Daily Mail, however, quoted statistics based on both age and marital status, and it is unclear how these have been derived.

 

Is abortion used as a 'form of contraception'?

In the UK, abortion is legal if one of several conditions apply:

• continuing the pregnancy would involve risk to the life of the woman
• termination of the pregnancy is required to prevent serious permanent injury to the woman
• the pregnancy has not gone beyond 24 weeks, and continuing would involve risk to the physical or mental health of the woman, greater than if the pregnancy was terminated
• the pregnancy has not gone beyond 24 weeks, and continuing would involve risk to the physical or mental health of any existing children, greater than if the pregnancy was terminated
• there is a significant risk that the child would suffer physical or mental abnormalities leading to serious handicap
• emergency situations to save the life of the woman
• emergency situations to prevent serious permanent injury to the woman

The Department of Health report on abortion statistics provides information on which of these conditions applies to each registered abortion. It does not, however, provide any specific data on the reasons why women decided to seek an abortion. The idea that abortion is used “as contraception”, as reported in the Daily Mail, appears to be an interpretation of the abortion statistics data by critics of the current legislation, with the newspaper quoting pro-life campaign groups and critics of current abortion legislation.

 

Who can give advice about reproductive health and contraception?

People seeking advice on reproductive health and contraception can speak with their GP or a community family planning clinic. GUM (genitourinary medicine) clinics, which are often located in hospitals, can also provide contraceptive services and sexual health advice. For younger adults in particular, voluntary organisations such as Brook advisory centres also provide a wide range of sexual health services.

Links To The Headlines

NHS spends £1m a week on repeat abortions: Single women using terminations 'as another form of contraceptive'. Daily mail, May 14 2012

NHS 'spends £1m on repeat abortions'. The Daily Telegraph, May 14 2012

Repeat abortions cost NHS £50m a year. Daily Express, May 14 2012

Cholesterol-lowering statin drugs “could more than halve the risk of bowel cancer”, according to the Daily Mail.

Millions of people take statins in a bid to prevent problems such as heart attacks and strokes, but several recent studies have looked at whether they might also cut the risk of cancer. This latest news is based on a study of statin use in people with and without bowel cancer. It looked at use of the drug in a group of 101 bowel cancer patients and 132 people without cancer. It found that statin users had a lower risk of developing bowel cancer, and that higher doses and longer duration of statin use were associated with a greater reduction in the odds of having the disease.

Previous research into the potential effect of statins on bowel cancer has had mixed results. Some studies have suggested that the drugs have a protective effect, and others have found no clear association between statin use and bowel cancer risk. It is important to note that this latest study is small, so its results may be inaccurate. This means the results need to be replicated in much larger samples of people. Also, all patients in this study – with or without cancer – were included because they were undergoing colon examinations for bowel symptoms, so they may not represent the general population.

Nevertheless, this small study adds to the mounting evidence that stains may have an effect in protecting against the development of certain cancers. However, more research is needed to confirm the findings and establish how large this protective effect may be.

 

Where did the story come from?

The study was carried out by researchers from the University of East Anglia and the Norfolk and Norwich University Hospital. It was funded by the Norwich Medical School.
 
The study was published in the peer-reviewed journal Biomed Central Gastroenterology.

This research was covered appropriately by the media, with the Daily Mail reporting that previous studies have found conflicting results and that additional research is needed. The newspaper also reported the possible side effects of statin use.

 

What kind of research was this?

This case-control study examined the association between statin use and bowel cancer. Case-control studies are a useful way of examining some types of association. They recruit and compare two groups of participants who either have or don’t have a particular disease or condition. For example, this study compared the histories of people with bowel cancer to those of similar participants without the condition. This allows researchers to study a relationship without having to recruit a large number of participants and follow them up over a long period.

Case-control studies have weaknesses, however, including relying on participants to accurately recall their past behaviour and exposures, often over many years. This can introduce bias into the results as such recollection can be difficult, particularly if someone is trying to understand why they have developed a condition such as cancer. Overall, the limitations of case-control studies mean they are considered to show only associations between two factors, and not that one factor causes the other.

Arguably, as both statin use and bowel cancer are fairly common among the general population, it would be possible to conduct a cohort study to examine bowel cancer development in a large sample of statin users and non-users. A study of this type would take a large group of participants using statins and follow them over time to see which of them developed cancer. It would then examine differences between the participants that may have contributed to the development of cancer. Alternatively, a carefully controlled randomised controlled trial would be the best way to examine this question, although it would need to be carried out over a long period as bowel cancer can take many years to develop.

As mentioned above, case-control studies cannot prove that a particular exposure (such as statin use) causes a particular outcome (such as a reduction in bowel cancer). They are, however, still a useful way to explore potential relationships, and are often conducted as a way to justify attempting large cohort studies or randomised controlled trials. In short, they provide useful initial data that will need to be corroborated through more intensive types of research.

 

What did the research involve?

The research included people who had undergone a colonoscopy at the Norfolk and Norwich University Hospital between September 2009 and May 2010. All the participants had bowel symptoms which led them to be referred to the hospital for a diagnostic colonoscopy examination. A colonoscopy involves inserting a long, flexible camera into the bowel to look for abnormalities such as tumours, pre-cancerous cells or damage. The study excluded patients who received a colonoscopy for surveillance of current or previous illnesses (such as inflammatory bowel disease), and symptomless patients who received a precautionary screening colonoscopy because they were considered to be at higher risk of bowel cancer (for example, those with a strong family history of bowel cancer).

Bowel cancer cases were identified based on a positive result during a diagnostic colonoscopy test, and control subjects were drawn from patients who had a negative test result. All the participants completed an interview during which information on statin use was collected. The researchers also collected information on other known risk factors for bowel cancer, which were adjusted for during the statistical analysis.

The researchers compared the percentages of cases and controls who reported taking statins, and determined whether the odds of having bowel cancer changed depending on statin use. They performed further analysis to determine whether or not the dose, duration or type of statin used was associated with differing risk of developing bowel cancer. All analyses were presented as odds ratios (OR). This is an appropriate statistical method to use in case-control studies. Odds ratios compare the odds of an outcome in an exposed group (statin users) with the odds of the same outcome in an unexposed group (non-users).

 

What were the basic results?

The research included 101 patients with bowel cancer and 132 cancer-free controls. There were some differences between the two groups. Cases were more likely to be male, older and to drink more alcohol during the course of a week. Controls were more likely to have diabetes and to have previously used aspirin (some research has linked long-term aspirin use to a reduced risk of bowel cancer). These factors were considered to be potential confounders and were controlled for in the statistical analysis.

The researchers found that previous statin use for at least six months was associated with significantly reduced odds of being diagnosed with bowel cancer (OR 0.43, 95% confidence interval [CI] 0.25 to 0.80).

When the researchers performed subgroup analysis based on the duration of statin use, they found that longer statin use was associated with a greater protective effect:

• 8 cases and 14 controls had used statins for less than 2 years. There was no significant difference in the odds of a bowel cancer diagnosis between statin users and non-users (OR 0.66, 95% CI 0.21 to 1.69).
• 7 cases and 23 controls had used statins for 2 to 5 years. There was no significant reduction in odds of bowel cancer diagnosis (OR 0.38, 95% CI 0.14 to 1.01).
• 5 cases and 31 controls had used statins for over 5 years. This was associated with an 82% reduction in the odds of being diagnosed with the disease (OR 0.18, 95% CI 0.06 to 0.55). This particular association was statistically significant.

When the researchers performed subgroup analysis based on the statin dose, they found larger doses were associated with a greater protective effect:

• 12 cases and 28 controls used a dose of less than 40mg a day. There was no significant reduction in odds of bowel cancer diagnosis at this dose (OR 0.51, 95% CI 0.21 to 1.24).
• 8 cases and 40 controls used a dose of 40mg or greater a day. This was associated with an 81% reduction in the odds of being diagnosed with the disease (OR 0.19, 95% CI 0.07 to 0.47).

 

How did the researchers interpret the results?

The researchers concluded that statin use was associated with a reduction in bowel cancer diagnosis, and that this reduction was largest at higher doses and with longer duration of statin use.

 

Conclusion

This study suggests that stains, a commonly prescribed class of cholesterol-lowering drugs, may protect against bowel cancer. However, further research with more participants and a more robust study design will be needed to confirm its findings.

This was a relatively small study, which was further divided during subgroup analysis. Analysing small numbers of participants increases the possibility that any risk associations calculated could be inaccurate. Larger studies are needed to verify the associations found in this research.

The researchers report that one of their study’s strengths is that a comprehensive drug history was available, both through prescription records and patient reports. This increases the likelihood that exposure to statins was correctly classified. Additionally, all the participants underwent the same diagnostic testing to confirm or rule out the presence of bowel cancer.

There were, however, limitations to the study. For instance, all the participants had symptoms that indicated the need for a colonoscopy. Given that the control group may have had health issues relating to their bowels, the results may not reflect the risk of bowel cancer in the wider population. Further studies including participants receiving a screening, rather than diagnostic, colonoscopy could help address this potential bias.

When being used to treat or prevent cardiovascular problems, statin drugs may be given as part of a package of treatments including dietary changes and salt reduction. It’s possible that people with the greatest need for cholesterol-lowering statins may also modify their diet alongside their use of statins. Given that diet is associated with bowel cancer risk, dietary changes (and not just the use of statins) may have played a role in the association. This study did not investigate the participants’ dietary habits. Future studies could examine this risk factor.

The researchers say that the protective effect seen in their study was greater than that seen in other studies with similar results. They also point out that not all previous research has found a protective effect, and that there are inconsistent findings across the field. They say that these inconsistencies may be due to differences in the populations studied, or the duration of statin use. Given the variability in results, more research is needed before we can be confident that statins are indeed associated with a reduced risk of developing bowel cancer. Ideally, this research should be a prospective cohort study or randomised controlled trial.

Overall, this case-control study adds to the existing evidence that statin use has a potential protective effect against the development of bowel cancer. Further research is needed to confirm the findings, and the risks associated with statin use will need to be weighed up against any benefits before the drugs are considered for cancer-prevention.

Analysis by Bazian

Links To The Headlines

Statins 'cut risk of bowel cancer': Danger 'halved' by cholesterol-busting pills. Daily Mail 11, May 2012

Links To Science

Broughton T, Sington J, Beales ILP. Statin use is associated with a reduced incidence of colorectal cancer: a colonoscopy-controlled case-control study. BMC Gastroenterology. April 24 2012

“Women using a vaginal ring or skin patch for contraception are at around double the risk of a blood clot compared to those taking the Pill,” the Daily Mail has reported.

The news is based on a large Danish study that looked at contraceptive use in more than 1.5 million women. The study looked at how different hormone-based methods such as implants, the patch and the pill related to the risk of blood clots. Between 2001 and 2010 researchers recorded a total of 3,434 blood clots, also known as venous thromboembolisms or VTE. The background rate of VTE among women not using hormonal contraception was 2.1 per 10,000 woman-years (for example, 2.1 would occur if 1,000 women were followed for 10 years). The highest rate of VTE was among women who used the contraceptive patch, with 9.7 per 10,000 woman-years. Women using a common oral contraceptive pill experienced a rate of 6.2 per 10,000 woman-years.

Despite what some news coverage might suggest, hormonal contraceptives containing oestrogen ( the combined oral contraceptive pill, transdermal patch and the vaginal ring) are already recognised as increasing the risk of VTE, although the risk is very low. Instead of discovering a new danger from using hormone-based contraceptives, the research simply refines estimates of the clot risk associated with different methods.

Women should be fully informed of the potential risks and benefits of any contraceptive option that they choose. They can talk to their GP or nurse about these. Despite the small increase in risk associated with the patch or vaginal ring compared with the combined oral contraceptive pill, there may be women for whom this is still an appropriate choice.

 

Where did the story come from?

The study was carried out by researchers from the University of Copenhagen and did not receive external funding. It was published in the peer-reviewed British Medical Journal.

