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In the news

Physically active mid-lifers more likely to be active into old age

20 Sep, 17 | by Emma Gray

Playing sport most likely to stand test of time – at least for men

Men who are physically active in mid-life are more likely to continue the habit into older age as well, finds a long term tracking study published in the online journal BMJ Open.

Playing sport is the physical activity most likely to stand the test of time, the findings show, prompting the researchers to suggest that encouraging early and sustained participation in sports might help people to stay active in old age.

The health benefits of being physically active throughout the life course are well known, but the transition from mid-life to old age often coincides with major life events, such as retirement, when both the amount and frequency of exercise are likely to change, say the researchers.

To find out what types of physical activity endure through middle age to later life, the researchers tracked the behaviour of nearly 3,500 men for up to 20 years, all of whom were taking part in the British Regional Heart Study.

This involved nearly 8,000 men on family doctor patient lists from 24 British towns, who first entered the study between 1978 to 1980 when they were aged between 40 and 59. They were subsequently monitored after 12, 16, and 20 years.

Each participant filled in a detailed questionnaire on their medical history and lifestyle, which included questions on the amount and type of physical activity they engaged in: walking; recreational activities, such as recreational walking, home improvements (DIY), gardening and chores; and sports/formal exercise.

The responses were scored according to the intensity and frequency of the activity, and the figures combined to give a total activity score. Men who played sports also disclosed how long they had been doing it for.

Complete data were available for 3,413 men who were still alive at the 20 year time point.

Throughout the 20-year study the proportion of men classified as active remained at around two thirds at each check up. However, this masked the changes in the types of activity the men did over time.

Sport was the most stable activity, with just under half of men reporting playing sport at least occasionally at each check up.

The proportion of men who reported high levels of walking rose from just under 27% at the start of the study to 62% at the 20 year check up, possibly because retirement might free up more time, say the researchers.

But there were sharp falls in the proportion who engaged in recreational activities, with over half the men (56%) reporting high levels at the start of the study, but only 40% doing so at the 20 year check up.

This could be because ill health may curtail more strenuous activities in older age, suggest the researchers.

The other key finding was that men who were active in midlife were nearly three times as likely to be physically active 20 years later, after taking account of potentially influential factors.

Interestingly, sport participation in midlife predicted physical activity in old age more strongly than other types of physical activity. The odds were even greater for those who had played sports for 25 years or more: these men were nearly 5 times as likely to be physically active into older age compared with men who didn’t play sports.

The authors of this research, from University College London, suggest there may be a number of reasons for this. “One possibility is that people’s enjoyment of sport may be more likely to persist into old age than preferences for other types of activity,” they write.

“Sport participation in mid-life may help maintain physical function and [physical activity] self-efficacy in later life, increasing psychological and physical readiness for [physical activity] in old age,” they add.

Daniel Aggio, lead author of this study, said: “Early engagement in sport and structured exercise may be vital for developing the necessary motor skills needed to establish a lifelong habit for physical activity. However, it may also be important to provide opportunities to take up other forms of activity, such as walking, during the transition to old age.”*

*Free text quote not found in the article text.

Evidence for potential harms of light drinking in pregnancy ‘surprisingly’ limited

11 Sep, 17 | by Emma Gray

But review confirms alcohol best avoided ‘just in case’, say researchers

The evidence for the potentially harmful effects of light or occasional drinking in pregnancy is ‘surprisingly limited,’ but women are still better off avoiding all alcohol while pregnant, just in case, concludes a pooled analysis of the available data, published in the online journal BMJ Open.

The UK Chief Medical Officer recently commissioned a review of current alcohol guidelines for the general public and also specifically for mums-to-be, which resulted in a proposal to recommend that women should not drink any alcohol at all while trying to conceive or while pregnant, on the grounds that it is ‘better to be safe than sorry.’

Women often ask about ‘safe’ levels of drinking during pregnancy, but there are no clinical trial data on this issue. In response, the researchers systematically reviewed all the data from a wide range of high quality observational studies on the impact of light drinking (two units up to twice a week, or four units a week, equivalent to a total of around 32 g) compared with no alcohol at all.

