David Metcalfe

Media coverage and public reaction to a celebrity cancer diagnosis.

BACKGROUNDnCelebrity diagnoses can have important effects on public behaviour. UK television celebrity Jade Goody died from cervical cancer in 2009. We investigated the impact of her illness on media coverage of cervical cancer prevention, health information seeking behaviour and cervical screening coverage.nnnMETHODSnNational UK newspaper articles containing the words Jade Goody and cancer were examined for public health messages. Google Insights for Search was used to quantify Internet searches as a measure of public health information seeking. Cervical screening coverage data were examined for temporal associations with this story.nnnRESULTSnOf 1203 articles, 116 (9.6%) included a clear public health message. The majority highlighted screening (8.2%). Fewer articles provided advice about vaccination (3.0%), number of sexual partners (1.4%), smoking (0.6%) and condom use (0.4%). Key events were associated with increased Internet searches for cervical cancer and smear test, although only weakly with searches for HPV. Cervical screening coverage increased during this period.nnnCONCLUSIONnIncreased public interest in disease prevention can follow a celebrity diagnosis. Although media coverage sometimes included public health information, articles typically focused on secondary instead of primary prevention. There is further potential to maximize the public health benefit of future celebrity diagnoses.

Obesity and diabetes: lipids, ‘nowhere to run to'

Although specific pathogenic entities contributing to diabetic risk, such as central adiposity, ectopic fat accumulation, hyperlipidaemia and inflammation, are well-characterized, the response of cellular systems to such insults are less well understood. This short review highlights the effect of increasing fat mass on ectopic fat accumulation, the role of triacylglycerols (triglycerides) in Type 2 diabetes mellitus and cardiovascular disease pathogenesis, and selected current therapeutic strategies used to ameliorate these risk factors.

Ultrasound and shockwave therapy for acute fractures in adults.

BACKGROUNDnThe morbidity and socioeconomic costs of fractures are considerable. The length of time to healing is an important factor in determining a persons recovery after a fracture. Ultrasound may have a therapeutic role in reducing the time to union after fracture. This is an update of a review previously published in February 2012.nnnOBJECTIVESnTo assess the effects of low-intensity ultrasound (LIPUS), high-intensity focused ultrasound (HIFUS) and extracorporeal shockwave therapies (ECSW) as part of the treatment of acute fractures in adults.nnnSEARCH METHODSnWe searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (2 June 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 5), MEDLINE (1946 to May Week 3 2014), EMBASE (1980 to 2014 Week 22), trial registers and reference lists of articles.nnnSELECTION CRITERIAnRandomised and quasi-randomised controlled trials evaluating ultrasound treatment in the management of acute fractures in adults. Studies had to include participants over 18 years of age with acute fractures, reporting outcomes such as function; time to union; non-union; secondary procedures such as for fixation or delayed union or non-union; adverse effects; pain; costs; and patient adherence.nnnDATA COLLECTION AND ANALYSISnTwo authors independently extracted data from the included studies. Treatment effects were assessed using mean differences, standardised mean differences or risk ratios using a fixed-effect model, except where there was substantial heterogeneity, when data were pooled using a random-effects model. Results from worst case analyses, which gave more conservative estimates of treatment effects for time to fracture union, are reported in preference to those from as reported analyses.nnnMAIN RESULTSnWe included 12 studies, involving 622 participants with 648 fractures. Eight studies were randomised placebo-controlled trials, two were randomised controlled trials without placebo controls, one was a quasi-randomised placebo-controlled trial and one was a quasi-randomised controlled trial without placebo control. Eleven trials tested LIPUS and one trial tested ECSW. Four trials included participants with conservatively treated upper limb complete fractures and six trials included participants with lower limb complete fractures; these were surgically fixed in four trials. The remaining two trials reported results for conservatively treated tibial stress fractures.Risk of bias assessment of the included studies was hampered by the poor reporting of methods, frequently resulting in the risk of bias of individual domains being judged as unclear. Both quasi-randomised studies were at high risk of bias, including selection and attrition bias. Three studies were at low risk of selection bias relating to allocation concealment the majority of studies were at low risk of performance bias as they employed a form of intervention blinding.Only limited data were available from three of only four studies reporting on functional outcome. One study of complete fractures found little evidence of a difference between the two groups in the time to return to work (mean difference (MD) 1.95 days favouring control, 95% confidence interval (CI) -2.18 to 6.08; 101 participants). Pooled data from two studies found LIPUS did not significantly affect the time to return to training or duty in soldiers or midshipmen with stress fractures (MD -8.55 days, 95% CI -22.71 to 5.61; 93 participants).We adopted a conservative strategy for data analysis that was more likely to underestimate than to overestimate a benefit of the intervention. After pooling results from eight studies (446 fractures), the data showed no statistically significant reduction in time to union of complete fractures treated with LIPUS (standardised mean difference (SMD) -0.47, 95% CI -1.14 to 0.20). This result could include a clinically important benefit or harm, and should be seen in the context of the highly significant statistical heterogeneity (I² = 90%). This heterogeneity was not explained by the a priori subgroup analyses (upper limb versus lower limb fracture, smoking status). An additional subgroup analysis comparing conservatively and operatively treated fractures raised the possibility that LIPUS may be effective in reducing healing time in conservatively managed fractures, but the test for subgroup differences did not confirm a significant difference between the subgroups.Pooled results from five of the eight trials (333 fractures) reporting proportion of delayed union or non-union showed no significant difference between LIPUS and control (10/168 versus 13/165; RR 0.75; 95% CI 0.24 to 2.28). Adverse effects directly associated with LIPUS and associated devices were found to be few and minor, and compliance with treatment was generally good. One study reporting on pain scores found no difference between groups at eight weeks (101 participants).One quasi-randomised study found no significant difference in non-union at 12 months between internal fixation supplemented with ECSW and internal fixation alone (3/27 versus 6/30; RR 0.56, 95% CI 0.15 to 2.01). There was a clinically small but statistically significant difference in the visual analogue scores for pain in favour of ECSW at three month follow-up (MD -0.80, 95% CI -1.23 to -0.37). The only reported complication was infection, with no significant difference between the two groups.nnnAUTHORS CONCLUSIONSnWhile a potential benefit of ultrasound for the treatment of acute fractures in adults cannot be ruled out, the currently available evidence from a set of clinically heterogeneous trials is insufficient to support the routine use of this intervention in clinical practice. Future trials should record functional outcomes and follow-up all trial participants.

Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres

Centralization of complex healthcare services into specialist high‐volume centres is believed to improve outcomes. For injured patients, few studies have evaluated the centralization of major trauma services. The aim of this study was to evaluate how a regional trauma network affected trends in admissions, case mix, and outcomes of injured patients.

Glucocorticoid injections in lesions of the achilles tendon.

Background: A number of non-operative interventions are used to manage Achilles tendinopathy. In particular, local glucocorticoid injections have generated controversy. Although a number of case reports indicate symptomatic relief following glucocorticoid injection, one systematic review found little evidence to support their efficacy. Furthermore, local glucocorticoid injections may be associated with rupture of the Achilles tendon. This systematic review considered all available clinical trials measuring the effect of local glucocorticoid injections on symptom relief in patients with Achilles tendinopathy. Materials and Methods: The search strategy encompassed five databases: Medline, EMBASE, CINAHL, AMED and the Cochrane Library. Only studies reporting the outcome of glucocorticoid injection for Achilles tendinopathy were included. Results: A total of 72 articles were identified, five of which met the inclusion criteria. These included one randomized controlled trial, three retrospective studies, and one prospective case series. Conclusion: There is no consensus as to whether local glucocorticoid injections have a therapeutic role in the treatment of Achilles tendinopathy However, they may incur a risk of tendon damage and therefore further research is required before glucocorticoid injections can be recommended for use in Achilles tendinopathy. Level of Evidence: III, Systematic Review of Level I-IV Studies