News coverage generally failed to reflect the true context of this research. It is already known that there is a clot risk associated with use of oestrogen-containing contraceptives, and this research has helped to analyse some of the finer points around the issue rather than revealing any previously unknown risk. This research provides valuable quantification of the possible risk among users of hormonal contraception but the findings are not as unexpected as the media implies.

In particular, the Daily Mail’s headline is misleading and may scare women: ‘Women using alternative contraception to the Pill are at double the risk of blood clot’. This might suggest to readers that any alternative option to the combined oral contraceptive pill doubles the risk. This is not true. The oestrogen-containing patch or vaginal ring increase risk slightly more than the oestrogen-containing pill, but the pill itself actually significantly increases risk of VTE compared with non-use, or use of progestogen-only contraceptives or barrier methods.

 

What kind of research was this?

This was a large, national cohort study that compared contraceptive use and VTE risk among more than 1 million Danish women. It used four national registries in Denmark to look at all non-pregnant women aged 15-49 (who were free of cancer or thrombotic disease) and collected data on their contraceptive use over the period 2001 to 2010. From these data, researchers were able to see how the rate of VTE among users of non-oral hormonal contraceptives compared with the rate in users of the oral contraceptive pill, as well as in women who didn’t use hormonal contraception.

A cohort study is a good way of evaluating whether a certain exposure increases risk of a certain outcome. The researchers of this cohort study when conducting their analyses have attempted to adjust for some of the possible confounding factors that could be affecting the results.

 

What did the research involve?

Data available in Danish registries allowed for 1,626,158 non-pregnant women to be followed between January 2001 and December 2010. The researchers were only interested in first-ever events of VTE, so excluded women who had had any type of thrombotic event in their veins or arteries before the study period (assessed by checking medical registries from 1977 to 2000). They also excluded those with cancer, those who had had a hysterectomy or both their ovaries removed and those who had been sterilised.

Since 1995 the registries consulted by the study have recorded all filled prescriptions, and so the researchers were able to obtain information on all hormonal contraceptives prescribed between 1995 and 2010. They recorded the products according to progestogen type, oestrogen dose, method of administration and duration of use. The registry also records all hospital admissions.

Any hospital admission for suspected VTE (a clot in a vein or blood vessel) or pulmonary embolus (a clot in the blood supply to the lungs) was confirmed by examining prescribed anticoagulation therapy recorded in the national registry of medicinal products for at least four weeks after the diagnosis. Fatal VTEs were captured by the national causes of death registry.

The researchers also obtained information on some possible confounders that could influence VTE risk, such as educational status, age and calendar year (contraceptives prescribed or healthcare in general may have changed subtly over the nine-year study period). However, they didn’t have information on other relevant confounders such as smoking.

 

What were the basic results?

The researchers had 9,429,128 woman-years of follow-up data (for example, 90 woman-years of follow-up could be 90 women followed for one year, or nine women followed for 10 years). Over this period there were 3,434 confirmed first-event VTEs.

The researchers then calculated the VTE rate according to use of different contraceptive types:

• not using hormone-based contraception: women not using any hormone-based contraception experienced a background rate of 2.1 events per 10,000 woman years (for example 2.1 would occur if 1,000 women were followed for 10 years)
• contraceptive patch: a rate of 9.7 per 10,000 woman years
• vaginal ring: a rate of 7.8 per 10,000 woman years
• combined oral contraceptive pill (30-40 micrograms of oestrogen in combination with levonorgestrel): a rate of 6.2 per 10,000 woman years
• combined oral contraceptive pill (30-40 micrograms of oestrogen in combination with norgestimate): a rate of 4.5 per 10,000 woman years
• progestogen implant: a rate of 1.7 per 10,000 woman years
• progestogen-releasing intrauterine system: a rate of 1.4 per 10,000 woman years

The researchers calculated that, after adjustment for confounders, the risk of confirmed VTE among users of the contraceptive patches was 7.9 times that of women not using hormonal contraception (95% confidence interval 3.54 to 17.65), and 2.3 times that of users of the combined oral contraceptive pill (95% CI 1.02 to 5.23).

The risk of confirmed VTE among users of the vaginal ring was 6.5 times that of non-users, and 1.9 times that of users of the combined oral contraceptive pill. Compared with women who did not use hormonal contraception, women who used the combined oral contraceptive pill had around a trebled risk of VTE.

Compared with women who did not use hormonal contraception, users of the progestogen implant or progestogen-releasing intrauterine system had no increased risk of VTE.

 

How did the researchers interpret the results?

The researchers conclude that “women who use transdermal patches or vaginal rings for contraception have [respectively] a 7.9 and 6.5 times increased risk of confirmed venous thrombosis compared with non-users of hormonal contraception of the same age”. Respectively, this equates to 9.7 and 7.8 events per 10,000 woman-years (for example, for the transdermal patch a rate of 9.7 events among 1,000 women followed for 10 years).

 

Conclusion

This large study provides valuable information on the rate of VTE that may be experienced among users of hormonal contraception.

However, the findings are not completely surprising. Oestrogen-containing hormonal contraceptives are already known to increase the risk of VTE, and medical professionals already consider this potential side effect when prescribing contraception and monitoring patients. Instead of revealing some new or major danger, this study provides a good indication of how the risks compare for a variety of different contraceptive methods.

The oestrogen-containing contraceptives currently available are the combined oral contraceptive pill, the transdermal patch (of which there is one licensed product – brand name Evra) and the vaginal ring (of which there is one licensed product – brand name NuvaRing). There are many different preparations of combined oral contraceptive pill that contain different strengths and forms of oestrogen and progestogen. Different progestogens contained in combined oral contraceptive pills are considered to have a differing effect on risk of venous thromboembolism. This study chose to look separately at VTE rate among users of combined oral contraceptive pills containing levonorgestrel or norgestimate, but there are various other types of progestogen contained in other combined pills, and this study has not examined those.

Progestogen-only contraceptives are not known to increase risk of VTE, and this study supports this. Users of implants and the progestogen-releasing intrauterine system had no higher risk than non-users of hormonal contraception. Information was not available for progestogen-only pills or injections.

There are some further points to note about the study:

• This was a cohort study looking at associations within a large population using contraception in an everyday setting rather than in the artificially controlled setting of a clinical trial. As such, the method of contraception used will have been down to the woman’s personal choice in consultation with her doctor, and there may be health and lifestyle factors that have influenced the choice of contraceptive and that could also influence risk of VTE. The researchers adjusted their results for possible confounders of age, education and calendar year, and also excluded women who may be at particularly increased risk of VTE. However, information on other relevant confounders such as smoking or body mass index was not available.
• Use of contraception was determined by looking at filled prescriptions. Although the women are likely to have used the method prescribed for them, and for the prescribed time period, this may not always have been the case.
• There were far fewer women in the study using the patch (6,178 woman years) or vaginal ring (50,334 woman years) compared with the combined oral contraceptive pill (530,241 woman years). The event rate of VTE among users of the patch or vaginal ring was correspondingly low (six events among users of the patch; 39 with the ring). Therefore, although the ring and patch were calculated to give double the risk of the combined oral contraceptive pill, the low event rates mean that the risk figures are only estimates, and may not be completely accurate. This is reflected by the wide confidence intervals. In other words, even a small spike in cases could inflate the rate seen.

Overall, the study highlights the importance of women being fully informed of the potential risks and benefits of any contraceptive option that they choose. Despite the small increase in risk associated with the patch or vaginal ring compared with the combined oral contraceptive pill, there may be women for whom this is still an appropriate choice and for whom the benefits, such as not having to take a daily pill, outweigh the small extra risk.

Analysis by Bazian

Links To The Headlines

Skin patch contraceptive linked to high blood clot risk: research. The Daily Telegraph, May 11 2012

Women using alternative contraception to the Pill 'are at double the risk of a blood clot'. Daily Mail, May 11 2012

Links To Science

Lidegaard Ø, Nielsen LH, Skovlund CS, Løkkegaard E. Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark 2001-10. BMJ. Published May 10 2012

The NHS is set to use Botox injections to treat chronic migraines, it has been widely reported today. The muscle-paralysing injections are popular as a cosmetic treatment but, due to its nerve-blocking effects, Botox also has a role in treating certain medical conditions.

The move to use Botox to prevent migraines is based on new guidance published today by the National Institute for Health and Clinical Excellence (NICE), which looks likely to come into force in the near future. NICE recommends that Botox can be considered as an option for the prevention of headaches for people who have chronic migraine (headaches on at least 15 days of every month, at least eight days of which are migraine) that has not responded to at least three prior preventative drug treatments.

This latter point is key – although this treatment will be available on the NHS very few people may actually be eligible. The treatment will be available for people whose migraine is debilitating enough to require preventative treatment to be taken, and then for only the small proportion of those who have not responded to other standard preventative drug options.

 

What is a migraine?

There are many different types of headache. A migraine is a type of headache where the person often has an intense throbbing headache and additional symptoms such as nausea, vomiting or increased sensitivity to bright light, noise or smell.

There are two recognised forms of migraine. A migraine is often described as a classic migraine with ‘aura’ if the person gets some form of visual distortions prior to the headache. These visual distortions are often in the form of zigzag or flashing patterns across their vision. Non-classic or common migraine does not have this aura.

Migraines are thought to be caused by changes in the chemicals of the brain, in particular serotonin. Serotonin levels are believed to decrease during a migraine, which can cause the blood vessels in the brain to spasm and then dilate, causing the headache. Other triggers can be hormonal changes, certain food items, environmental situations, emotions, stress and physical triggers (for example muscular tension or poor sleep).

Acute migraines are usually treated using painkillers and anti-sickness medications. For people whose migraine does not respond to over-the-counter medications, stronger painkillers may be prescribed by a doctor. If a person suffers from regular debilitating migraines they may need to be prescribed preventative (prophylactic) medications, which they take to stop them getting migraines. There are various drugs currently prescribed for migraine prophylaxis, including beta-blockers and certain antidepressants or anticonvulsants.

 

What is botulinum toxin type A (Botox)?

Botulinum toxin type A, or Botox as it is commonly known, is a purified neurotoxin (nerve toxin) derived from the bacterium Clostridium botulinum. It works by paralysing the nerve supply to muscles, thereby restricting their movement.

The reasons why Botox might aid migraine are not clear, and several theories have been put forward. At various points it has been suggested that:

• Botox might relax muscles around the head and thereby reduce blood pressure within the brain
• Botox might reduce the nerves’ ability to send pain signals during a migraine
• Botox might prevent the nerves from sending signals that will lead to a migraine

While the mechanism behind any effect is not clear, NICE feels the results of research indicate Botox should be considered as a potential treatment for migraine. Under the new guidelines Botox for the treatment of chronic migraine would be given (to those eligible) by intramuscular injection to between 31 and 39 sites around the head and back of the neck. A new course of treatment can be administered every 12 weeks.

 

How effective is Botox for migraine?

NICE looked at a systematic review that had identified all randomised controlled trials comparing botulinum toxin type A with placebo for people with chronic headache. Two large trials were identified, and in both of these trials Botox injections reduced the frequency of headache days, which was the main trial outcome that the researchers were interested in. Botox also helped to improve quality of life on validated scales, but was no more effective than placebo in reducing the use of painkillers to treat acute pain.

 

Is Botox safe for migraine?

In the reviewed trials the most frequently reported adverse reactions in the Botox group were neck pain, headache, migraine, eyelid drooping, muscular stiffness and muscular weakness. Neck pain was the only adverse effect that occurred at a rate of 5% or more in the Botox groups compared with the placebo groups. Other recognised adverse effects of Botox are itching, injection site pain and other muscular effects such as aching, tightness or spasms.

The manufacturer’s summary of product characteristics states that “in general, adverse reactions occur within the first few days following injection and, while generally transient, may have a duration of several months or, in rare cases, longer”.

 

What does the guideline say?