They looked particularly at complications of pregnancy and birth characteristics, such as miscarriage, premature birth, and undersized babies, and longer term issues, such as the developmental delays, impaired intellect, and behavioural difficulties typical of fetal alcohol syndrome–a consequence of heavy drinking in pregnancy.

From among nearly 5000 articles, they selected 26 relevant studies with data suitable to be pooled.

The analysis showed that drinking up to four units a week while pregnant, on average, was associated with an 8 per cent higher risk of having a small baby, compared with drinking no alcohol at all . There was also some evidence of a heightened risk of premature birth, but this was less clear.

For most of the outcomes the researchers analysed, there were only a few studies  that compared light to non-drinkers.

The issue remains of great public health importance, say the researchers, because up to 80 per cent of mums-to-be in the UK, Ireland, New Zealand and Australia drink some alcohol during their pregnancy.

But the evidence on how much, if any, is safe to drink, or at what stages of pregnancy, is notable by its absence, they add.

The lack of high quality data illustrates the difficulties of designing research that can truly evaluate the causal impact of light drinking while minimising the risks of bias and confounding, say the researchers.

And it also illustrates the failure of researchers so far to focus on ‘light’ drinking versus no drinking, rather than just on moderate and heavy drinking – a question many expectant mums care very much about (‘But one glass is OK, isn’t it?’), they add.

“Despite the distinction between light drinking and abstinence being the point of most tension and confusion for health professionals and pregnant women, and contributing to inconsistent guidance and advice now and in the past, our extensive review shows that this specific question is not being researched thoroughly enough, if at all,” they write.

In the absence of any strong evidence, advice to women to steer clear of alcohol while pregnant should be made on the basis that it is a precautionary measure, they say.

“Women who have had a drink while pregnant should be reassured that they are unlikely to have caused their baby considerable harm, but if worried, they should discuss this with their GP or midwife,” say the researchers.

They conclude: “Evidence of the effects of drinking up to 32 g/week in pregnancy is sparse. As there was some evidence that even light prenatal alcohol consumption is associated with being SGA [underweight] and preterm delivery, guidance could advise abstention as a precautionary principle.”

People with disabilities face major hurdles accessing healthcare in UK

11 Sep, 17 | by Emma Gray

Disabled women are particularly disadvantaged

People with disabilities in the UK face major hurdles accessing healthcare, reveals research published in the online journal BMJ OpenDisabled women are particularly disadvantaged, the findings show

Around one in five (19%) people in the UK is thought to live with a disability, but little is known about their access to healthcare services and what barriers they might face.

In a bid to rectify this, the researchers analysed nearly 13,000 anonymised responses from the European Health Interview Survey (2013 and 2014) to assess use of services and any unmet healthcare need.

From among this sample, more than 5,200 adults (aged 16+) had disabilities, defined as a health problem which limited routine activities and had lasted for more than six months.

Depending on the severity of their disability, they were classified as ‘mild’ or ‘severe.’ The remaining 7,500 people in the sample were classified as having no disability.

The researchers then applied five different variables to assess unmet healthcare need over the previous 12 months. These were: long waiting list(s); distance or transport issues; cost of medical examination or treatment; cost of prescribed medicines; cost of mental healthcare.

The analysis showed that those who were severely disabled made up the largest proportion of those with an unmet healthcare need. By far the biggest obstacle they faced was a long wait for treatment, which affected more than one in four living with a severe disability.

A comparison of unmet healthcare needs in people with and without a disability, showed that those who were severely disabled were most likely to be affected, followed by those who were mildly disabled.

The largest difference in unmet healthcare needs between the two groups was generated by the cost of mental healthcare: those with a mild or severe disability were between 4.5 and more than 7 times as likely to face hurdles in accessing this as were those without a disability.

Similarly, those with a mild disability were 3.6 times, and those with a severe disability nearly 5.5 times, more likely to experience difficulties accessing healthcare because of the cost of prescribed drugs.

Transport was another barrier: people with a mild or severe disability were between 2 and more than 4 times as likely to say this hindered their access as people without a disability.

The smallest difference in unmet healthcare needs between those with and without a disability was generated by long waiting lists, although people with a mild or severe disability were still up to 2.4 times as likely to face access problems because of this.

