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Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study

June 20, 2014 Comments off

Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study
Source: British Medical Journal

Objective
To investigate if the widely publicized warnings in 2003 from the US Food and Drug Administration about a possible increased risk of suicidality with antidepressant use in young people were associated with changes in antidepressant use, suicide attempts, and completed suicides among young people.

Design
Quasi-experimental study assessing changes in outcomes after the warnings, controlling for pre-existing trends.

Setting
Automated healthcare claims data (2000-10) derived from the virtual data warehouse of 11 health plans in the US Mental Health Research Network.

Participants
Study cohorts included adolescents (around 1.1 million), young adults (around 1.4 million), and adults (around 5 million).

Main outcome measures
Rates of antidepressant dispensings, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides.

Results
Trends in antidepressant use and poisonings changed abruptly after the warnings. In the second year after the warnings, relative changes in antidepressant use were −31.0% (95% confidence interval −33.0% to −29.0%) among adolescents, −24.3% (−25.4% to −23.2%) among young adults, and −14.5% (−16.0% to −12.9%) among adults. These reflected absolute reductions of 696, 1216, and 1621 dispensings per 100 000 people among adolescents, young adults, and adults, respectively. Simultaneously, there were significant, relative increases in psychotropic drug poisonings in adolescents (21.7%, 95% confidence interval 4.9% to 38.5%) and young adults (33.7%, 26.9% to 40.4%) but not among adults (5.2%, −6.5% to 16.9%). These reflected absolute increases of 2 and 4 poisonings per 100 000 people among adolescents and young adults, respectively (approximately 77 additional poisonings in our cohort of 2.5 million young people). Completed suicides did not change for any age group.

Conclusions
Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting.

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Helmet therapy in infants with positional skull deformation: randomised controlled trial

May 2, 2014 Comments off

Helmet therapy in infants with positional skull deformation: randomised controlled trial
Source: British Medical Journal

Objective
To determine the effectiveness of helmet therapy for positional skull deformation compared with the natural course of the condition in infants aged 5-6 months.

Design
Pragmatic, single blinded, randomised controlled trial (HEADS, HElmet therapy Assessment in Deformed Skulls) nested in a prospective cohort study.

Setting
29 paediatric physiotherapy practices; helmet therapy was administered at four specialised centres.

Participants
84 infants aged 5 to 6 months with moderate to severe skull deformation, who were born after 36 weeks of gestation and had no muscular torticollis, craniosynostosis, or dysmorphic features. Participants were randomly assigned to helmet therapy (n=42) or to natural course of the condition (n=42) according to a randomisation plan with blocks of eight.

Interventions
Six months of helmet therapy compared with the natural course of skull deformation. In both trial arms parents were asked to avoid any (additional) treatment for the skull deformation.

Main outcome measures
The primary outcome was change in skull shape from baseline to 24 months of age assessed using plagiocephalometry (anthropometric measurement instrument). Change scores for plagiocephaly (oblique diameter difference index) and brachycephaly (cranioproportional index) were each included in an analysis of covariance, using baseline values as the covariate. Secondary outcomes were ear deviation, facial asymmetry, occipital lift, and motor development in the infant, quality of life (infant and parent measures), and parental satisfaction and anxiety. Baseline measurements were performed in infants aged between 5 and 6 months, with follow-up measurements at 8, 12, and 24 months. Primary outcome assessment at 24 months was blinded.

Results
The change score for both plagiocephaly and brachycephaly was equal between the helmet therapy and natural course groups, with a mean difference of −0.2 (95% confidence interval −1.6 to 1.2, P=0.80) and 0.2 (−1.7 to 2.2, P=0.81), respectively. Full recovery was achieved in 10 of 39 (26%) participants in the helmet therapy group and 9 of 40 (23%) participants in the natural course group (odds ratio 1.2, 95% confidence interval 0.4 to 3.3, P=0.74). All parents reported one or more side effects.

Conclusions
Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformation.

Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality

April 23, 2014 Comments off

Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality
Source: British Medical Journal

Objectives
To determine the relationship between the reduction in salt intake that occurred in England, and blood pressure (BP), as well as mortality from stroke and ischaemic heart disease (IHD).

Design
Analysis of the data from the Health Survey for England.

Setting and participants
England, 2003 N=9183, 2006 N=8762, 2008 N=8974 and 2011 N=4753, aged ≥16 years.

Outcomes
BP, stroke and IHD mortality.