The guideline says that botulinum toxin type A may be prescribed on the NHS for the prevention of chronic migraine, but only if specific criteria are met. These are as follows:

• The person has chronic migraine, defined as headaches on at least 15 days a month, of which at least eight days are with migraine.
• The person has not responded to at least three drug-based treatments intended to prevent migraines.
• The person is being appropriately managed for medication overuse. The regular use of painkillers to treat headaches can lead to withdrawal headaches as the effect of the painkillers wears off. For some people with chronic headaches this compounds the problem.

If botulinum toxin type A is prescribed, NICE recommends that it should then be stopped if the following criteria are met:

• the person is not adequately responding to treatment (defined as less than a 30% reduction in headache days per month after two treatment cycles)
• the headache has changed from chronic to episodic migraine (defined as fewer than 15 headache days per month) for three consecutive months

 

What sort of guidance is this?

NICE produces many different types of evidence-based appraisals evaluating the evidence on treatments or interventions for different conditions. Their aim is to ensure that treatments offered are of the highest quality and the best value for money. Rather than being a full guideline that covers all the different ways to manage migraine, the current publication is a ‘technology appraisal’ specifically assessing Botox use for the prevention of headaches in adults with chronic migraine. Technology appraisals evaluate when and how new and existing medicines and treatments should be used in the NHS.

 

Will Botox definitely be made available?

The current publication is NICE’s final recommendation on the use of botulinum toxin type A for the prevention of headaches in adults with chronic migraine. It is not completely approved as it is currently open to appeal, a process NICE allows with all evaluations. Unless there is later a successful appeal against the decision to approve Botox for migraines, the guidance will be adopted for people with chronic migraine who meet the specific criteria as outlined above.

Links To The Headlines

Botox given go-ahead for migraine sufferers. The Guardian, May 11 2012

Botox migraine jab set to be offered on NHS, says NICE. BBC News, May 11 2012

Botox to be the new treatment for chronic migraine. The Independent, May 11 2012

Hope for thousands who suffer migraines as treatment involving botox is given the green light. Daily Mail, May 11 2012

Free Botox on the NHS... but only for those with chronic migraines. Daily Mirror, May 11 2012

Botox jabs on the NHS to bash migraine on the head. Metro, May 11 2012

Migraine sufferers to get botox jabs on NHS. Daily Express, May 11 2012

Links To Science

NICE. Migraine (chronic) - botulinum toxin type A: final appraisal determination. Published online May 10 2012

Thousands of heart attack survivors are too worried to have sex because they fear it will trigger another attack, the Daily Mail has reported today.

The story is based on a US study that looked at patients’ sexual activity both before their heart attack and in the year that followed. The study looked at the factors that affected whether people were still sexually active. It found that almost half of men and nearly 60% of women were less sexually active after a heart attack than previously, and that about one in ten who had been sexually active before a heart attack did not have sex in the year afterwards.

The study also found that only a third of women and 47% of men reported receiving any counselling about resuming sexual activity on leaving hospital. Those who had not received counselling were more likely to report reduced sexual activity in the following year. The study also found that patients who had sex in the year following a heart attack were no more likely to die than those who were sexually inactive, with mortality rates among both groups being similar.

Although it did not explore the reasons why some people were less sexually active after a heart attack, this study suggests that lack of any advice on the topic may leave patients fearing that sexual activity could put them at risk of a repeat heart attack, and that the issue needs to be addressed.

Most people value sexual activity as an important part of life, whatever their health. In the UK, the current advice is that anyone who has had a heart attack should be able to have sex without risk to their heart once they are fit enough to walk briskly up two flights of stairs without getting chest pains or becoming out of breath. This is usually about four weeks after having a heart attack. At this point, having sex will not put you at further risk of another heart attack.

 

Where did the story come from?

The study was carried out by researchers from the University of Chicago, the University of Missouri and Yale University. It was funded by the US National Heart, Lung and Blood Institute, and the non-profit corporation Cardiovascular Outcomes Inc. The study was published in the peer-reviewed American Journal of Cardiology.

The research was reported accurately in the Daily Mail, which pointed out that men having heart attacks during sex is rare, despite what “dramatic movie scenes” might suggest. To aid readers in the understanding of this complex medical issue the paper featured a run down of a famous coital heart attack on film, experienced by Jack Nicholson’s character Harry Sanborn in the film Something’s Gotta Give. The Daily Telegraph combined its report of the study with comments from a doctor explaining that TV programmes often mislead people into thinking heart attacks after sex are common. The doctor gave the examples of the TV shows Downton Abbey and Mad Men, which both “feature dramatic scenes where philandering men suffer heart attacks in bed”.

 

What kind of research was this?

This was an observational study that looked at sexual activity among 1,879 heart attack patients both before their heart attack and in the following year. It also looked at whether these patients received any instructions on the subject when being discharged from hospital, and whether any information provided covered sexual activity. Finally, it looked at any association between sexual activity and mortality rates within a year of having a heart attack.

 

What did the research involve?

The study, which was part of a larger study monitoring the health of heart attack patients, began in 2007. It included 1,879 patients (1,274 men and 605 women) who were followed for a year after they had been admitted to hospital with a heart attack.

Patients included in the study were first interviewed at the bedside by trained staff within 24 to 72 hours of the event, and the details gathered were added to information from their medical records. Data collected by the interviewers included information on income and social class, depression, severity of their disease and physical functioning.

Patients who took part in the sexuality study were interviewed by telephone at one month and 12 months after being enrolled. They were asked a series of questions including whether they had been sexually active in the year before having a heart attack, and whether they had had sex since having a heart attack (asked at both one and 12 months). Those who reported being sexually active before their heart attack were also asked whether they had had sex with more, less or the same frequency afterwards. 
Patients were also asked if they had received any instructions at hospital discharge about when to resume sexual activity, and whether they had discussed sex with their doctor during the period after being in hospital.

The researchers obtained mortality data on the patients through social security records at 12 months.

They analysed the findings to assess any factors associated with “loss of sexual activity” 12 months after heart attack.

 

What were the basic results?

The study featured 1,274 men and 605 women, with average ages of 58.6 years and 61.1 years, respectively. Researchers found that:

• Forty-four per cent of women and 74% of men were sexually active in the year before hospitalisation and 40% and 68% were sexually active afterwards.
• Of these groups, 48% of men and 59% of women reported less-frequent sexual activity in the 12 months after a heart attack.
• About one in 10 patients who were sexually active before their heart attack were not active in the subsequent year.
• One-third of women and 47% of men reported receiving hospital discharge instructions about resuming sex.
• Those who did not receive instructions were more likely to report loss of sexual activity (women, adjusted relative risk 1.44, 95% confidence interval 1.16 to 1.79; men, adjusted relative risk 1.27, 95% confidence interval 1.11 to 1.46).
• One-year mortality after heart attack was similar in those who reported sexual activity in the first month after their attack (2.1%) and those who were sexually inactive (4.1%). This suggests that whether or not people are sexually active has little bearing on their risk of death following a heart attack.

The study also found that men who had discussed sex with their doctor following their heart attack were less likely to be sexually active. The researchers say this could be because men who are anxious about having sex after a heart attack may be more likely to initiate a discussion with their doctor.

While nearly half of patients who were married and sexually active received no counselling about resuming sexual activity, two-thirds of unmarried patients who were sexually active, did not receive counselling.

Other factors such as age, marital status, depression and severity of heart disease were not associated with loss of sexual activity.

 

How did the researchers interpret the results?

The researchers conclude that, although many patients were sexually active before their heart attack, only a minority received counselling about resuming sexual activity at their discharge from hospital. Lack of counselling was associated with loss of sexual activity one year later. Mortality was not significantly increased in patients who were sexually active soon after their heart attack.

They say the study indicates that counselling may be an important factor in the likelihood of being sexually active after a heart attack, and that men and women can benefit equally.

They also argue that sexually inactive older adults with chronic illness value sexuality as an important part of life and that sexual inactivity before a heart attack should not exclude patients from receiving counselling in this area. “Profiling” patients for counselling based on previous sexual activity or on marital status, they argue, will exclude some patients who could benefit from this information.

 

Conclusion

This study had a number of limitations, including its reliance on patients recalling both their sexual activity in the year following their heart attack and also whether they received advice or counselling on the topic when discharged from hospital. This reliance on patients self-reporting past events could affect the reliability of the results, particularly as they were estimating these factors in the wake of a potentially life-changing heart attack.

Also, the researchers did not objectively measure whether it was patients or staff who initiated counselling on this topic at the time of discharge. Although counselling is likely to be initiated by hospital staff, it is possible that patients who were more interested in resuming sexual activity may also have been more likely to ask for counselling.

Previous research has already established the extremely low risk of a heart attack from having sex, and this study raises a number of important issues including a possible lack of medical advice causing heart attack patients to be anxious about resuming sexual activity. This is unlikely to be good for people’s sex life or their peace of mind as they recover.

Most people value sexuality as an important part of life, whatever their health. In the UK, the current advice is that anyone who has had a heart attack should be able to have sex without risk to their heart once they are fit enough to walk briskly up two flights of stairs without getting chest pains or becoming out of breath. This is usually about four weeks after having a heart attack for most patients. Having sex will not put you at further risk of having another heart attack, although you can speak to your doctor or read NHS Choices’ guide to sex after a heart attack if you require further information.

Links To The Headlines

Sex after heart attacks 'not the preserve of Mad Men'. The Daily Telegraph, May 10 2012

It is safe to have sex with a heart condition, say doctors (as long as patients can climb a flight of stairs). Daily Mail, May 10 2012

Links To Science

Tessler Lindau S, Abramsohn E, Gosch K et al. Patterns and Loss of Sexual Activity in the Year Following Hospitalization for Acute Myocardial Infarction (a United States National Multisite Observational Study). American Journal of Cardiology, Volume 109 Issue 10 , Pages 1439-1444, May 15 2012

“A simple drawing test may help predict the risk of older men dying after a first stroke,” says BBC News. The test asks participants to draw lines between a series of ascending numbers in as short a time as possible. The aim of the test is to indicate how well their minds are working.

In a new study published this week researchers looked at whether performance in the test could predict the risk of dying after suffering a stroke. In the study, the test, known as the Trail Making Test, was given to 919 older men at the start of the research. The participants were then followed using medical records for the next 14 years. In total, 155 participants had a stroke, of whom 84 died. When researchers examined the risk of dying in relation to men's cognitive test scores they found that doing poorly on the test was associated with an increased risk of dying following a stroke. The researchers say that the Trail Making Test offers an easy-to-use option for predicting death after a stroke.

Overall, this small study suggests that the simple test may offer an additional tool for identifying individuals at high risk of death from stroke. Given that the test does not require specialised equipment or extensive training it may, in theory, be helpful when used alongside other diagnostic techniques such as brain scans. However, the mechanism that explains the predictive power of this test is still uncertain, and the idea would benefit from testing in a more diverse group.

 

Where did the story come from?

The study was carried out by researchers from Uppsala University in Sweden and was funded by Uppsala University and the Swedish Stroke Association (STROKE-Riksforbundet). The study was published in the peer-reviewed American Journal of Cardiology.

The media reported the story appropriately, with the BBC pointing out that the study was relatively small and that the underlying causes of poor performance on the test are not known.

 

What kind of research was this?

This was a prospective cohort study in which a group of men were given a cognition test. The results were then analysed to assess how they related to the participants’ risk of dying from a stroke in the years that followed.

The researchers initially recruited 919 white men who had never had a stroke and asked them to complete the Trail Making Test (TMT), a simple cognitive test that involves drawing lines between numbers and letters in ascending order as quickly as possible. Participants performed two slightly different versions, A and B (TMT-A and TMT-B). TMT-A simply involves joining up ascending numbers scattered randomly across a page, while TMT-B adds letters to the task, and involves alternating between letters and numbers in ascending order, again, as quickly as possible. Requiring a long time to complete the tests is considered to reflect impairment in movements associated with mental activity.