Disabled women were the most badly affected across all five domains.

They were more than 7 times as likely to have an unmet healthcare need because of the cost of treatment, and more than 5 times as likely to face a problem because of the cost of prescribed medicines as were men with no disability.

Men without a disability were the least likely to experience access problems.

Women’s lower income and caring responsibilities – factors that health services tend to ignore – may help explain this gender divide, explain the researchers.

This is an observational study, so no firm conclusions can be drawn about cause and effect.

There was also no information available on the type of disability people had, while disability was self-assessed, a fact which might have introduced response bias, say the researchers.

But the study’s strengths lie in the nationally representative sample and the focus on several factors that might affect healthcare access, say the researchers, who describe the findings as “alarming” on several counts.

“People with disabilities often have greater healthcare needs and therefore may need to access healthcare services more than the general population,” they write. “The existence of barriers in their access may further compromise their health, leading to a vicious cycle: poorer access to healthcare can lead to even poorer health.”

And they conclude: “The fact that these results come from the UK, a country with a national, public and free at the point of access healthcare system (apart from prescriptions), is particularly worrying.”

Improvised explosive devices inflict much more serious injuries than land mines

23 Aug, 17 | by Emma Gray

Multiple amputations much more likely

The types of close contact injuries inflicted by improvised explosive devices (IEDs) are much more serious than those associated with land mines, finds research published in the online journal BMJ Open.

Landmines came into widespread use in the Second World War, where they were designed to injure/maim rather than to kill, with a view to stressing the medical resource of the enemy.

Many were left buried in the ground in regions of conflict long after the fighting had ended, causing them to be inadvertently detonated by civilians stepping on them. But after a high profile campaign, 162 countries signed the 1997 Ottawa Treaty pledging to stop their production and use.

However, they have increasingly been replaced in modern warfare with improvised explosive devices, usually known as IEDs.

The mechanism of injury is the same for landmines and IEDs, while the seriousness of injuries for either device depends on how close the victim is to the centre of the explosion, say the researchers.

But they suspected that pattern 1 injuries—those where the victim suffers the full effects of the explosion at close quarters—would be more serious when they involved IEDs.

They therefore assessed pattern 1 injuries sustained by 100 people during IED attacks in Afghanistan over 18 months in 2010-11 and compared them with pattern 1 injuries previously described for landmines.

All the casualties, who comprised both local civilians and military personnel, were male, and aged between 6 and 44 years of age. Their average age was 25; nine were under the age of 18.

They were all treated at the NATO Role 3 Multinational Medical Unit in Kandahar Air Field, Afghanistan, a facility equivalent to a level II civilian trauma centre.

Eleven victims were dead on arrival; a further eight subsequently died of their wounds in hospital, giving a fatality rate of one in five (19%).

IED victims were more likely than those similarly injured by landmines to have more than one amputation (70% vs 10.5%). Five out of the 70 multiple amputees had four amputations; 27 had three amputations, and 38 had a double amputation.

Among the nine children and teens, three had a triple amputation; five had a double amputation.

IED victims were also twice as likely to sustain genital/gluteal (buttocks) injuries (26% vs 13.4%).

Pelvic fracture was more common among IED victims who had multiple amputations and/or genital/gluteal injuries than it was among landmine victims with similar injuries (28.6% vs 3.3%).

And IED victims with this pattern of injuries were also nearly four times as likely to die than were similarly injured landmine victims (24.3% vs 6.7%).

In all, the typical injury profile of IED victims included amputations of both legs (often above the knee); mangling or amputation of an arm/hand; extensive soft tissue injuries with deep penetration of soil, extending into the gluteal and perineal areas; pelvic fracture; and genital mutilation.

Soil forced into a soft tissue injury may worsen the level of amputation required and condemns the victim to serial surgery to remove it. And even then, it may leave that person at the mercy of antibiotic resistant soil organisms, the researchers point out.

IEDs are sometimes portrayed as a primitive or crude weapon crafted from locally available resources because of a lack of access to conventional weapons, but they have evolved and are now more sophisticated, directed, and destructive, say the researchers.