Results
From 2003 to 2011, there was a decrease in mortality from stroke by 42% (p<0.001) and IHD by 40% (p<0.001). In parallel, there was a fall in BP of 3.0±0.33/1.4±0.20 mm Hg (p<0.001/p<0.001), a decrease of 0.4±0.02 mmol/L (p<0.001) in cholesterol, a reduction in smoking prevalence from 19% to 14% (p<0.001), an increase in fruit and vegetable consumption (0.2±0.05 portion/day, p<0.001) and an increase in body mass index (BMI; 0.5±0.09 kg/m2, p<0.001). Salt intake, as measured by 24 h urinary sodium, decreased by 1.4 g/day (p<0.01). It is likely that all of these factors (with the exception of BMI), along with improvements in the treatments of BP, cholesterol and cardiovascular disease, contributed to the falls in stroke and IHD mortality. In individuals who were not on antihypertensive medication, there was a fall in BP of 2.7±0.34/1.1±0.23 mm Hg (p<0.001/p<0.001) after adjusting for age, sex, ethnic group, education, household income, alcohol consumption, fruit and vegetable intake and BMI. Although salt intake was not measured in these participants, the fact that the average salt intake in a random sample of the population fell by 15% during the same period suggests that the falls in BP would be largely attributable to the reduction in salt intake rather than antihypertensive medications.

Conclusions
The reduction in salt intake is likely to be an important contributor to the falls in BP from 2003 to 2011 in England. As a result, it would have contributed substantially to the decreases in stroke and IHD mortality.

Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial

February 18, 2014 Comments off

Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial (PDF)
Source: British Medical Journal

Objective
To compare breast cancer incidence and mortality up to 25 years in women aged 40-59 who did or did not undergo mammography screening.

Design
Follow-up of randomised screening trial by centre coordinators, the study’s central office, and linkage to cancer registries and vital statistics databases.

Setting 15 screening centres in six Canadian provinces,1980-85 (Nova Scotia, Quebec, Ontario, Manitoba, Alberta, and British Columbia).

Participants 89 835 women, aged 40-59, randomly assigned to mammography (five annual mammography screens) or control (no mammography).

Interventions
Women aged 40-49 in the mammography arm and all women aged 50-59 in both arms received annual physical breast examinations. Women aged 40-49 in the control arm received a single examination followed by usual care in the community.

Main outcome measure
Deaths from breast cancer.

Results
During the five year screening period, 666 invasive breast cancers were diagnosed in the mammography arm (n=44 925 participants) and 524 in the controls (n=44 910), and of these, 180 women in the mammography arm and 171 women in the control arm died of breast cancer during the 25 year follow-up period. The overall hazard ratio for death from breast cancer diagnosed during the screening period associated with mammography was 1.05 (95% confidence interval 0.85 to 1.30). The findings for women aged 40-49 and 50-59 were almost identical. During the entire study period, 3250 women in the mammography arm and 3133 in the control arm had a diagnosis of breast cancer, and 500 and 505, respectively, died of breast cancer. Thus the cumulative mortality from breast cancer was similar between women in the mammography arm and in the control arm (hazard ratio 0.99, 95% confidence interval 0.88 to 1.12). After 15 years of follow-up a residual excess of 106 cancers was observed in the mammography arm, attributable to over-diagnosis.

Conclusion
Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available. Overall, 22% (106/484) of screen detected invasive breast cancers were over-diagnosed, representing one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial.

Christmas 2013 Research — Following celebrities’ medical advice: meta-narrative analysis

December 19, 2013 Comments off

Christmas 2013 Research — Following celebrities’ medical advice: meta-narrative analysis
Source: British Medical Journal

Objective
To synthesise what is known about how celebrities influence people’s decisions on health.

Design
Meta-narrative analysis of economics, marketing, psychology, and sociology literatures.

Data sources
Systematic searches of electronic databases: BusinessSource Complete (1886-), Communication & Mass Media Complete (1915-), Humanities Abstracts (1984-), ProQuest Political Science (1985-), PsycINFO (1806-), PubMed (1966-), and Sociology Abstracts (1952-).

Inclusion criteria
Studies discussing mechanisms of celebrities’ influence on people in any context.

Results
Economics literature shows that celebrity endorsements act as signals of credibility that differentiate products or ideas from competitors and can catalyse herd behaviour. Marketing studies show that celebrities transfer their desirable attributes to products and use their success to boost their perceived credibility. Psychology shows that people are classically conditioned to react positively to the advice of celebrities, experience cognitive dissonance if they do not, and are influenced by congruencies with their self conceptions. Sociology helps explain the spread of celebrity medical advice as a contagion that diffuses through social networks and people’s desire to acquire celebrities’ social capital.