The participants were then followed over time to see how their performance in the TMT tests related to their risk of dying of a stroke.

A prospective cohort study is necessary to determine the predictive or prognostic ability of a test. During research of this type, researchers can require participants to complete the test while healthy, and then follow them up to assess how their health changes. In this study that means the researchers were able to assess how well the TMT-A and TMT-B test predicted the participants’ risk of future stroke.

 

What did the research involve?

The research included 919 men between the ages of 69 and 75. At the beginning of the study information was also collected on medical history, alcohol habits, demographic factors and physical health status. Participants who had had a previous stroke were excluded from entering the study. The participants then completed the TMT-A and TMT-B, and their times were recorded.

The researchers followed the men for up to 13.6 years (median follow-up 11.2 years) and, using hospital discharge records and cause of death registries, recorded:

• how many participants had a stroke during follow-up
• how many of those who had a stroke died within two and a half years of it occurring

The researchers then compared the risk of dying among stroke patients according to TMT-A and TMT-B test performances at the start of the study. To do this, they split the cohort into three groups (or tertiles), with tertile 1 comprised of the men with the best (fastest) scores on the TMT-A and TMT-B tests, tertile 2 comprised of the men with intermediate scores and tertile 3 comprised of the men who performed the worst (slowest) on the tests.

During this analysis they controlled for multiple variables that had the potential to distort or influence the relationship between test performance and death risk, including age, education, social group and health status.

 

What were the basic results?

In all, 155 (16.9%) of the participants suffered a stroke or ‘mini-stroke’ during the follow-up period. A mini-stroke, also known as a transient ischaemic attack or TIA, occurs when the blood supply to parts of the brain is momentarily restricted. The event generally lasts a few minutes and causes similar symptoms to a stroke. Although a TIA can cause lasting effects, most symptoms generally resolve within a day or so. Having a TIA can be a warning sign that a person is at risk of having a stroke in the future.

On average (median) participants were followed for 2.5 years after their first ever stroke or TIA, and during this time 84 of the 155 men who suffered a stroke or TIA died (equating to 54% of patients who had a stroke dying). Twenty-two of the deaths occurred within the first month after the stroke or TIA.

The researchers found that diabetes (Hazard Ratio [HR] 1.67, 95% CI 1.04 to 2.69) and treatment for high blood pressure (HR 1.56, 95% CI 1.02 to 2.40) at the start of the study (the baseline) were significantly related to the risk of death after first ever stroke or TIA. No other variables at baseline were significantly associated with risk of death following stroke.

The researchers first assessed the relationship between performance on the TMT-A test (involving joining numbers only) and fatal stroke. They found that, overall, for each standard deviation increase in test time (about 20 seconds), the risk of dying after a first ever stroke or TIA increased by 88% (HR 1.88, 95% CI 1.31 to 2.71).

When comparing mortality between test time groups, the researchers found that the men who performed worst on the test were nearly three times more likely to have died following a stroke than those who performed the best (HR 2.90, 95% CI 1.24 to 6.77). There was no significant increase in mortality between men in the middle group and the best performers.

The researchers then examined the association between performance in the TMT-B test (involving both letters and numbers) and mortality after a stroke. They found that a standard deviation increase in test time (about 45 seconds) was associated with a significantly increased risk of mortality after a stroke (HR 2.01, 95% CI 1.28 to 3.15).

Compared with the fastest test performers, the slowest group were more than three times more likely to have died after a stroke (HR 3.53, 95% CI 1.21 to 10.34). Once again, there was no significant difference in mortality between the middle group and the fastest group.

 

How did the researchers interpret the results?

The researchers conclude that levels of cognitive functioning before a stroke, assessed using a simple test, predicted survival following a stroke in a sample of elderly men.

 

Conclusion

This study suggests that the results of a relatively simple test given at age 70 could predict the likelihood of dying after a stroke. This particular study did not, however, assess whether or not the TMT-A or TMT-B could itself predict the likelihood of having a stroke, as some internet coverage has suggested.

At present there are many risk factors that are used to identify individuals at an increased risk of having a stroke, including age, family history, ethnicity and medical history, as well as lifestyle factors such as smoking, excessive alcohol consumption and diet. This research suggests that the Trail Making Test may be useful for predicting outcomes after a stroke, although this particular paper did not provide data on the test’s ability to predict who will have a stroke in the first place. That said, the researchers highlight that previous research has shown that the TMT-B is also useful for predicting stroke in elderly men.

The study did have several strengths that allow us to be fairly confident in its results. First, the researchers were able to follow up on all of the study participants, which limits the likelihood of people dropping out of the study, biasing the results. Second, both the TMT test and the outcome of interest (death following a first stroke) were measured in a consistent manner across all the participants, and important potential confounders were accounted for in the data analysis.

The study sample was, however, not completely representative of the people that are likely to take such a test. While the age range of the sample is likely to be similar to that of patients who would be given this test, all of the study participants were white men. It is unclear whether the same or similar results would be seen in women or other ethnicities.

Also, as a test of observation and manual dexterity the TMT test may not be suitable for people with certain conditions such as sight problems or joint problems, which may hinder performance in the test. These are generally more prevalent among older people, who also have a greater risk of stroke, further complicating the issue.

The mechanism underlying this association is unclear, the researchers point out that having dementia before a stroke is known to be a predictor for stroke severity and death from stroke. So it is possible that this cognitive test is identifying early cases of sub-clinical dementia. This theory will, however, need further research.

Analysis by Bazian

Links To The Headlines

Strokes: Drawing test 'may predict risks in older men'. BBC News, May 9 2012

Links To Science

Wiberg B, Kilander L, Sundström J et al. The relationship between executive dysfunction and post-stroke mortality: a population-based cohort study. BMJ Open 2012;2:e000458

“The coil is a much more effective form of emergency contraception than the morning-after pill,” the Metro has reported. The coil, medically known as an intrauterine device or IUD, is often used as a form of long-term contraception, but it can also be implanted after sex to provide emergency protection against pregnancy.

IUDs are in the news as researchers have today published findings on how effectively they prevent pregnancy in women who have them implanted after unprotected sex. Drawing on data from 43 previous studies, the review found women who had an IUD fitted after having unprotected sex had a pregnancy rate of 0.09% – the equivalent of less than 1 pregnancy out of every 1,000 IUDs inserted. Another way of saying this is that 99.91% of women who used an IUD as emergency contraception did not become pregnant.

The study was mainly based on findings relating to IUDs containing copper, rather than all-plastic devices, and the data came largely from Chinese studies. As a consequence, the results may not reflect the effectiveness of other types of coil or use of the IUD in the UK. Also, the research did not directly compare the coil to the effectiveness of emergency contraceptive pills, or examine how easily women could obtain an emergency coil following unprotected sex. These will both be important factors for women deciding which option to use.

 

Where did the story come from?

The study was led by researchers from the University of Princeton USA in collaboration with researchers based in South Africa, China and the UK. It was funded by a grant from Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the researchers declared that they had no conflicts of interest.

The study was published in the peer-reviewed medical journal Human Reproduction.

Some news coverage of this research suggested women should “forget morning-after pills” as a form of emergency contraception, which is somewhat irresponsible as they remain an effective form of emergency contraception for some women. Also, emergency contraceptive pills may be a more practical and accessible option at times.

Women seeking emergency contraception should be informed about the full range of options available to them to help them make a decision about the most appropriate method for them.

 

What kind of research was this?

This research was a systematic review investigating how effective intrauterine devices are at preventing pregnancy when used for emergency contraception.

An intrauterine device (IUD) or ‘the coil’ is a form of birth control that is placed in the uterus of a woman to prevent pregnancy. An IUD is made of copper and plastic and works by physically preventing sperm from fertilising the egg. They can also prevent any fertilised eggs from implanting in the womb. Some devices, known as intrauterine systems, also release hormones that prevent fertilisation, but these were not included in this review and are not recommended for emergency contraception.

A systematic review seeks to identify and summarise all known literature published on a specific topic. It is an effective way of summarising a large body of research to answer a specific research question.

It should also be noted that the study did not directly compare the use of IUDs with the use of the morning after pill, nor did it compare how easily women could access either option after unprotected sex. This means we cannot tell which is a more viable option for women seeking emergency contraception, or say that one is intrinsically ‘better’ than the other based on the study’s results alone.

 

What did the research involve?

The researchers performed searches of research databases to gather all relevant published studies on women being given an IUD after seeking emergency contraception.

Studies were only included if clear information was available on whether the emergency contraception was effective and whether or not the women became pregnant. Only studies published in English or Chinese were included. The authors state that research published in Chinese was included because there is a high volume of contraceptive research taking place in China.

Those studies that met the inclusion criteria were analysed in more detail and data were extracted from them by two reviewers working independently of one another, which is intended to reduce errors and bias during data selection. The authors then described the results from the individual studies.

The researchers then used a simple method to pool the results of the different studies. During this process they combined the number of women seeking contraception and the number who became pregnant from across all the studies, which was intended to estimate the overall effectiveness of IUDs at preventing pregnancy.

 

What were the basic results?

The researchers included 42 studies that provided data on the effectiveness of IUDs in women seeking emergency contraception. These represented studies conducted in six countries between 1979 and 2011, and included 7,034 women using eight different types of IUD. Nearly all the IUDs were devices containing small amounts of copper, and only a small number of plastic-only IUDs were included, in the older pre-1985 studies. Most of the study data came from research based in China.

The main finding was that, out of the total 7,034 IUD insertions after unprotected sex, there were 10 recorded pregnancies. This gave a combined IUD failure rate (failure to prevent pregnancy) of 0.14% (95% CI 0.08 to 0.25%).

The authors commented that a study in Egypt gave a “surprisingly high” failure rate of 2%, which was vastly different from all the other studies. If this single atypical study was excluded the combined failure rate of using an IUD fell to 0.09% (95%CI 0.04 to 0.19%).

This rate means that less than one woman in every 1,000 would fall pregnant using the IUD as an emergency contraceptive. Another way of saying this is that 99.91% of women who used an IUD as emergency contraception did not become pregnant.

The maximum length of time from intercourse to IUD insertion ranged from two days to 10 or more days. Most of the insertions (74% of the studies) occurred within five days of intercourse. However, the studies did not include sufficient detail about the delay between intercourse and insertion of IUD for the researchers to analyse accurately how the effectiveness of the IUD was affected by any delay.

 

How did the researchers interpret the results?

The researchers conclude that “IUDs are a highly effective method of emergency contraception, with a failure rate of less than one per thousand”.

In discussing the different types of IUD they concluded that use of a copper IUD “is by far the most effective emergency contraception option” compared with the non-copper alternatives.

 

Conclusion

This systematic review of IUD use in emergency contraception provides useful estimates of pregnancy rates following insertion after unprotected sex. To assess the issue it drew upon studies in several different countries, although the studies were primarily carried out in China. The results of the study suggest that IUDs are a highly effective form of emergency contraception, with a very low failure rate of around 0.09%.

It should be noted that the research primarily estimates how likely it is that a woman would become pregnant after having unprotected sex and having an IUD fitted. It does not, however, tell us important related factors such as how available IUDs are after unprotected sex, nor does it confirm that they are necessarily a better option than emergency contraceptive pills. For example, women can obtain emergency contraceptive pills from specially trained pharmacists, whereas an IUD needs to be fitted by a trained clinician. This is not to say that either is better or more practical, rather that there are particular considerations to take into account with each form or contraception beyond overall failure rate.

The research also has some limitations, which should be considered when interpreting the results. For example, most of the results included in the review related to the copper coil and some were older devices, so the overall failure rate of 0.09% may not accurately represent the failure rate of newer IUDs or ones that contain hormones (known as intrauterine systems). More data on these devices are needed to establish whether they have a similar failure rate leading to pregnancy as the copper options included in the review. Similarly, most of the data feeding into the 0.09% figure come from studies based in China. Hence, this overall estimate best reflects copper IUD use in Chinese women. The effectiveness in other countries and for other IUDs is less certain based on this study alone.