Just like landmines, they indiscriminately maim and kill. And that includes children, who tend to suffer the most severe injuries as a result of the powerful explosive force of an IED.

“The injury pattern suffered by the survivors of the IED is markedly worse than that of conventional [landmines],” they write. “It is a weapon, which, of its nature, causes superfluous injury and unnecessary suffering.”

The evidence gathered on the horrors inflicted by the use of landmines prompted international condemnation resulting in a ban. And the researchers conclude: “It is hoped that reports regarding the pattern of injury caused by the modern IED will result in an abhorrence of this weapon and those that use it.”

Drugs to curb excess stomach acid may be linked to heightened risk of death

3 Jul, 17 | by Emma Gray

May be time to restrict use of widely available proton pump inhibitors, say researchers

Proton pump inhibitors (PPIs)—a widely available class of drug designed to curb excess stomach acid production—may be linked to a heightened risk of death, indicates research published in the online journal BMJ Open.

Given how widely available these drugs are, and the accumulating evidence pointing to links with a range of potentially serious side effects, it may be time to restrict the indications for use and duration of treatment with PPIs, suggest the researchers.

Recent research has indicated a link between PPI use and a heightened risk of chronic kidney disease/kidney disease progression, dementia, C difficile infections, and bone fractures in people with brittle bone disease (osteoporosis).

Although far from conclusive, emerging evidence suggests that PPIs may boost the risk of tissue damage arising from normal cellular processes, known as oxidative stress, as well as the shortening of telomeres, which sit on the end of chromosomes and perform a role similar to the plastic tips on the end of shoelaces.

The researchers base their findings on national US data obtained from a network of integrated healthcare systems involving more than 6 million people whose health was tracked for an average of almost six years—until 2013 or death, whichever came first.

They carried out three comparative analyses: those taking PPIs with those taking another type of drug used to dampen down acid production called histamine H2 receptor antagonists or H2 blockers for short  (349, 312 people); users and non-users of PPIs (3,288,092 people);  and users of PPIs with people taking neither PPIs nor H2 blockers.

Compared with H2 blocker use, PPI use was associated with a 25% heightened risk of death from all causes, a risk that increased the longer PPIs were taken.

The other analyses revealed a similar level of risk between users and non-users of PPIs and between those taking PPIs and those taking no acid suppressant drugs.

The risk of death was also heightened among those who were taking PPIs despite having no appropriate medical indication for their use, such as ulcers, H pylori infection, Barrett’s oesophagus (pre-cancerous changes to the food pipe) and gullet (oesophageal) cancer.

This is an observational study, so no firm conclusions can be drawn about cause and effect, added to which participants were mostly older white US veterans, possibly limiting the wider applicability of the findings. Nor were the researchers able to obtain information on the causes of death.

Although there is no obvious biological explanation for their findings, the researchers nevertheless suggest that the consistency of their results and the growing body of evidence linking PPI use with a range of side effects is “compelling.”

They write: “Although our results should not deter prescription and use of PPIs where medically indicated, they may be used to encourage and promote pharmacovigilance [monitoring the side-effects of licensed drugs] and [they] emphasise the need to exercise judicious use of PPIs and limit use and duration of therapy to instances where there is a clear medical indication and where benefit outweighs potential risk.”

Study reveals lack of supporting evidence for claims about fertility treatments

28 Nov, 16 | by Emma Gray

Many claims made by UK fertility clinics about the benefits of treatments beyond standard IVF procedures are not backed up by evidence, finds a study published in the online journal BMJ Open.

These can range from £50 for a single screening blood test to as much as £8000 for egg freezing packages.

The researchers, led by Professor Carl Heneghan at Oxford University’s Centre for Evidence Based Medicine (CEBM), say “there is a need for more information on interventions to be made available by fertility centres, to support well informed treatment decisions.”

The findings will be part of a Panorama undercover investigation broadcast on Monday 28 November at 8.30pm on BBC One.

Infertility is a significant problem, affecting about 1 in 7 UK couples, many of whom seek medical help to have a child.

UK fertility centres are regulated by the Human Fertilisation and Embryology Authority (HFEA). But despite this regulation it has been suggested that some of the treatments offered on top of routine IVF might not be evidence based, are costly, and some clinics might be using techniques that have not been stringently tested.