Conclusions
The influence of celebrity status is a deeply rooted process that can be harnessed for good or abused for harm. A better understanding of celebrity can empower health professionals to take this phenomenon seriously and use patient encounters to educate the public about sources of health information and their trustworthiness. Public health authorities can use these insights to implement regulations and restrictions on celebrity endorsements and design counter marketing initiatives—perhaps even partnering with celebrities—to discredit bogus medical advice while promoting evidence based practices.

A retrospective cohort study of mode of delivery among public and private patients in an integrated maternity hospital setting

November 29, 2013 Comments off

A retrospective cohort study of mode of delivery among public and private patients in an integrated maternity hospital setting
Source: British Medical Journal

Objective
To examine the associations between mode of delivery and public versus privately funded obstetric care within the same hospital setting.

Design
Retrospective cohort study.

Setting
Urban maternity hospital in Ireland.

Population
A total of 30 053 women with singleton pregnancies who delivered between 2008 and 2011.

Methods
The study population was divided into those who booked for obstetric care within the public (n=24 574) or private clinics (n=5479). Logistic regression analyses were performed to examine the associations between operative delivery and type of care, adjusting for potential confounding factors.

Main outcome measures
Caesarean section (scheduled or emergency), operative vaginal delivery (vacuum or forceps), indication for caesarean section as classified by the operator.

Results
Compared with public patients, private patients were more likely to be delivered by caesarean section (34.4% vs 22.5%, OR 1.81; 95% CI 1.70 to 1.93) or operative vaginal delivery (20.1% vs 16.5%, OR 1.28; 95% CI 1.19 to 1.38). The greatest disparity was for scheduled caesarean sections; differences persisted for nulliparous and parous women after controlling for medical and social differences between the groups (nulliparous 11.9% vs 4.6%, adjusted (adj) OR 1.82; 95% CI 1.49 to 2.24 and parous 26% vs 12.2%, adj OR 2.08; 95% CI 1.86 to 2.32). Scheduled repeat caesarean section accounted for most of the disparity among parous patients. Maternal request per se was an uncommonly reported indication for caesarean section (35 in each group, p<0.000).

Conclusions
Privately funded obstetric care is associated with higher rates of operative deliveries that are not fully accounted for by medical or obstetric risk differences.

The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis

November 15, 2013 Comments off

The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis
Source: British Medical Journal

Objective
To examine whether total joint arthroplasty of the hip and knee reduces the risk for serious cardiovascular events in patients with moderate-severe osteoarthritis.

Design
Propensity score matched landmark analysis.

Setting
Ontario, Canada.

Participants
2200 adults with hip or knee osteoarthritis aged 55 or more at recruitment (1996-98) and followed prospectively until death or 2011.

Main outcome measure
Rates of serious cardiovascular events for those who received a primary total joint arthroplasty compared with those did not within an exposure period of three years after baseline assessment.

Results
The propensity score matched cohort consisted of 153 matched pairs of participants with moderate-severe arthritis. Over a median follow-up period of seven years after the landmark date (start of the study), matched participants who underwent a total joint arthroplasty during the exposure period were significantly less likely than those who did not to experience a cardiovascular event (hazards ratio 0.56, 95% confidence interval 0.43 to 0.74, P<0.001). Within seven years of the exposure period the absolute risk reduction was 12.4% (95% confidence interval 1.7% to 23.1%) and number needed to treat was 8 (95% confidence interval 4 to 57 patients).

Conclusions
Using a propensity matched landmark analysis in a population cohort with advanced hip or knee osteoarthritis, this study found a cardioprotective benefit of primary elective total joint arthroplasty.

Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care: pragmatic randomised factorial trial

November 5, 2013 Comments off

Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care: pragmatic randomised factorial trial
Source: British Medical Journal

Objective
To assess strategies for advice on analgesia and steam inhalation for respiratory tract infections.

Design
Open pragmatic parallel group factorial randomised controlled trial.

Setting
Primary care in United Kingdom.

Participants
Patients aged ≥3 with acute respiratory tract infections.

Intervention
889 patients were randomised with computer generated random numbers in pre-prepared sealed numbered envelopes to components of advice or comparator advice: advice on analgesia (take paracetamol, ibuprofen, or both), dosing of analgesia (take as required v regularly), and steam inhalation (no inhalation v steam inhalation).