Also, the research originally set out to assess the effectiveness of IUDs in detail so the researchers could see how many days had elapsed between unprotected sex and insertion of the IUD. However, the studies they identified did not contain sufficient detail for this to be possible. Hence, the combined IUD failure rate represents all cases together regardless of the time between intercourse and insertion of IUD. It is likely that the time between unprotected sex and insertion of the IUD directly influences the effectiveness of the contraceptive device, but this review was unable to analyse this. The recommended maximum interval after unprotected sex is 120 hours (five days) for most currently marketed devices.

As research was restricted to studies published in English or Chinese, this will exclude potentially informative research in other languages. The results of these excluded studies may have influenced the conclusions of this review had they been included.

When discussing their research the authors highlight recent studies exploring attitudes towards IUDs, which identified several potential barriers to a greater use of IUDs as emergency contraception. These included the waiting time (not being able to get a coil on the day emergency contraception is requested), low levels of awareness and understanding among patients, and a lack of understanding among healthcare providers. The results of this study, which show that IUDs are a highly effective option, may renew efforts to increase awareness of IUDs as an emergency contraceptive option. On this note, a spokeswoman for the Family Planning Association is quoted in the Metro as calling for more women to be offered the IUD routinely as a method of contraception.

The Metro’s headline suggesting that women should “forget morning-after pills” is somewhat irresponsible, as morning after pills remain an acceptable and effective method of emergency contraception for some women. A previous systematic review carried out by the Cochrane collaboration in 2008 concluded that drugs (such as the morning after pill) and copper IUDs were both effective and safe methods of emergency contraception.

The risks of sexually transmitted diseases associated with unprotected sex are well known and the coil, whether used as a standard contraceptive or an emergency contraceptive, does not reduce these risks.

Analysis by Bazian

Links To The Headlines

Forget morning-after pills, the coil is far more reliable. Metro, May 9 2012

Coil 'could be a more effective form of emergency contraception than the Morning-after pill'. Daily Mail, May 9 2012

Links To Science

Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Human Reproduction, Published online May 8 2012

It's normal for babies to develop skin rashes, but it's important to know the difference between a minor irritation and a condition that requires attention. Use this visual guide to familiarise yourself with everything from nappy rash and eczema to impetigo and meningitis.

Teen aggression and arguments

Many parents find that when their child becomes a teenager, their behaviour becomes more challenging. But how do you cope if they become aggressive or even violent towards you?

Find out how to cope with heated arguments with your teen, and what to do if they become violent.

If you’re experiencing aggression or violence from your teen, you’re not alone. A recent Parentline Plus survey found that 60% of calls (between October 2007 and June 2008) included verbal aggression from a teenager, and 30% involved physical aggression, much of it aimed at the parent themselves.

It is common to keep this kind of abuse behind closed doors and not confide in anyone. Many parents feel  that they have failed to control their child, or that they are responsible for the behaviour in some way. In addition, they may not know where to turn. However, any kind of aggression can be stressful, and can cause an atmosphere of tension and fear for the entire family, not to mention the possibility of physical harm if their teen becomes violent. No parent should feel obliged to put up with an unruly teen, and as with any type of domestic abuse, help and support is available. You can find appropriate organisations and helpline numbers in ‘Help and support’ below. There are also a number of techniques and tips that you might find helpful.

Defusing heated arguments

It’s useful to remember that your own behaviour can improve or worsen an aggressive situation, so it’s important to be a good role model for your teen.

Linda Blair, clinical psychologist working with families, advises: “Bear in mind that you are their principal role model. If you act aggressively but tell them not to, they won’t listen. It’s also helpful to remember that their anger is often based on fear – fear that they’re losing control.”

With that in mind, it is worth trying to maintain a calm and peaceful presence. You need to be strong without being threatening. Remember that your body language, as well as what you say and how you say it, should also reflect this. Avoid staring them in the eye, and give them personal space. Allow them the opportunity to express their point of view, then respond in a reasoned way.

If an argument becomes very heated, Linda suggests that you “stop for a moment". Take a deep breath, hold it for a few seconds and then exhale. Repeat five times. This technique is very useful in intense situations. If your teen is becoming aggressive during arguments, suggest this technique to them when they’re calm, so they too have a way of controlling their anger.

If an argument feels out of control, you can also try explaining to them that you are going to walk away, and that you’ll come back again in half an hour. Given the chance to reflect and calm down, you and your teen will both be more reasonable when you resume your discussion.

As with toddlers, if you give in to teenagers because their shouting and screaming intimidates or baffles you, you are in effect encouraging them to repeat the unreasonable behaviour as a way of getting what they want.

Family Lives is a charity dedicated to helping families. They suggest that if very heated arguments happen frequently, it may be worth suggesting counselling to your teen. They’ll benefit from talking to someone new and unbiased, someone who isn’t in their family and who won’t judge them. Remember they may not know how to handle their anger, and this can leave them frustrated and even frightened. Some guidance from an outsider can be very helpful.

Dealing with violent behaviour

Sometimes, teen aggression can turn into violence. If they lash out at you, or someone or something else, put safety first. Let your teenager know that violence is unacceptable and you will walk away from them until they’ve calmed down. If leaving the room or house isn’t helping, call the police – after all, if you feel threatened or scared, then you have the right to protect yourself.

Family Lives offer this advice for coping with, and helping, a violent teen:

• Give them space – once they have calmed down, you may want to talk to them about what has happened and suggest that they let you find them some help.
• Be clear – teenagers need to know that you will stand by the boundaries you set. They need to know that any kind of violence is unacceptable.
• Talk to their school and find out if their aggressive behaviour is happening there as well. Some schools offer counselling.
• Arrange counselling – if your teen admits they have a problem and is willing to get help, book an appointment with a counsellor or psychologist as soon as possible. Speak to your GP or their school about what help is available.

Help and support

There are many organisations that offer emotional support and practical advice. Getting some support can help you and your child. At such an important development stage, it’s important that they learn how to communicate well and express anger in a healthy way.

• You can call Family Lives' Parentline on 0800 800 2222 any time, or email for a personalised reply within three days. They also offer i-parent modules to help you learn more about communicating better with your teen.
• You can call the Samaritans on 08457 909090 any time to talk about any type of distress and to get confidential support and advice.
• The Family Safe Project is run by Gingerbread and aims to support single parents whose children display challenging, violent or aggressive behaviour. Parents are offered three telephone support sessions to help them handle these most difficult of behaviours more effectively. Call 0808 802 0925 for more information.
• Youth Access has details about youth organisations and services offering teens counselling, advice and support.
• Young Minds is a charitable organisation supporting children and young people with mental health issues, and their parents. They provide information to help young people with anger issues. If you discuss your child’s behaviour with them and they are open to getting help, you might like to direct them to the information on the Young Minds website.

Concerned about mental health issues?

If you’re worried that your teen has a mental health problem such as depression, talk to your GP. He or she can refer them to the Child and Adolescent Mental Health Services, who in turn can refer all or some of you for Family Therapy. Or contact the Young Minds Parents’ Helpline on 0808 802 5544 for advice and support concerning mental health issues in young people.

If you are having trouble coping with your teenager, and you suspect you may have symptoms of depression or other mental health problems, discuss this with your GP. He or she can then suggest suitable treatment. You may, for example, be referred for counselling, or directed to support groups or other services in your area.

Worried about your teenager?

Are you worried about your teenager? Many parents find that their children act differently during the teenage years.

It is common to worry that they may be affected by mental health issues such as depression or eating disorders, or be involved in risky behaviour such as taking drugs, abusing alcohol, having unprotected sex, or committing crimes.

Normal teenage behaviour or something more serious?

Teenage behaviour can be erratic and upredictable, so it can difficult to distinguish when they are just ‘being a teenager’ and when something more serious is going on. But, as a parent, there are certain warning signs to look out for.

Linda Blair, clinical psychologist, advises: “As a parent what you can do is look out for unexpected and persisting changes. Have they changed in any way that is particularly out of character for them? For example, if your teenager is usually very sociable – and  he or she withdraws socially to a large degree – there could be a problem. If they’re normally very chatty and they become completely uncommunicative, it may be worth exploring whether it’s due to more than just teenage angst.”

Encourage them to talk

Most teenagers  become moody and uncommunicative from time to time. This is often due to hormonal changes, which make the teenage years an emotional time. Many teenagers haven’t yet developed the skills to talk about emotions, so communication becomes very difficult. Teenagers also have to go through a process of setting themselves physically and emotionally apart from their parents.

However, if you’re worried about them, you may be able to encourage them to open up. Direct questioning can make them feel very threatened, so a more subtle approach is more effective.

Linda Blair suggests: “If you’re having trouble getting them to open up to you, be available to them as much as possible. Take every opportunity to be there for them at times when they feel comfortable talking freely. A great example is to provide a taxi service – being in the car is a non-threatening situation for them because you’re not looking at one another. Have meals together whenever you can – perhaps take them out for a pizza, for example.

If they refuse to talk to you and you are worried that something more serious is going on, you may need to open up other channels of communication for them. Be honest and explain that you’re worried that they’re going through something difficult, and if they can’t talk to you, that’s fine, but they should talk to someone. Try offering helpline numbers, or suggesting a GP or a friend of the family.

Allowing them to make a decision about how and where to seek help can also be beneficial. Linda explains: “If you’re very worried, whether about drugs or an eating disorder, you can try  offering them what’s known as a ‘forced choice decision’. Present them with two choices, both of which represent a positive step. For example, suggest they talk either to your GP or to a named family friend. That way, they feel more in control.

Spotting the signs

Many of the symptoms listed below can often be attributed to normal teenage behaviour. However, if you’re worried, it can be helpful to know the signs of a possible problem. You may then choose to discuss your concerns with your teen, or get advice from your GP.

Depression in teenagers

Noticeable symptoms of depression in teenagers can include:

• continuous low mood or sadness
• voicing/showing feelings of hopelessness and helplessness
• frequent tearfulness
• being irritable and intolerant of others
• apparent lack of energy or motivation, and little or no enjoyment of things that were once interesting to them
• slowed movement or speech
• changes in appetite or weight (usually decreased, but sometimes increased)
• frequent unexplained aches and pains
• disturbed sleep patterns (for example, problems going to sleep and/or waking throughout the night, particularly in the early hours of the morning)
• losing interest or being disruptive at school or playing truant
• constantly complaining that they feel bored or lonely

Read more about depression.

Teenage eating disorders

The most common eating disorders include anorexia, bulimia and binge eating. Signs of eating disorders can include:

• having a preoccupation and concern about food and gaining weight
• a desire to lose weight even though their friends or other family members worry that they’re underweight
• letting people around them think they have eaten when they haven’t
• being secretive about their eating habits
• becoming anxious, upset or guilty when asked to eat
• vomiting, or using laxatives in order to lose weight

Read more about eating disorders.

Get advice if you have a child with an eating disorder.

Self-harming teenagers

people who self-harm usually try to keep it a secret from their friends and family and often injure themselves in places that can be hidden easily by clothing.

if you suspect that your teenager is self-harming, look out for any of the following signs:

• unexplained cuts, bruises or cigarette burns, usually on their wrists, arms, thighs and chest
• keeping themselves fully covered at all times, even in hot weather
• signs of depression, such as low mood, tearfulness, a lack of motivation or lack of interest in everything
• changes in eating habits or being secretive about eating, and any unusual weight loss or weight gain
• signs of low self-esteem, such as blaming themselves for any problems or thinking they are not good enough
• signs they have been pulling out their hair
• signs of alcohol or drug misuse

Read more about self-harm.