So the researchers set out to record claims of benefit for treatments offered on top of standard IVF by UK fertility centre websites – and identify the evidence used to support these claims.

A total of 74 fertility centre websites, incorporating 1401 web pages were examined for claims. The team found 276 claims of benefit relating to 41 different fertility interventions made by 60 of the 74 centres.

79 (29%) of the claims included numbers to explain the chances of improved fertility outcomes, but the team identified only 13 websites where any references were included, which referred to just 16 published references. Of these 16 references, only five were high level systematic review evidence.

The authors point to some study limitations, but say it is unlikely that a repeat of their analysis would change the pattern of findings substantially.

“Our findings demonstrate that whilst many claims were made on the benefits of fertility treatments, there was a lack of supporting evidence cited, with the majority of the websites providing no sources for claims made,” they conclude.

In a linked analysis published by The BMJ, Professor Heneghan and colleagues searched for evidence to support 38 interventions offered by UK fertility centres on top of standard IVF, focusing on the key outcome of live birth rates.

They found that most treatments are not supported by good evidence. The National Institute for Health and Care Excellence (NICE) provides clear advice on only 13 (34%) of the 38 interventions investigated, and systematic reviews (the highest level of available evidence) were available for only 27.

They also found that information on harms is often poorly reported.

People seeking fertility treatment need good quality evidence to make informed choices, they write. The current approach by HFEA leaves patients and clinicians to seek evidence for themselves or from staff in private clinics selling fertility services.

“We do not believe this approach is realistic.”

They say there is “an urgent need for randomised controlled trials for many interventions that are currently being offered” and call for changes in guidance to help couples make informed decisions.

Panorama: Inside Britain’s Fertility Business will be broadcast on Monday 28 November at 8:30pm on BBC One

BBC Panorama will reveal that 26 out of 27 so-called “add-on” treatments being offered by UK fertility clinics have no good scientific evidence from trials that they improve the chance of having a baby.  Some may even be harmful.

“Add-on” treatments include things like additional procedures, additional drugs or devices to house an embryo. They can cost anywhere between £100 and £3000 on top of standard fertility care.

Panorama commissioned Oxford University’s Centre for Evidence-Based Medicine to do the research, which has taken almost a year to complete.  

Researchers identified 27 treatments on offer at UK fertility clinics they considered to be “add-ons”.

Only one treatment – called endometrial scratch – had even moderate quality evidence that shows an increase in the chances of a baby with standard fertility care like IVF.  There are still question marks over the evidence for that treatment.  Due to its limitations the researchers noted there is currently a randomised trial ongoing in the UK to determine its effectiveness.  

One “add-on” treatment called Preimplantation Genetic Screening (PGS) tests embryos for abnormalities. A trial in 2007 discovered that an earlier version of this process may have lowered birth rates.  

Many clinics sell newer, more accurate versions, in some cases for up to £3000.  Initial research looks promising and randomised trials are underway, but as yet there is no high quality evidence from robust trials that these new versions improve your chances of having a baby.

Panorama found evidence that, when marketing this add-on treatment, not all clinics are giving patients the full picture to enable them to make a properly informed decision.  

A Panorama reporter went to a fertility fair in November last year and was not given the full picture about the evidence for PGS by every one of clinics she spoke to.

She approached staff from 18 British and foreign clinics at random, asking if PGS would improve her chances on top of IVF.  She told them she was 38 and had been trying for a baby for a year without success.

Five of the 18 clinics were positive about the treatment. Eight said they would only offer it to women over the age of 40 or those who had experienced repeated IVF failures.  There is currently no good scientific evidence from trials that it can increase the birth rate among women in these categories.

Only five clinics gave the full picture, saying that they would not recommend PGS because it lacked evidence.

Pre-teens whose dads embrace parenthood may be less prone to behavioural issues

22 Nov, 16 | by Emma Gray

How new fathers see themselves in child’s early years seems to be most influential

Kids whose dads adjust well to parenthood and feel confident about their new role may be less likely to have behavioural problems in the run-up to their teens, indicates research published in the online journal BMJ Open.