Outcomes
Primary: mean symptom severity on days 2-4; symptoms rated 0 (no problem) to 7 (as bad as it can be). Secondary: temperature, antibiotic use, reconsultations.

Results
Neither advice on dosing nor on steam inhalation was significantly associated with changes in outcomes. Compared with paracetamol, symptom severity was little different with ibuprofen (adjusted difference 0.04, 95% confidence interval −0.11 to 0.19) or the combination of ibuprofen and paracetamol (0.11, −0.04 to 0.26). There was no evidence for selective benefit with ibuprofen among most subgroups defined before analysis (presence of otalgia; previous duration of symptoms; temperature >37.5°C; severe symptoms), but there was evidence of reduced symptoms severity benefit in the subgroup with chest infections (ibuprofen −0.40, −0.78 to −0.01; combination −0.47; −0.84 to −0.10), equivalent to almost one in two symptoms rated as a slight rather than a moderately bad problem. Children might also benefit from treatment with ibuprofen (ibuprofen: −0.47, −0.76 to −0.18; combination: −0.04, −0.31 to 0.23). Reconsultations with new/unresolved symptoms or complications were documented in 12% of those advised to take paracetamol, 20% of those advised to take ibuprofen (adjusted risk ratio 1.67, 1.12 to 2.38), and 17% of those advised to take the combination (1.49, 0.98 to 2.18). Mild thermal injury with steam was documented for four patients (2%) who returned full diaries, but no reconsultations with scalding were documented.

Conclusion
Overall advice to use steam inhalation, or ibuprofen rather than paracetamol, does not help control symptoms in patients with acute respiratory tract infections and must be balanced against the possible progression of symptoms during the next month for a minority of patients. Advice to use ibuprofen might help short term control of symptoms in those with chest infections and in children.

Non-publication of large randomized clinical trials: cross sectional analysis

October 30, 2013 Comments off

Non-publication of large randomized clinical trials: cross sectional analysis
Source: British Medical Journal

Objective
To estimate the frequency with which results of large randomized clinical trials registered with ClinicalTrials.gov are not available to the public.

Design
Cross sectional analysis

Setting
Trials with at least 500 participants that were prospectively registered with ClinicalTrials.gov and completed prior to January 2009.

Data sources
PubMed, Google Scholar, and Embase were searched to identify published manuscripts containing trial results. The final literature search occurred in November 2012. Registry entries for unpublished trials were reviewed to determine whether results for these studies were available in the ClinicalTrials.gov results database.

Main outcome measures
The frequency of non-publication of trial results and, among unpublished studies, the frequency with which results are unavailable in the ClinicalTrials.gov database.

Results
Of 585 registered trials, 171 (29%) remained unpublished. These 171 unpublished trials had an estimated total enrollment of 299 763 study participants. The median time between study completion and the final literature search was 60 months for unpublished trials. Non-publication was more common among trials that received industry funding (150/468, 32%) than those that did not (21/117, 18%), P=0.003. Of the 171 unpublished trials, 133 (78%) had no results available in ClinicalTrials.gov.

Conclusions
Among this group of large clinical trials, non-publication of results was common and the availability of results in the ClinicalTrials.gov database was limited. A substantial number of study participants were exposed to the risks of trial participation without the societal benefits that accompany the dissemination of trial results.

See: Unpublished Trial Data ‘Violates an Ethical Obligation’ to Study Participants, Say Researchers (Science Daily)

Residential exposure to aircraft noise and hospital admissions for cardiovascular diseases: multi-airport retrospective study

October 10, 2013 Comments off

Residential exposure to aircraft noise and hospital admissions for cardiovascular diseases: multi-airport retrospective study
Source: British Medical Journal

Objective
To investigate whether exposure to aircraft noise increases the risk of hospitalization for cardiovascular diseases in older people (≥65 years) residing near airports.

Design
Multi-airport retrospective study of approximately 6 million older people residing near airports in the United States. We superimposed contours of aircraft noise levels (in decibels, dB) for 89 airports for 2009 provided by the US Federal Aviation Administration on census block resolution population data to construct two exposure metrics applicable to zip code resolution health insurance data: population weighted noise within each zip code, and 90th centile of noise among populated census blocks within each zip code.

Setting
2218 zip codes surrounding 89 airports in the contiguous states.

Participants
6 027 363 people eligible to participate in the national medical insurance (Medicare) program (aged ≥65 years) residing near airports in 2009.

Main outcome measures
Percentage increase in the hospitalization admission rate for cardiovascular disease associated with a 10 dB increase in aircraft noise, for each airport and on average across airports adjusted by individual level characteristics (age, sex, race), zip code level socioeconomic status and demographics, zip code level air pollution (fine particulate matter and ozone), and roadway density.