Teenagers who take drugs

signs that your teenager is taking drugs can include:

• losing interest in hobbies, sports or other favourite activities
• losing interest in their appearance or personal hygiene
• dramatic changes in behaviour
• suddenly forming an almost totally new group of friends
• excessive tiredness and lack of appetite
• playing truant from school
• dilated pupils, red eyes, bad skin
• spending an increased amount of money, coupled with a refusal to explain why
• stealing money from you

Finding any of the following items in their room or in the house, could indicate that they are using drugs:

• pipes
• rolling papers
• small medicine bottles
• eye drops
• butane lighters
• homemade 'bongs' (pipes that use water as a filter) made from tin cans or plastic drinks bottles
• scorched tinfoil
• razor blades
• syringes

Find out more about drug use and getting help.

Coping with your teenager

Many parents feel stressed by their teenager’s behaviour, and worry about whether it is normal. We look at what changes children go through in their teenage years, and how to deal with the effects of bad teenage behaviour.

They say being a parent is the toughest job in the world. For some, it can certainly feel that way during the teenage years.

Teenage behaviour

Teenagers' behaviour can be baffling, stressful, hurtful and often worrying. But in most cases it doesn't mean that there is anything more serious going on than the natural process of becoming an adult.

Many of the common behaviour issues that parents find hard are an essential part of puberty and growing up.

Surges of hormones, combined with body changes, struggling to find an identity, pressures from friends and a developing sense of independence, means the teenage years are a confusing time for your child. It can mean that they, for example, become aloof, want more time alone or with friends, feel misunderstood, reject your attempts to talk or show affection, or appear sullen and moody.

These changes in personality may be natural, but it doesn't mean as a parent you don't feel hurt and worried by them.

Your feelings about your teen’s behaviour

Teenagers can challenge even the calmest of parents. When you have further pressures in your life, such as other children, work, relationships, family commitments, illness, it can feel as though your teenager is going to push you over the edge.

Try to step back from the situation, and remember that they have physiological reasons for behaving in the ways that are so difficult to live with. They’re probably not enjoying it either. You’re the adult, and it is your responsibility to guide them through the difficult times. Don’t expect to enjoy your time with them all of the time, and remember to look after yourself.

If you’re feeling rejected because your teenager is keeping a distance, remember that forming strong friendships outside of the family is an important part of growing up. Try not to be offended. Try turning to your own friends, partner or family for support when it’s hard.

How do I cope with the stress?

Young Minds, a mental health charity, advises that an effective way of coping with a troublesome teenager is to start by looking after yourself. For example:

• Get a good night’s sleep.
• Eat healthily.
• Make sure you get time to relax and have a break from your children.
• Get regular exercise.
• Talk to friends, partner, external help, support group.
• Learn techniques for coping with stress and know the signs of depression or anxiety. If you’re concerned that you’re depressed, anxious or stressed, talk to your GP.

How should I act with my teenager?

Be calm and consistent

Linda Blair, a clinical psychologist who works with families, explains that: “Teenagers can be largely emotional rather than logical because of the hormones rampaging through their bodies. It is not necessarily pleasant for them, and it can even feel frightening. Although it might be hard for you, they need you to maintain a calm consistent presence.”

Remember that you are a role model for your teenager

Linda says: “If they see you smoking, drinking, taking drugs, they will see that as a green light to do the same themselves. And they won’t listen to you if you tell them not to do it.”

Don’t bottle up your concerns

If you’re worried that your teenage son or daughter might be having unprotected sex, for example, don't assume they know the facts. Don’t, however, challenge them. Instead, simply offer them information, such a leaflet or website URL, to make sure they know the risks and how to be safe.

Give them your time

Make sure you allow them the time to be with you and talk to you when it seems right for them. And make sure you listen when they do want to talk. For example, offer a lift when they need to go somewhere – car journeys are a good time for talking.

Offer some time alone

Allow them to have their own space and privacy.

Show them love

Even if they don’t seem responsive, they do need to know you love them.

Set boundaries

Boundaries allow teenagers to feel safe. Decide what the limits are and then stick to them.

A collection of real tips from real carers, on healthcare, personal hygiene, communication, behaviour and routine. These tips were provided by Netbuddy, a site for swapping practical tips and information on all aspects of supporting people with learning difficulties.

What to do if you relapse after quitting smoking

Many people who quit smoking relapse at some point. Don’t be put off trying again. The key is to learn from what went wrong so you’re more likely to succeed next time.

If you're tempted to start smoking again, call the free NHS Smokefree helpline on 0800 022 4332 to get support from a trained adviser

When you quit smoking, it’s important to be positive and really believe that you’ll be successful. You shouldn’t expect to start smoking again.

But some people who try to quit will return to smoking the way they did before, usually in the first few months.

If you do relapse, don't worry, it can take a few tries to quit smoking for good. That's not to say you shouldn't take relapse seriously – but don't be too hard on yourself either.

The more times you try to quit, the better your chances of success. So, look on a relapse as ‘practice’ for stopping smoking.

Preventing relapse

Why is it that some smokers who quit fall off the wagon?

The main reason is giving in to cravings. These are powerful urges to smoke, often triggered by stress, seeing other people smoking, getting drunk or emotional events such as arguments.

The best way to withstand cravings is a combination of stop smoking medicines and behavioural changes.

It’s also important to stay away from people who smoke. Nearly three quarters of all quitters who relapse do so in the presence of people who are smoking – usually after having asked one of them for a cigarette!

Get practical advice on how to relieve cravings.

Help for relapse

The risk of relapse is highest in the first few weeks after quitting. However, some people can relapse several months, or even years, after stopping smoking

Avoiding a relapse is best, but if you do yield to temptation, don’t despair – it can take several tries to quit smoking for good. You've tried before and this experience can help you now.

If you’ve had a cigarette or two:

• Don’t give up on quitting. You can still avoid a full relapse. Throw the rest of the packet away and continue your quit attempt.
• Remind yourself why you want to quit. Then take control again.
• Get support. Call the free NHS Smokefree helpline on 0800 022 4332 to speak to a trained adviser. Lines are open Monday-Friday 9am-8pm and Saturday & Sunday 11am-5pm.
• Make it hard to smoke. Avoid places where you can easily ask someone for a cigarette. And don’t buy a packet.
• Stay strong. If you’re tempted to smoke again, force yourself to wait two hours. Then decide if you really need the cigarette.
• Keep taking any prescribed stop smoking medicine or using NRT unless you go back to regular smoking. It can help you get back on track.

If you’ve relapsed and are back to regular smoking:

• Don’t become despondent. Set a new quit date, maybe in a week or so.
• Learn from your mistakes. What caused you to slip up? Think of ways you could have avoided smoking. Work on your coping skills so you’re prepared next time you’re in the same situation.
• Talk to your doctor or NHS Stop Smoking Adviser if you need more help to cope with cravings in your next quit attempt. Read how an NHS Stop Smoking Adviser can help you quit.
• Stay positive. You’re learning how to quit cigarettes. Remember, you’ll be stronger next time because you’ll know what to look out for.

Use our stop smoking tool to get daily tips for success.

Common quit smoking questions

Read the answers to common questions about stopping smoking, including: 

• Why should I stop smoking if I’m pregnant?
• Who can use nicotine replacement therapy?
• Where can I get help to stop smoking?

Women diagnosed with cervical cancer through a smear test “have a far better chance of being cured than women who do not go for tests,” BBC News has today reported.

The news is based on Swedish research that looked at 1,230 women diagnosed with cervical cancer, examining patterns between how their disease was detected and how likely it was they would be cured and survive. Following them for an average of 8.5 years after diagnosis, it found that the cure rate was 92% among those whose cancer was detected through cervical screening and 66% among those who were diagnosed after they developed symptoms. Of note, they found a lower chance of being cured among women with symptoms who were overdue for screening.

These findings are perhaps unsurprising, as women who have developed cancer symptoms generally would be expected to have a more advanced stage of cancer than women whose cancer is detected at screening and is not yet causing them symptoms. As such, women identified through symptoms, rather than screening, may be expected to have a lower chance of being cured. The study’s results support the value of the UK’s current cervical screening programme and the importance of attending screening.

 

Where did the story come from?

The study was carried out by researchers from Uppsala University, the County Council of Gävleborg and other institutions in Sweden. Funding was provided by grants from the Swedish Cancer Society, the Swedish Foundation for Strategic Research, the Gävle Cancer Fund, and the Centre for Research and Development, Uppsala University and the County Council of Gävleborg. The study was published in the peer-reviewed British Medical Journal.

News coverage has reflected the findings of this research.

 

What kind of research was this?

This was a nationwide population-based cohort study looking at whether detection of cervical cancer through screening improves cancer cure and survival rates. Cure rates are of particular interest as it has been suggested that cervical screening may have the apparent effect of prolonging survival times simply because the cancer is detected at an earlier stage than it otherwise would have been (i.e. screening could cause women to just live for longer with a diagnosis of cancer). If screening actually improves cure rates this would be an important finding (though arguably this could still be just because being diagnosed at an earlier stage the cancer is more likely to be curable).

Using a cohort study to answer this question has some limitations, as the outcomes in a cohort study may be influenced by other health and lifestyle differences between those women who chose to attend screening and those who did not. These differences may be the cause of any relationship seen, meaning in this case we cannot be certain that screening is the only factor affecting survival rates.

Ideally this sort of question would be addressed using a randomised controlled trial that randomised people into different screening practices and then followed them up over time looking at cancer outcomes and cure rates. However, as cervical screening is already offered in countries such as Sweden and the UK, carrying out a randomised trial that withheld cervical screening would not be considered ethical.

 

What did the research involve?

The Swedish cervical screening programme invites women for screening every three years among those aged 23-50, and every five years for women aged 51-60. In the UK it is every three years between 25 and 49, and every five years between 50 and 64.

The current study linked all women with cervical cancer in Sweden diagnosed between 1999 and 2001 to the national Swedish causes of death register.  The researchers then followed the women to the end of 2006 to check survival in the years following diagnosis.

The researchers analysed women separately according to their age at diagnosis (23-65 years old), including those with a diagnosis more than five years beyond the last invitation to screening (66 years or above). Screening-detected cancers were defined as cancers in women who had an abnormal smear test result recorded between one and six months prior to their diagnosis. The remaining women who did not have an abnormal smear test between one and six months prior to their diagnosis were classed as having had a ‘symptomatic diagnosis’, i.e. a diagnosis based on detectable symptoms rather than screening. Abnormal smear tests taken within one month of diagnosis were also not considered to be screen-detected, as it was considered this might have been part of the diagnostic assessment in women with symptoms of cancer.

The researchers also looked at women with symptomatic cancer who were diagnosed more than six months after their last smear test and outside of the recommended screening interval of 3.5 years if they were under the age of 54; or an interval of 5.5 years if they were 55 or over. These women were considered to be overdue for having their screening test and were compared with women who were not overdue their screening test when they were diagnosed symptomatically.

The outcomes examined were survival rates (survival in the cohort compared with expected survival in the general female population); and ‘statistical cure’ rates (defined as the women no longer experiencing any greater risk of death compared with the general female population).

 

What were the basic results?

This cohort of 1,230 women was followed for an average of 8.5 years after diagnosis of cervical cancer. Five years after their diagnoses 440 of the women had died, 373 of these deaths were recorded as being due to cervical cancer (31 died from other cancers, and 36 from a non-cancer cause).

The proportion for women with screen-detected cancer who survived for at least five years was 95% (95% confidence interval [CI] 92 to 97%), whereas for women with symptomatic cancers it was 69% (95% CI 65 to 73%). The cure rate for screen-detected cancers was 92% (95% CI 75 to 98%) compared with 66% (95% CI 62 to 70%) for symptomatic cancers. This 26% difference in cure rate was statistically significant. 

Among women with symptomatic cancers, the proportion cured was significantly lower among those overdue for screening compared to those who had been last screened within the recommended interval (difference in cure 14%, 95% CI 6 to 23%).

Cure proportions were related to the stage of the cancer at the time of diagnosis, but even after taking into account stage at diagnosis, cure rates still remained higher among screen-detected cancers than symptomatic cancers.

 

How did the researchers interpret the results?