It’s how fathers see themselves as parents in the child’s early years, rather than the amount of direct childcare they give, that seems to be important, the findings suggest.

The nature of parenting in a child’s early years is thought to influence their short and long term wellbeing and mental health, which are in turn linked to development and educational attainment.

But it’s not entirely clear what impact the father’s role might have, as much of the research to date has tended to characterise paternal involvement in a child’s upbringing as one dimensional.

The researchers therefore drew on data from the Avon Longitudinal Study of Parents and Children (ALSPAC) study, which has been tracking the health of nearly 15,000 children since birth, to assess several aspects of paternal involvement.

The parents of 10,440 children who were living with both their mum and dad at the age of 8 months were asked to complete a comprehensive questionnaire about their and their child’s mental health; their attitudes to parenting; time spent on childcare; their child’s behaviour and development; as well as details of household income/education.

When the children were aged 9 and 11, their behaviour was assessed using the strength and difficulties questionnaire (SDQ). This covers emotional symptoms, behaviour (conduct) problems, hyperactivity, peer relationship issues, and helpfulness (pro-social behaviour).

Fathers’ parental involvement was measured by asking them to rate their level of agreement with 58 statements, reflecting the amount of direct childcare they engaged in, including household chores; their attitudes to parenting; the relationship with their child; and how they felt about the birth 8 weeks and 8 months afterwards.

The final analysis was based on almost 7000 9 year olds and nearly 6500 of the same children at the age of 11.

Three key factors emerged in relation to the children’s SDQ scores: (1)  fathers’ emotional response to the baby and their parenting role; (2) how much time the dads spent on direct childcare; and (3) how well they adjusted to their new role, including how confident they felt in their abilities as a parent and partner.

But emotional response and confidence in their new role were most strongly associated with lower odds of behavioural problems when their children reached 9 and 11 years of age.

A high paternal factor 1 score was associated with 21% and 19% lower odds of a higher SDQ score at the ages of 9 and 11, respectively. Similarly, a high paternal factor 3 score was associated with 28% lower odds of a higher SDQ score at both time points.

After taking account of potentially influential factors, such as age at fatherhood, educational attainment and household income, hours worked, and sex of the child, every unit increase in factor 1 scores was associated with 15% lower odds of behavioural problems at the age of 9 and 12% lower odds at the age of 11, compared with kids of the same age, sex, and family background.

Similarly, every unit increase in factor 3 scores was associated with 12% lower odds at the age of 9, and 10% lower odds at the age of 11.

This is an observational study so no firm conclusions can be drawn about cause and effect, and as the researchers note, the study dates back 25 years, since when parenting styles may have changed, so the findings may therefore not be widely generalisable.

But they write: “The findings of this research study suggest that it is psychological and emotional aspects of paternal involvement in a child’s infancy that are most powerful in influencing later child behaviour, and not the amount of time that fathers are engaged in childcare or domestic tasks in the household.”

London 2012 Olympics inspired many local kids to get more involved in sport

22 Nov, 16 | by Emma Gray

But levels of physical fitness significantly worsened

The London 2012 Olympic Games inspired many local children to get more involved in sport, reveal the results of a before and after study, published in the online journal BMJ Open.

But this inspiration did not translate into improved physical fitness, levels of which declined significantly in the aftermath of the event, the findings indicate.

When Britain was awarded host status for the Olympic Games in London 2012 in 2005, this was based on a bid which promised to “inspire a generation” and “create a legacy of sport and healthy living,” despite there being no evidence of any such outcome from previous events of this kind, say the researchers.

The Active People Survey showed an initial increase of around half a million adults participating in a weekly 30 minute session of sporting activities between April 2012 and April 2013.

But the data indicate that since then, the number of 16-25 year olds doing this has fallen, a trend that has continued, say the researchers.

To find out if London 2012 was associated with increased levels of physical activity, physical fitness and changes in body mass index (BMI), the researchers carried out a before and after study among pupils at six schools within a 50 km radius of the Olympic park in East London.

Some 733 children between the ages of 10 and 16 were assessed in 2008-9, up to 3+years before London 2012, and 931 from the same schools in 2013-14, up to 18 months afterwards.