Results
Averaged across all airports and using the 90th centile noise exposure metric, a zip code with 10 dB higher noise exposure had a 3.5% higher (95% confidence interval 0.2% to 7.0%) cardiovascular hospital admission rate, after controlling for covariates.

Conclusions
Despite limitations related to potential misclassification of exposure, we found a statistically significant association between exposure to aircraft noise and risk of hospitalization for cardiovascular diseases among older people living near airports.

See also: Aircraft noise and cardiovascular disease near Heathrow airport in London: small area study

Course of bereavement over 8-10 years in first degree relatives and spouses of people who committed suicide: longitudinal community based cohort study

October 10, 2013 Comments off

Course of bereavement over 8-10 years in first degree relatives and spouses of people who committed suicide: longitudinal community based cohort study
Source: British Medical Journal

Objective
To identify factors predicting the long term course of complicated grief, depression, and suicide ideation in a community based sample of relatives bereaved through suicide.

Design
Longitudinal cohort study. Included in the multilevel regression models were sociodemographic and personality features, mental health history, records of received help, long term complicated grief, depression, and suicide ideation.

Setting
Community based sample located in the northern part of the Netherlands.

Participants
153 first degree relatives and spouses of 74 people who had committed suicide.

Main outcome measures
Complicated grief, depression, and suicide ideation assessed at 2.5 months, 13 months and 96-120 months (8-10 years) by means of self report questionnaires.

Results
Complicated grief, depression, and suicide ideation were mutually associated in relatives and spouses of people who had committed suicide. A history of attempted suicide was associated with long term suicide ideation (odds ratio 5.5, 95% confidence interval 1.8 to 16.7; P=0.003). Depression was more likely to be predicted by female sex and low mastery, whereas complicated grief was more likely to be predicted by the trauma of losing a child. The risk of both complicated grief and depression decreased over time; for complicated grief the change corresponded with a Cohen’s d effect size of 0.36 at 13 months and 0.89 at 96-120 months; for depression these figures were 0.28 at 13 months and 0.94 at 96-120 months. The long term course of bereavement was not affected by family based cognitive behavioural therapy, support from a general practitioner, and/or mental healthcare. Mutual support was associated with an increased risk of complicated grief: B regression coefficient=6.4 (95% confidence interval 1.8 to 11.0; P=0.006). Throughout this long term study, selection bias might have affected some outcomes.

Conclusion
In relatives bereaved by suicide, suicide ideation is associated with an increased risk of long term complicated grief and depression. The risk of complicated grief and depression decreases over time. Although mutual support is associated with an increased risk of complicated grief, we could not draw conclusions about a causal relation.

The temporal relationship between drug supply indicators: an audit of international government surveillance systems

October 4, 2013 Comments off

The temporal relationship between drug supply indicators: an audit of international government surveillance systems
Source: British Medical Journal

Objectives
Illegal drug use continues to be a major threat to community health and safety. We used international drug surveillance databases to assess the relationship between multiple long-term estimates of illegal drug price and purity.

Design
We systematically searched for longitudinal measures of illegal drug supply indicators to assess the long-term impact of enforcement-based supply reduction interventions.

Setting
Data from identified illegal drug surveillance systems were analysed using an a priori defined protocol in which we sought to present annual estimates beginning in 1990. Data were then subjected to trend analyses.

Main outcome measures
Data were obtained from government surveillance systems assessing price, purity and/or seizure quantities of illegal drugs; systems with at least 10 years of longitudinal data assessing price, purity/potency or seizures were included.

Results
We identified seven regional/international metasurveillance systems with longitudinal measures of price or purity/potency that met eligibility criteria. In the USA, the average inflation-adjusted and purity-adjusted prices of heroin, cocaine and cannabis decreased by 81%, 80% and 86%, respectively, between 1990 and 2007, whereas average purity increased by 60%, 11% and 161%, respectively. Similar trends were observed in Europe, where during the same period the average inflation-adjusted price of opiates and cocaine decreased by 74% and 51%, respectively. In Australia, the average inflation-adjusted price of cocaine decreased 14%, while the inflation-adjusted price of heroin and cannabis both decreased 49% between 2000 and 2010. During this time, seizures of these drugs in major production regions and major domestic markets generally increased.