The researchers conclude that screening is associated with improved rates of curing cervical cancer. They note that they cannot rule out the possibility that factors other than screening may have contributed to the differences they observed. They also said that using cure as an outcome removes the problem of ‘lead time bias’ that occurs when looking at length of survival as an outcome of screening (discussed in the conclusion section below).

They recommend that further evaluations of cervical screening programmes should consider using a similar approach of looking at the proportions of women with cancer who are cured.

 

Conclusion

As the researchers discuss, women with cervical cancers detected by screening are known to have an improved chance of surviving their cancer. The study’s apparent improvement in survival outcome may be partly due to a phenomenon known as ‘lead time bias’, meaning that women diagnosed through screening are simply diagnosed at an earlier stage than they would have been if they waited for symptoms to develop. That is to say, that they might not live any longer, just live for longer knowing they had cancer, having detected it at a point before outward symptoms appear. This cohort study aimed to see whether screening improves cure rates, which the researchers hoped would avoid this problem.

A cohort study isn’t the best type of study design to assess the effect of a screening or therapeutic practice against disease outcome, as in a cohort there may be other health and lifestyle differences between women who chose to attend screening or not. The researchers themselves acknowledge that the possibility of such confounding cannot be ruled out. A more reliable way to assess this question would be a randomised controlled trial that randomly assigned women different screening practices and then followed them up over time looking at cancer outcomes and cure rates. However, as cervical screening is already offered in countries such as Sweden and the UK, blocking women access to cervical screening would not be considered ethical, and such a study is highly unlikely to be approved.

These findings are perhaps unsurprising. Women who have developed cancer symptoms are likely to have a more advanced stage of cancer than women whose cancer was detected incidentally through screening. As such, symptomatic women may have a lower chance of cure than women detected at an earlier stage. The fact that there was a lower chance of cure among symptomatic women who were overdue for screening further supports this.

However, the researchers’ further analyses suggested that this was not simply a case of the cancers being diagnosed at an early stage: though cure rate was related to cancer stage, taking into account stage at diagnosis did not remove the difference in cure rates between screen-detected and symptomatic-detected women. The reasons for this cannot be explained by this study, and as the researchers conclude, further evaluations of the benefit of cervical screening programmes should consider looking at cure proportions.

The UK has a slightly different schedule for cervical screening than Sweden, where this study was carried out. The Swedish cervical screening programme invites women for screening every three years among those aged 23-50, and every five years for women aged 51-60, while in the UK it is three-yearly between 25 and 49, and five-yearly between 50 and 64. This and other differences between the countries may mean that the results may not be representative of the UK. However, they generally appear to support the value of cervical screening programmes and the importance of women attending such screenings.

Analysis by Bazian

Links To The Headlines

Smear tests raise chances of beating cervical cancer to 9 in 10. The Daily Telegraph, March 2 2012

Smear tests 'boost cure chances'. March 2 2012

Links To Science

Andrae B, Andersson TML, Lambert PC et al. Screening and cervical cancer cure: population based cohort study. BMJ 2012; 344

“Babies born just a few weeks early have a higher risk of poor health,” The Guardian reported today. According to the newspaper, new research has found that being born just a few weeks early can raise their risk of conditions such as asthma.

It is already known that babies born prematurely (before 37 weeks of pregnancy) may have a higher risk of immediate or longer-term health problems, and the earlier a baby is born, the higher the risk. To examine the issue researchers followed the health of over 14,000 children born between 2000 and 2002, and examined their health at the ages of three and five years old. Outcomes including growth, hospital admissions, use of medication, asthma and long-standing illnesses were looked at particularly in relation to whether the children were moderately premature (32-36 weeks of pregnancy) or born at what the researchers called “early” full term (37-38 weeks). Babies born moderately prematurely or at early term were more likely to have been re-admitted to hospital in the first few months of life than babies born at 39-41 weeks. Babies born moderately prematurely also had a higher risk of asthma symptoms than full-term babies.

These findings are broadly in line with what is already known about the effects of prematurity, and do not change the UK’s current definition of full-term pregnancy as 37 weeks and over. However, the study does show how different degrees of prematurely may affect health. Further study of the issue would be valuable, to explore longer-term health outcomes that may be caused by prematurity and the factors that may influence the likelihood of these poor health outcomes.

 

Where did the story come from?

The study was carried out by researchers from the University of Leicester and other UK institutions. It was funded by the Bupa Foundation and published in the peer-reviewed British Medical Journal.

The media generally covered this research in a balanced way.

 

What kind of research was this?

In the UK, the normal length of a pregnancy is classed as 37 weeks or above. It is already known that babies born prematurely (before 37 weeks) may be at increased risk of immediate and longer-term health problems, and that the risks are higher the earlier a baby is born. However, the authors say that there has been minimal research into the longer-term health outcomes of infants specifically born moderately preterm (which this study defines as 32-36 weeks) and at what the researchers termed as ‘early full term’ (37-38 weeks).

To investigate this, the researchers used a cohort study. This is a good way to follow up and compare health outcomes in groups of people that have been exposed to different factors. In this case, the exposure was the number of weeks of pregnancy at which the babies were born. However, a cohort study that looks at a group’s health relies on the accuracy of reported health outcomes and diagnoses. For example, one condition this study looked at was asthma, and the researchers asked parents about whether their child had wheezing symptom or asthma. However, this does not necessarily equate to a medical diagnosis of asthma.

This type of study also needs to take into account potential factors that could be related to both risk of prematurity and risk of the health outcome. For example, parental smoking is linked to an increase risk of prematurity, and also to an increased risk of asthma in the child.

 

What did the research involve?

This study involved participants of the Millennium Cohort Study (MCS), a piece of research in which the subjects were gathered by random sampling of child benefit registers. It featured 18,818 infants born in the UK between 2000 and 2002. The number of weeks of pregnancy at birth was calculated from the mother’s report of her expected due date. Births were grouped into:

• very preterm (defined by the authors as 23-31 weeks)
• moderate preterm (32-33 weeks)
• late preterm (34-36 weeks)
• early term (37-38 weeks)
• full term (39-41 weeks)

These are not the standard accepted definitions. For example, the charity BLISS, for “babies born too soon”, defines full-term pregnancy as 37 weeks or more, moderately premature as 35-37 weeks, very premature as 29-34 weeks, and extremely premature as birth before 29 weeks.

Child health outcomes were monitored over five years of follow-up. Outcomes assessed included:

• child height, weight and body mass index at three and five years
• parental reports of the number of hospital admissions (not related to accidents) since birth or the previous interview, collected at nine months and at three and five years.
• parental reports of any longstanding illness or disability of more than three months’ duration and diagnosed by a health professional, collected at three and five years (a limiting longstanding illness was defined as one which limited activities that are normal for the child’s age group)
• parental reports of wheezing within the previous 12 months, and parental reports of asthma collected at three and five years
• parental reports of the use of prescribed drugs, collected at five years
• parents’ ratings of child health, defined as excellent, very good, good, fair or poor, collected at five years

The researchers used statistical methods to look at the outcomes in groups groups born at different stages of pregnancy and compared them to (their definition of) full-term babies. Analyses were adjusted to account for various potential confounding factors, principally numerous social and demographic factors. The researchers also estimated “population attributable fractions” (PAFs) associated with preterm and early term birth, which is an estimate of the contribution that a particular risk factor has to a health outcome. PAF represents the reduction in the proportion of people in the population with a particular health problem that could be expected if the exposure to a risk factor were reduced to the ideal exposure. In this case, it would represent the proportion of children that would no longer have a particular health problem if all babies were born at full term rather than preterm.

 

What were the basic results?

After the researchers excluded participants in the MCS study with incomplete data on time in the womb at birth, they interviewed the parents of 14,273 children at 3 years of age and 14,056 at 5 years. They found certain sociodemographic factors, such as lower maternal educational status and maternal smoking, to be associated with prematurity, as is already known.

The researchers generally found a “dose response” effect of prematurity, meaning that the more premature a baby was, the higher the likelihood of general health problems, hospital admissions and longstanding illnesses. They calculated the odds of each outcome compared to children born at 39-41 weeks. The full details of these outcomes are as follows:

The odds for three or more hospital admissions by five years of age were:

• 6.0 times higher for children born at 23-31 weeks
• 3.0 times higher for children born at 32-33 weeks
• 1.9 times higher for children born at 34-36 weeks
• 1.4 times higher for children born at 37-38 weeks

The odds for any longstanding illness at five years of age were:

• 2.4 times higher for children born at 23-31 weeks
• 2.0 times higher for children born at 32-33 weeks
• 1.5 times higher for children born at 34-36 weeks
• 1.1 times higher for children born at 37-38 weeks

The odds for the child’s health being rated as only fair or poor by parents at five years of age were:

• 2.3 times higher for children born at 23-31 weeks
• 2.8 times higher for children born at 32-33 weeks
• 1.5 times higher for children born at 34-36 weeks
• 1.3 times higher for children born at 37-38 weeks

The odds for asthma and wheezing at five years of age were:

• 2.9 times higher for children born at 23-31 weeks
• 1.7 times higher for children born at 32-33 weeks
• 1.5 times higher for children born at 34-36 weeks
• 1.2 times higher for children born at 37-38 weeks

The greatest contribution to the burden of disease at three and five years was among children born at late/moderate preterm or early term. The calculated PAFs for being admitted to hospital at least three times between the ages of 9 months and 5 years were:

• 5.7% for children born at 32-36 weeks (i.e. you would expect a 5.7% reduction in the number of young children admitted three or more times if babies were born at full term rather than moderate preterm)
• 7.2% for children born at 37-38 weeks (you would expect a 7.2% reduction in the number of young children being admitted if babies were born at full term rather than early term)
• 3.8% for children born before 37 weeks (you would expect a 3.8% reduction in the number of young children being admitted if babies were born at full term rather than very preterm)

Similarly, PAFs for longstanding illnesses were:

• 5.4% for early term births
• 5.4% for moderate or late preterm births
• 2.7% for very preterm births

 

How did the researchers interpret the results?

The researchers concluded that “the health outcomes of moderate/late preterm and early term babies are worse than those of full term babies.” They say that it would be useful for further research to look into how much of the effect is due to prematurity itself, and how much is due to other factors such as maternal or foetal complications.

 

Conclusion

This valuable research examined childhood health outcomes in a large group of children born at different stages of pregnancy.

Important points to consider when interpreting this research include:

• The authors generally found that the likelihood of poorer health outcomes was higher with increasing prematurity (a dose response effect). This is in line with what is already known about the generally poor immediate and longer-term health outcomes among babies born increasingly prematurely.
• The greatest contribution to overall burden of disease at ages three and five years was calculated to be among children born at 32-36 weeks or at 37-38 weeks. Though a gestation of less than 32 weeks might be expected to have a greater influence on the burden of disease, it must be remembered that many more babies are born above 32 weeks of gestation than below it. Therefore, in the population as a whole, the greater number of babies born within the 32-38 week range would have a greater effect than the small number of babies born extremely early.
• The definitions that the authors used for the purposes of this study are not standard definitions. For example, the standard definition of full-term pregnancy is birth at 37 weeks or more, and it is not split into “early term” at 37-38 weeks and “full term” only at 39-41 weeks. Similarly, definitions of prematurity differ from those used by other UK health organisations.
• There is a possibility of inaccuracy as both age at birth and health outcomes were reported by parents, rather than assessed through medical records. For example, a parental report of wheezing or asthma does not necessarily constitute a confirmed medical diagnosis of asthma.

Overall, the study found that the more premature a baby is, the greater the likelihood of health problems in childhood, and that some effect of prematurity may even be seen in pregnancies approaching full term. Further study in this area would be valuable, both to explore the wider range of longer-term health outcomes that may be caused by prematurity, and to look into associated factors (medical or sociodemographic, for example) that may influence the likelihood of these outcomes.