At both time points they were quizzed about how much inspiration they took from the Games, and how much physical activity they did. Their cardiorespiratory fitness was assessed in a 20 metre shuttle run by peak V02—a measure of oxygen uptake that is linked to the capacity to perform sustained exercise.

Over half (53%) of the children said London 2012 had inspired them to try new sports/ activities.

Children who continued to take part in sports/activities in the 18 months after London 2012 were more active and fitter than those who didn’t. And average BMI was also lower among the girls.

Compared with those who said they weren’t inspired by the Olympics, peak V02 was higher among those who continued to participate in sports/activities 18 months after London 2012.

This 45% of the sample was also more physically active than those who said they were not inspired, or had been only briefly inspired, by London 2012.

But peak V02 was significantly lower after London 2012 than it had been before among all the children. This is a cause for concern as low levels of cardiorespiratory fitness in childhood are associated with a heightened risk of metabolic disorders in adulthood, say the researchers.

This is an observational study so no firm conclusions can be drawn about cause and effect. Furthermore, the researchers caution that they cannot discount the possibility that the children who had been inspired by the Olympics might already have been fitter and more active, or that other factors might have offset any fitness benefits arising from London 2012.

And the true scale of the legacy may never be known due to the lack of any appropriate measures to monitor changes associated with events like London 2012, they point out.

“High levels of inspiration to participate in new activities reported following London 2012 and positive associations with fitness are encouraging…[But] these associations must be interpreted in the context of the significant declines in fitness shown by our repeated cross-sectional comparison,” they write.

“The cost of hosting future mega-events cannot be justified based on the assumption that they will automatically produce health related benefits,” they add.

‘Worried well’ may be boosting their risk of heart disease

3 Nov, 16 | by Emma Gray

Potential consequences of health anxiety underlines need to treat it, say researchers

People who needlessly worry that they have, or will develop, serious illness—popularly referred to as ‘the worried well’—may be boosting their risk of developing heart disease, suggests research published in the online journal BMJ Open.

Anxiety is a known risk factor for heart disease. And health anxiety, which describes persistent preoccupation with having or acquiring a serious illness, and seeking prompt medical advice, on the basis of misattributed bodily symptoms in the absence of any physical disease, seems to be no exception, say the researchers.

And as such, it needs to be taken seriously and treated properly, they suggest.

They base their findings on 7052 participants of the Norwegian Hordaland Health Study (HUSK), a long term collaborative research project between the National Health Screening Service, the University of Bergen, and local health services.

The participants, all of whom were born between 1953 and 1957, filled in two questionnaires about their health, lifestyle, and educational attainment. And they had a physical check-up, consisting of blood tests, weight, height, and blood pressure measurements, taken between 1997 and 1999.

Levels of health anxiety were assessed using a validated scale (Whiteley Index), comprising 14 items scored from 1-5. Those (710) whose total score amounted to 31 or more were in the top 10% of the sample and considered to have health anxiety.

The heart health of all the participants was subsequently tracked using national data on hospital treatment episodes and death certification up to the end of 2009.

Anyone who received treatment for, or whose death was linked to, coronary artery disease occurring within a year of entering the study, was excluded, on the grounds that they might already have been ill.

In all, 234 (3.3%) of the entire sample had an ischaemic event—a heart attack or bout of acute angina—during the monitoring period, with the average time to the first incident just over 7 years.

But the proportion of those succumbing to heart disease was twice as high (just over 6%) among those who displayed health anxiety as it was among those who didn’t (3%).

While established risk factors for heart disease explained part of the association found, health anxiety was still linked to a heightened risk, after taking account of other potentially influential factors.

Those with health anxiety at the start of the study were 73% more likely to develop heart disease than those who weren’t in this state of mind, the analysis showed. And the higher the Whiteley Index score, the greater was the risk of developing heart disease.

This is an observational study, so no firm conclusions can be drawn about cause and effect, added to which the researchers admit that health anxiety often exists alongside other mental health issues, such as general anxiety and depression, making it hard to differentiate.

But the findings back current thinking on the potentially harmful effects of anxiety on health, they say.

“[Our research] further indicates that characteristic behaviour among persons with health anxiety, such as monitoring and frequent check-ups of symptoms, does not reduce the risk of [coronary heart disease] events,” they write.