Conclusions
With few exceptions and despite increasing investments in enforcement-based supply reduction efforts aimed at disrupting global drug supply, illegal drug prices have generally decreased while drug purity has generally increased since 1990. These findings suggest that expanding efforts at controlling the global illegal drug market through law enforcement are failing.

Impact of 2008 global economic crisis on suicide: time trend study in 54 countries

October 4, 2013 Comments off

Impact of 2008 global economic crisis on suicide: time trend study in 54 countries
Source: British Medical Journal

Objective
To investigate the impact of the 2008 global economic crisis on international trends in suicide and to identify sex/age groups and countries most affected.

Design
Time trend analysis comparing the actual number of suicides in 2009 with the number that would be expected based on trends before the crisis (2000-07).

Setting
Suicide data from 54 countries; for 53 data were available in the World Health Organization mortality database and for one (the United States) data came the CDC online database.

Population
People aged 15 or above.

Main outcome measures
Suicide rate and number of excess suicides in 2009.

Results
There were an estimated 4884 (95% confidence interval 3907 to 5860) excess suicides in 2009 compared with the number expected based on previous trends (2000-07). The increases in suicide mainly occurred in men in the 27 European and 18 American countries; the suicide rates were 4.2% (3.4% to 5.1%) and 6.4% (5.4% to 7.5%) higher, respectively, in 2009 than expected if earlier trends had continued. For women, there was no change in European countries and the increase in the Americas was smaller than in men (2.3%). Rises in European men were highest in those aged 15-24 (11.7%), while in American countries men aged 45-64 showed the largest increase (5.2%). Rises in national suicide rates in men seemed to be associated with the magnitude of increases in unemployment, particularly in countries with low levels of unemployment before the crisis (Spearman’s rs=0.48).

Conclusions
After the 2008 economic crisis, rates of suicide increased in the European and American countries studied, particularly in men and in countries with higher levels of job loss.

The global burden of unsafe medical care: analytic modelling of observational studies

September 19, 2013 Comments off

The global burden of unsafe medical care: analytic modelling of observational studies
Source: British Medical Journal

Objective
To contextualise the degree of harm that comes from unsafe medical care compared with individual health conditions using the global burden of disease (GBD), a metric to determine how much suffering is caused by individual diseases.

Design
Analytic modelling of observational studies investigating unsafe medical care in countries’ inpatient care settings, stratified by national income, to identify incidence of seven adverse events for GBD modelling. Observational studies were generated through a comprehensive search of over 16 000 articles written in English after 1976, of which over 4000 were appropriate for full text review.

Results
The incidence, clinical outcomes, demographics and costs for each of the seven adverse events were collected from each publication when available. We used disability-adjusted life years (DALYs) lost as a standardised metric to measure morbidity and mortality due to specific adverse events. We estimate that there are 421 million hospitalisations in the world annually, and approximately 42.7 million adverse events. These adverse events result in 23 million DALYs lost per year. Approximately two-thirds of all adverse events, and the DALYs lost from them, occurred in low-income and middle-income countries.

Conclusions
This study provides early evidence that adverse events due to medical care represent a major source of morbidity and mortality globally. Though suffering related to the lack of access to care in many countries remains, these findings suggest the importance of critically evaluating the quality and safety of the care provided once a person accesses health services. While further refinements of the estimates are needed, these data should be a call to global health policymakers to make patient safety an international priority.

Suicides associated with the 2008-10 economic recession in England: time trend analysis

September 19, 2013 Comments off

Suicides associated with the 2008-10 economic recession in England: time trend analysis
Source: British Medical Journal

Objective
To determine whether English regions worst affected by the economic recession in the United Kingdom in 2008-10 have had the greatest increases in suicides.

Design
Time trend analysis comparing the actual number of suicides with those that would be expected if pre-recession trends had continued. Multivariate regression models quantified the association between changes in unemployment (based on claimant data) and suicides (based on data from the National Clinical Health Outcomes Database).

Setting
93 English regions, based on the Nomenclature of Territorial Units Statistics level 3 groupings of local authorities at county level and groups of unitary local authorities.

Participants
Men and women with a record of death from suicide or injury of undetermined cause in 2000-10.

Main outcome measure
Number of excess suicides during the economic recession (2008-10).

Results
Between 2008 and 2010, we found 846 (95% confidence interval 818 to 877) more suicides among men than would have been expected based on historical trends, and 155 (121 to 189) more suicides among women. Historically, short term yearly fluctuations in unemployment have been associated with annual changes in suicides among men but not among women. We estimated that each 10% increase in the number of unemployed men was significantly associated with a 1.4% (0.5% to 2.3%) increase in male suicides. These findings suggest that about two fifths of the recent increase in suicides among men (increase of 329 suicides, 126 to 532) during the 2008-10 recession can be attributed to rising unemployment.