Analysis by Bazian

Links To The Headlines

Infancy health risk linked to early birth by research. BBC News, March 2 2012

Babies born a few weeks early 'suffer health risks'. The Guardian, March 2 2012

Links To Science

Boyle EM, Poulsen G, Field DJ et al. Effects of gestational age at birth on health outcomes at 3 and 5 years of age: population based cohort study. BMJ 2012; 344

Press release: Population-based cohort study of the effects of gestational age at birth on health outcomes at three and five years of age. BMJ, March 1 2012

Cases of the deadly Schmallenberg virus sweeping across Europe have loomed large in the media in recent weeks. The virus, reported to be “killing thousands of lambs”, has spawned alarming headlines.

These reports are of significant interest to farmers who are likely to be concerned about their animals’ welfare and potential financial loss. Following major incidents of livestock diseases spreading to humans, including foot and mouth, BSE and bluetongue, any possible link between farm animal diseases and human health is a serious concern.

However, the fact that Schmallenberg virus is almost certainly confined to livestock has been quite widely reported.

 

Why is Schmallenberg virus in the news?

Schmallenberg virus causes transient fever, diarrhoea and reduced milk yield in adult animals. It has also caused stillbirths and foetal abnormalities in lambs, cows and goats. Because the virus has only just been identified, the long-term consequences for infected animals are not yet known.

The virus was first detected in Germany in August 2011,and has since spread through Europe, reaching the UK in late 2011. The full extent of Schmallenberg virus spread is currently unknown. However, according to the Department for Environment, Food and Rural Affairs (Defra), 83 farms (78 sheep farms, five cattle farms) in 14 English counties are now confirmed to have animals that tested positive for the virus (to February 27).

Insects such as midges or mosquitoes are the most likely carriers of the disease, according to the Health Protection Agency. Agriculture and health officials in the UK and other European countries are monitoring the disease to see how it spreads. Defra has said that further spread of the virus to new farms will depend on the seasonal temperature and how many midges migrate as a result.

 

Is it a risk to human health?

As yet, no human cases of Schmallenberg virus have been detected in any country, and the most closely related viruses only cause animal disease. Early assessments of the virus suggest that it is unlikely that it can spread to humans.

German researchers have looked at the virus’ DNA and found it lacking genetic sequences that would make it a threat to people. However, human implications cannot be ruled out completely until there is a better understanding of the virus.

Because this risk cannot be ruled out, pregnant women are advised to avoid close contact with animals that are giving birth, as there is a theoretical risk of infection from sheep, goats and cattle that could harm a woman’s own health and that of her unborn child.

Very few pregnant women are likely to come into contact with an infected animal. However, pregnant women who do so are advised to seek medical advice if they’re concerned that they could have been infected by farm livestock.

 

Can I still eat lamb?

The Food Standards Agency has said that on current evidence there is little health risk for consumers from meat. No illness has been reported to date in humans exposed to animals infected with Schmallenberg virus.

The agency advises people to follow normal food hygiene precautions when handling, preparing and cooking all foods, to reduce the risk of food-poisoning.

 

What’s being done to stop it spreading further?

There is currently no vaccine or treatment for SBV. However, countries affected by Schmallenberg virus are monitoring the situation and considering the impact it might have on farms. Researchers are trying to understand how the virus spreads and how it can be treated.

The animal and human health authorities in the UK, other countries and at EU level are collaborating to ensure any changes in the disease are detected quickly. Farmers have been told to report signs of congenital deformities in newborn lambs to their vets. This will help to aggregate information and inform governments and the EU of any impact.

Some researchers are exploring how the Schmallenberg virus is transmitted and are developing a test to improve detection. If such a test is successfully developed, far larger numbers of infected animals could be found in British farms.

Links To The Headlines

Schmallenberg virus cases reach 83. The Daily Telegraph, March 2 2012

Birth defect disease kills thousands. The Sun, March 2 2012

Killer sheep virus 'may last for a year': Deadly disease spreading at alarming rate, experts warn. Daily Mail, March 2 2012

Schmallenberg virus: Climate 'raising UK disease risk'. BBC News, March 1 2012

Farmers on alert for Schmallenberg virus. BBC News, February 27 2012

“We've had bird flu and swine flu - now scientists have found BAT FLU,” says the Daily Mail. The newspaper reports that the strain “could pose a risk to humans if it mingled with more common forms of flu”.

The Mail has got in a flap over the flying mammals based on new research that found type A flu virus in fruit bats captured in Guatemala in Central America. The discovery in bats is new as the virus is typically found in winged birds, and not winged mammals.

Researchers collected 316 bats of 16 different Latin American species. Types of flu virus were found in three bats of the little yellow-shouldered species, which is a fruit eating variety common across Central and South America. After analysing the genetic code of the bat flu virus the scientists concluded it contained segments that were significantly different from those found in known influenza A viruses. They also found that some aspects of the bat flu virus could work inside human lung cells grown in the lab. This led them to conclude that the virus has the potential to mix with human flu virus, which could, in rare circumstances, lead to the creation of a new flu strain that is capable of causing a flu pandemic, like bird flu or swine flu.

Despite this warning, scientists have not been able to grow the new bat virus in chicken eggs or human cells, which is possible with existing flu strains. This suggests that the immediate risk of infection to humans is small. Rather than highlighting a danger to human health, this study is likely to guide further research that may improve the understanding of potential pandemic flu threats to humans in the future.

 

Where did the story come from?

The study was carried out by researchers from Centres for Disease Control and Prevention outposts in Atlanta and Guatemala, and was funded by the agency’s Global Disease Detection Program.

The study was published in the peer-reviewed science journal Proceedings of the National Academy of Sciences USA (PNAS).

The story has appeared on several online news sites and in the Daily Mail. In its headline the newspaper suggests that bat flu “could pose a threat to humans”. While the inclusion of the word “could” makes this a fair statement, the article does not make clear that the immediate risk to humans is very low. Generally, the tone of the piece emphasises a potential risk from the virus. It says there is a hypothetical risk of transmission to humans if they eat food contaminated with traces of the virus. Again, the risk of this happening seems low.

 

What kind of research was this?

This study was laboratory research looking at the genetics of a specific strain of type A flu virus found in bats captured in Guatemala. Originally, the bats had been examined as part of a study looking at rabies, which revealed that bats were able to carry certain forms of the flu virus.

As their names suggest, new pandemic flu strains such as the high-profile bird flu and swine flu strains often originate in animals, typically waterfowl and pigs. Usually, non-human flu strains do not cause serious harm in the original host, for instance, bird-flu does not cause death to most birds and human flu is not usually fatal to healthy humans. However, animal flu strains have the potential to swap genetic material with human strains and create a new virus strain capable of infecting and harming humans. It is the mixing of genetic material and the creation of these new viruses that represents the main danger of new flu pandemics.

The researchers say that early detection, characterisation and risk assessment of flu viruses in their animal hosts before they spread to humans is “critical” to protect public health.

 

What did the research involve?

Researchers collected 316 bats from 21 different species from eight locations in southern Guatemala over the course of two years.

Researchers swabbed the bats’ bottoms to gather traces of any influenza virus A. The swabs were tested in the laboratory for signs of flu genetic material using standard molecular biology techniques. Tissue samples from the bats’ mouths, livers, intestines, lungs and kidneys were also tested for flu virus.

Researchers then examined the genetic code of the viral material that had been detected in the bats and looked at how similar they were to other flu viruses that have previously been decoded.

To demonstrate ‘proof of theory’ that the bat virus could function within human cells the scientists created a mini version of the flu virus’ genetic material. They placed this into human lung cells in the laboratory and assessed whether certain functions of the bat virus could be carried out within a human cell.

The researchers attempted to grow the virus strains in a variety of mammalian cells (including bat cells and human lung cells grown in the laboratory) to study how infectious the strains were to these different types of cells.

 

What were the basic results?

Three of the 316 bats tested positive for influenza virus A from their swabs. All three samples were collected from little yellow-shouldered bats, which is a fruit-eating bat that is abundant throughout Central and South America.

In these three bats, all of the further samples taken from the liver, intestine, lung and kidney tissue tested positive for flu virus genetic material.

Researchers found that a specific genetic sequence within the virus, containing the code for making a vitally important flu protein called haemagglutinin, showed differences from the previously documented strains. In one of the bats the genetic material coding for a second crucially important flu protein, called neuraminidase, showed “extraordinary” differences from other known flu viruses.

In influenza A viruses the forms of haemagglutinin (H) and neuraminidase (N) proteins on the surface of each virus provide the main basis for the way it will be named and classified. For example, the combination of these proteins found in the recent swine flu outbreak meant it was known as H1N1, while the latest bird flu scare was caused by a virus known as H5N1. There are many influenza A virus subtype combinations circulating in animals in the wild. In this research the H proteins found in the samples were so different from other types of influenza that the authors say it could be classified as a new subtype, which they called “H17”. In one of the samples the researchers say they could not classify its N type as there were so many different and unusual types of N proteins.

The scientists reported that attempts to grow the virus in human cells in the laboratory and chicken embryos were unsuccessful. This suggested the virus differed from other known viruses, which can be grown under these conditions.

The researchers demonstrated that some functions of the bat flu virus had the potential to work inside laboratory-cultured human lung cells.

 

How did the researchers interpret the results?

The researchers conclude that “despite its divergence from known influenza A viruses, the bat virus is compatible for genetic exchange with human influenza viruses in human cells”. This leads them to suggest that there is potential for the bat virus to mix with existing human flu viruses creating a “new pandemic” virus that could pose a threat to human health.

 

Conclusion

This study of the genetic material of flu virus A in three fruit bats in Guatemala provides important new information to those involved in flu research and pandemic awareness. Previously, non-human flu strains were thought to be confined largely to birds and pigs, but this study highlights the potential for bats also to harbour flu viruses that could potentially threaten humans, given the correct sequence of rare events. The awareness this research provides may lead to a better understanding of the potential risks posed by bat flu to humans in the future.

The following points should be considered when interpreting the results of the study:

• It is important to realise that the researchers have found a new segment of genetic material in the bat flu virus that is different from other flu strains sequenced. They have not discovered a completely new virus in bats that is capable of infecting humans, and so the immediate threat to humans is likely to be minimal.
• As yet, scientists have not been able to grow the bat flu virus in chicken eggs or human cells, which is possible with all other commonly occurring flu strains. Given that they were actively trying to grow the virus and failed, this also suggests the immediate risk of infection and harm to humans is small.
• The potential threat the authors and the media warn against for the future is that the new bat virus genetic material could mix with other flu strains to create a new strain that will be capable of infecting and harming humans, like swine flu and bird flu. To date, there is no evidence that this has happened so there is no cause for immediate concern.
• Fruit bats in Guatemala do not bite people, so direct transmission of the bat virus to humans is unlikely. A suggested route of virus transmission has been if bat droppings contaminate food that is then eaten by people. This could allow the bat flu and human flu genetic material to mix, potentially creating a new strain capable of a pandemic.

This study provides no evidence to support or refute the implication that if someone were infected with the bat virus now it would be harmful, and the risk of this bat strain causing a pandemic is not known at the present time. However, a series of rare events would need to happen in sequence for a pandemic to occur. Despite the rarity, this has happened before in the case of other pandemic flu strains including swine and bird flu, although the initial transmission from these species has generally occurred through sustained close contact with livestock, such as sleeping among the droppings of chickens reared in the home.

Following the discovery of this new form of flu it will surely be explored further by agencies such as the Centers for Disease Control and Prevention, which would report any evidence of risk to the World Health Organization and its flu surveillance teams, which constantly monitor and evaluate any potential flu-based threat.

Analysis by Bazian

Links To The Headlines

We've had bird flu and swine flu - now scientists have found BAT FLU (and it could pose a threat to humans). Daily Mail, March 1 2012

Scientists report first evidence of flu in bats. The Daily Telegraph, March 1 2012

Links To Science

Tong S, Li Y, Rivailler P et al. A distinct lineage of influenza A virus from bats. PNAS, Published online before print February 27, 2012