If anything, putting the body on a permanent state of high alert may have the opposite effect, they suggest.

“These findings illustrate the dilemma for clinicians between reassuring the patient that current physical symptoms of anxiety do not represent heart disease, contrasted against the emerging knowledge on how anxiety, over time, may be causally associated with increased risk of [coronary artery disease],” they conclude.

The findings “underline the importance of proper diagnosis and treatment of health anxiety,” they add.

Current system unlikely to pick up surgeons with above average patient death rates

31 Oct, 16 | by Emma Gray

Performance within ‘expected’ range not good enough to detect outliers, say researchers

Publishing the patient death rates of individual surgeons in England is unlikely to pick up those whose mortality rates are above average, because the caseload varies so much, concludes the first analysis of its kind published in the online journal BMJ Open.  

Performance within the ‘expected’ range is too crude a measure to detect doctors whose practice might be a cause for concern, and is therefore creating a false sense of security, say the researchers.

When the patient death rates for individual surgeons were first published in June 2013, the move was hailed as a major breakthrough in transparency that would drive up standards of care in England.

But the chances of detecting a surgeon whose death rates are worse than the national average is a question of statistical power, say the researchers: in other words, the greater the caseload, the greater the ability to detect worrying trends.

To assess how reliable the available data for individual surgeons are, the researchers reviewed the outcomes for three common high risk procedures—bowel surgery, gullet surgery, and planned aortic aneurysm repair—and three common low risk procedures—hip replacement, bariatric surgery, and thyroid removal.

And they analysed every surgeon’s caseload for each of the procedures, all of which were carried out between 2010 and 2014 across England.

They focused in particular on how well these data would be able to detect a surgeon whose patient death rate in hospital or within 30 or 90 days of the patient’s discharge was between two and five times higher than the national average.

Unsurprisingly, the higher risk procedures were associated with a higher death rate of between 2.2-4.5% while the lower risk ones were associated with a death rate of 0.07-0.4%.

But caseload was an issue. For example, the average number of bowel surgery operations carried out by individual surgeons was 55 over three years, but ranged from just 3 to 237.

With an average national 90 day death rate of 3%, the national average of 55 cases provides 20% statistical power to detect a mortality rate three times the national average. That means that around 20 out of 100 individual surgeons with an actual death rate of 9% would fall outside the expected range.

But the caseload would have to be more than 200 to provide 90% statistical power of detecting a surgeon whose 90 day mortality rate is three times the national average.

Similar findings emerged for gullet surgery, where the average number of procedures was 23 over a two year period, but ranged from 10 to 81.

Based on national 30 day death rates of 2.4%, the average number of cases would provide less than 20% statistical power to detect a surgeon with a patient death rate four times the national average.

And a caseload of 300 procedures would be needed to provide 80% statistical power to detect a 90 day mortality rate twice as high as the national average over two years.

For low risk procedures, the national average caseload ranged from 48 to 75 per surgeon, meaning that fewer than 20 out of 100 surgeons with an actual mortality rate five times the national average would be picked up.

For hip replacements, for example, an annual caseload of more than 500 cases would be needed to provide 80% statistical power to pick up just one individual with a mortality rate five times the national average.

At these kinds of rates it is unlikely that a surgeon would ever perform enough procedures in his/her entire career for a mortality rate five times the national average to be detected, say the researchers.

“On the basis of these rates and published case volumes, surgeons with mortality rates in excess of that expected are highly unlikely to be detected,” they write. “Performance within an expected mortality rate range cannot therefore be considered reliable evidence of acceptable performance.”

More meaningful outcome measures are required, they say. These could include patient satisfaction, the ease with which routine daily tasks can be performed (functional health status), and other health related quality of life indicators.

And an individual’s performance could be addressed by regular internal appraisal and feedback from multiple sources, they suggest.

Interpreting performance data for individual surgeons has major implications for patient care, the individual practitioner, and their employer, they emphasise

But they conclude: “This analysis demonstrates that, for these common procedures, mortality rates are not a robust method for detecting divergent practice. It is not surprising that the performance of all but one surgeon across all six procedures was found to be acceptable.”