Conclusion
The study provides evidence linking the recent increase in suicides in England with the financial crisis that began in 2008. English regions with the largest rises in unemployment have had the largest increases in suicides, particularly among men.

Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis

September 11, 2013 Comments off

Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis
Source: British Medical Journal

Clinical context
Dementia is age related and with an ageing global population is predicted to become an overwhelming and costly problem.

Diagnostic change
Introduction of broader diagnostic criteria for mild cognitive impairment and pre-dementia based on new cognitive screening tests coupled with cerebrospinal fluid biomarkers and neuroimaging.

Rationale for change
Past neglect of services and research in dementia has fuelled international calls for action and earlier treatment.

Leap of faith
People with mild symptoms will eventually develop dementia and interventions are more likely to be effective at an early stage.

Impact on prevalence
The current prevalence of dementia is thought to be 10-30% in people over the age of 80, but the adoption of new diagnostic criteria will result in up to 65% of this age group having Alzheimer’s disease diagnosed and up to 23% of non-demented older people being diagnosed with dementia.

Evidence of overdiagnosis
Screening for cognitive impairment and measurement of biomarkers and neuroimaging are increasing the diagnosis of mild cognitive impairment, which in many people will improve spontaneously.

Harms from overdiagnosis
Unnecessary investigation and treatments with side effects; adverse psychological and social outcomes; and distraction of resources and support from those with manifest dementia in whom need is greatest.

Limitations
Current case identification and screening policy relies mostly on anecdotal and observational data from potentially biased sources, including those with vested commercial interests, rather than evidence from clinical trials. There is a lack of research focused on older people, in whom dementia is most prevalent.

Conclusions
Current policy is rolling out untested and uncontrolled experiments in the frailest people in society without a rigorous evaluation of its benefits and harms to individuals, families, service settings, and professionals.

Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies

September 4, 2013 Comments off

Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies
Source: British Medical Journal

Objective
To determine whether individual fruits are differentially associated with risk of type 2 diabetes.

Design
Prospective longitudinal cohort study.

Setting
Health professionals in the United States.

Participants
66 105 women from the Nurses’ Health Study (1984-2008), 85 104 women from the Nurses’ Health Study II (1991-2009), and 36 173 men from the Health Professionals Follow-up Study (1986-2008) who were free of major chronic diseases at baseline in these studies.

Main outcome measure
Incident cases of type 2 diabetes, identified through self report and confirmed by supplementary questionnaires.

Results
During 3 464 641 person years of follow-up, 12 198 participants developed type 2 diabetes. After adjustment for personal, lifestyle, and dietary risk factors of diabetes, the pooled hazard ratio of type 2 diabetes for every three servings/week of total whole fruit consumption was 0.98 (95% confidence interval 0.96 to 0.99). With mutual adjustment of individual fruits, the pooled hazard ratios of type 2 diabetes for every three servings/week were 0.74 (0.66 to 0.83) for blueberries, 0.88 (0.83 to 0.93) for grapes and raisins, 0.89 (0.79 to 1.01) for prunes, 0.93 (0.90 to 0.96) for apples and pears, 0.95 (0.91 to 0.98) for bananas, 0.95 (0.91 to 0.99) for grapefruit, 0.97 (0.92 to 1.02) for peaches, plums, and apricots, 0.99 (0.95 to 1.03) for oranges, 1.03 (0.96 to 1.10) for strawberries, and 1.10 (1.02 to 1.18) for cantaloupe. The pooled hazard ratio for the same increment in fruit juice consumption was 1.08 (1.05 to 1.11). The associations with risk of type 2 diabetes differed significantly among individual fruits (P<0.001 in all cohorts).

Conclusion
Our findings suggest the presence of heterogeneity in the associations between individual fruit consumption and risk of type 2 diabetes. Greater consumption of specific whole fruits, particularly blueberries, grapes, and apples, is significantly associated with a lower risk of type 2 diabetes, whereas greater consumption of fruit juice is associated with a higher risk.

Maternal obesity during pregnancy and premature mortality from cardiovascular event in adult offspring: follow-up of 1 323 275 person years

August 14, 2013 Comments off

Maternal obesity during pregnancy and premature mortality from cardiovascular event in adult offspring: follow-up of 1 323 275 person years
Source: British Medical Journal

Objectives
To determine whether maternal obesity during pregnancy is associated with increased mortality from cardiovascular events in adult offspring.

Design
Record linkage cohort analysis.

Setting
Birth records from the Aberdeen Maternity and Neonatal databank linked to the General Register of Deaths, Scotland, and the Scottish Morbidity Record systems.

Population
37 709 people with birth records from 1950 to present day.

Main
outcome measures Death and hospital admissions for cardiovascular events up to 1 January 2012 in offspring aged 34-61. Maternal body mass index (BMI) was calculated from height and weight measured at the first antenatal visit. The effect of maternal obesity on outcomes in offspring was tested with time to event analysis with Cox proportional hazard regression to compare outcomes in offspring of mothers in underweight, overweight, or obese categories of BMI compared with offspring of women with normal BMI.

Results
All cause mortality was increased in offspring of obese mothers (BMI >30) compared with mothers with normal BMI after adjustment for maternal age at delivery, socioeconomic status, sex of offspring, current age, birth weight, gestation at delivery, and gestation at measurement of BMI (hazard ratio 1.35, 95% confidence interval 1.17 to 1.55). In adjusted models, offspring of obese mothers also had an increased risk of hospital admission for a cardiovascular event (1.29, 1.06 to 1.57) compared with offspring of mothers with normal BMI. The offspring of overweight mothers also had a higher risk of adverse outcomes.

Conclusions
Maternal obesity is associated with an increased risk of premature death in adult offspring. As one in five women in the United Kingdom is obese at antenatal booking, strategies to optimise weight before pregnancy are urgently required.

Related editorial: Maternal obesity and heart disease in the offspring

Consumers’ estimation of calorie content at fast food restaurants: cross sectional observational study

May 24, 2013 Comments off

Consumers’ estimation of calorie content at fast food restaurants: cross sectional observational study

Source: British Medical Journal

Objective
To investigate estimation of calorie (energy) content of meals from fast food restaurants in adults, adolescents, and school age children.

Design
Cross sectional study of repeated visits to fast food restaurant chains.

Setting
89 fast food restaurants in four cities in New England, United States: McDonald’s, Burger King, Subway, Wendy’s, KFC, Dunkin’ Donuts.

Participants
1877 adults and 330 school age children visiting restaurants at dinnertime (evening meal) in 2010 and 2011; 1178 adolescents visiting restaurants after school or at lunchtime in 2010 and 2011.

Main outcome measure
Estimated calorie content of purchased meals.

Results
Among adults, adolescents, and school age children, the mean actual calorie content of meals was 836 calories (SD 465), 756 calories (SD 455), and 733 calories (SD 359), respectively. A calorie is equivalent to 4.18 kJ. Compared with the actual figures, participants underestimated calorie content by means of 175 calories (95% confidence interval 145 to 205), 259 calories (227 to 291), and 175 calories (108 to 242), respectively. In multivariable linear regression models, underestimation of calorie content increased substantially as the actual meal calorie content increased. Adults and adolescents eating at Subway estimated 20% and 25% lower calorie content than McDonald’s diners (relative change 0.80, 95% confidence interval 0.66 to 0.96; 0.75, 0.57 to 0.99).

Conclusions
People eating at fast food restaurants underestimate the calorie content of meals, especially large meals. Education of consumers through calorie menu labeling and other outreach efforts might reduce the large degree of underestimation.

The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers

May 22, 2013 Comments off

The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers

Source: British Medical Journal

Objective

To examine the mortality experience of psychiatric patients in Western Australia compared with the general population.

Design

Population based study.

Setting

Western Australia, 1985-2005.

Participants

Psychiatric patients (292 585) registered with mental health services in Western Australia.

Main outcome measures

Trends in life expectancy for psychiatric patients compared with the Western Australian population and causes of excess mortality, including physical health conditions and unnatural causes of death.

Results

When using active prevalence of disorder (contact with services in previous five years), the life expectancy gap increased from 13.5 to 15.9 years for males and from 10.4 to 12.0 years for females between 1985 and 2005. Additionally, 77.7% of excess deaths were attributed to physical health conditions, including cardiovascular disease (29.9%) and cancer (13.5%). Suicide was the cause of 13.9% of excess deaths.

Conclusions

Despite knowledge about excess mortality in people with mental illness, the gap in their life expectancy compared with the general population has widened since 1985. With most excess deaths being due to physical health conditions, public efforts should be directed towards improving physical health to reduce mortality in people with mental illness, in addition to ongoing efforts to prevent suicide.

See also: Premature death among people with mental illness (editorial)

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