Involving medical students in research

Undergraduate research is not a new phenomenon in medicine. Charles Best was a medical student at the time that he and his supervisor, Frederick Banting, discovered insulin. Insulin arises from the pancreatic islets of Langerhans, themselves discovered in 1869 by medical student Paul Langerhans. In biomedical research, Alan Hodgkin, formerly professor of biophysics at the University of Cambridge, won the Nobel Prize in 1972 for work on nerve transmission that he began as an undergraduate. n nMedical student research can be mandatory, elective or extracurricular. In Germany, medical school graduates practice medicine but cannot assume the title ‘Doctor’ until they have submitted a thesis. As a result, around 90% of practicing German physicians have undertaken a period of research.1 Although research is usually voluntary for UK medical students, there is increasing undergraduate interest in research and publication. The 2007 MTAS form, for example, awards credit to medical graduates for a first author paper in a peer-reviewed journal. n nThe GMC document Tomorrows Doctors states that medical school graduates must be able to ‘critically evaluate evidence’ and ‘use research skills to develop greater understanding and to influence their practice’.2 It has been suggested that a period of research might help fulfill this requirement of new doctors.3,4 Despite this possibility, medical students have only limited opportunities to pursue original research. However, a number of institutions offer intercalated degree courses in which students suspend their medical training to undertake a second degree, often with a strong research component. These attract around a third of UK medical students each year.5,6 n nReasons for medical students choosing to intercalate are varied and include improving their long-term career prospects as well as establishing a broad knowledge base.6 The opportunity to conduct original research is, however, less frequently given as a reason for pursuing an intercalated degree.5,6 In addition, two thirds of new doctors in the UK have not undertaken an intercalated degree5,6 and may graduate without experiencing research. A number of barriers explain the reluctance of medical students to intercalate. One survey found the most common reasons were financial constraints, lack of interest, and reluctance to prolong medical training.6 n nNevertheless, there are many benefits of undergraduate participation in research. For example, student researchers can greatly increase the publication output of their medical school. Academic supervisors at one German institution have reported that students appear as co-authors on approximately 28% of papers published in Medline-indexed journals.8 n nResearch experience may also boost the career profile of graduating medical students. When a cohort of students at the Stanford University School of Medicine was encouraged to participate in research, 75% gained authorship of a paper and 52% presented data to a national conference.3 In Germany, around 66% of medical students obtain a Medline-indexed publication before qualifying. This does not include data presented to meetings or published in peer-reviewed journals not indexed by Medline.8 n nIn addition to boosting graduate employability, publication as an undergraduate can have long-term career implications for doctors. For example, one survey of academic physicians found that career success is independently associated with having conducted research as a student.9 In addition, physicians who undertook extracurricular research at medical school produced four times as many publications as their peers.10 n nUndergraduate research may also provide a solution for countries in which academic medicine is experiencing a crisis in recruiting postgraduate clinical researchers.11 For example, a survey of medical student researchers found that 75% were motivated to pursue further research and 60% aspired to a full-time academic career.3 n nThose students not considering research careers may nevertheless develop skills transferable to clinical practice. In particular, medical student research may help instil a culture of evidence-based medicine (EBM) in clinical medicine. According to one author, ‘the practice of EBM is not a “behaviour”… it is an internalized spirit of enquiry born of a deep understanding… of the value and the limitations of biomedical research’.5 Indeed, there is evidence to suggest that research experience as an undergraduate may foster this ‘deeper understanding’.3–5 According to one survey, American medical students participating in research found that the experience ‘taught them to ask questions, review the literature critically, and analyse data’.3 Students undertaking a mandatory literature review further developed ‘critical appraisal, information literacy, and critical thinking skills’ and the opportunity to make ‘contacts for postgraduate training’.4 n nDespite these apparent benefits, there are objections to involving undergraduates in research. Intensive projects may, for example, disrupt the progress of students through the core medical curriculum. Similarly, supervision requirements may distract faculty members from their own clinical and research commitments. However, students do not have to run a clinical trial to learn about the research process. If there are not pre-existing clinical projects suitable for student participation, undergraduates might be involved in critically appraising literature for a review article, or preparing patient case reports for publication. Projects such as these require little supervision while still immersing students in the research culture of their profession. n nIn summary, research opportunities for medical students are often confined to intercalated degree courses; potentially increasing financial burden, prolonging the curriculum and delaying clinical experience. As a result, around two thirds of medical students eschew the opportunity to intercalate5,6 and miss out on conducting original research. Nevertheless, the benefits of student participation in research are well-documented for graduates, institutions and the academic community as a whole.3–5,7–10 As a result, senior doctors should strongly consider involving motivated students in elective or extracurricular research projects. Furthermore, medical educators should recognize the value of student research and incorporate opportunities into the curriculum wherever practicable. Only in these ways can we secure a future for academic medicine and foster a genuine respect for EBM in tomorrows doctors.

Should doctors spurn Wikipedia

Wikipedia is a free, online encyclopedia that anyone can edit, regardless of experience or qualification. It is the most frequently used online educational resource with 17 million articles appearing in 262 languages. The English version alone claims over 3.1 million articles and attracts 65 million visitors every month.1 Anecdotally, it is a popular medical student resource with almost 9000 trainee doctors joining the online group ‘Wikipedia is helping me get through med school!’. Wikipedia use among junior physicians is as high as 70%.2 n nThese observations are unsurprising given the increasing reliance of doctors on Internet resources. One survey of radiology trainees suggested 83% use the Internet as their ‘first port of call’.3 Despite widespread use, Wikipedia has received criticism. Doctors and medical students are frequently discouraged from relying on Wikipedia as a source of information given concerns about its accuracy and provenance. n nAlthough Wikipedia entries are often poorly structured and difficult to understand4 they are comparable in accuracy to some online resources, such as health insurance websites.5 Clauson et al. found Wikipedia answered only 40% of pharmaceutical questions compared with the Medscape Drug Reference (MDR) which answered 82.5%. Wikipedia articles were less complete (76%) than the MDR entries (95.5%) but no factual inaccuracies were identified in any drug-related Wikipedia article.6 Another survey found Wikipedia compared favorably with the Encyclopedia Britannica.5 n nThere are particular concerns over the value of Wikipedia as an educational resource. For example, one study found it to be less efficient than Google or other search engines for medical students answering multiple choice questions.7 However, there is evidence to suggest that Wikipedia is a more dynamic source than textbooks given its potential for immediate updating. One survey of Wikipedia healthcare articles found they were well-referenced to recent scholarly literature.1 n nThe accuracy of Wikipedia relies on two premises. First, that interested and informed parties are more likely to correct entries than casual readers. A survey of Nature contributors found that 17% regularly used Wikipedia, suggesting a substantial pool of professional scientists engage with this resource.4 However, there is little evidence to date on how many ‘experts’ actively contribute. The second premise is that such high volume readership (e.g. 2.5 billion views per month) should ensure errors are swiftly erased.8 Magnus intentionally introduced small errors into biographical articles about deceased philosophers and found 50% were corrected within 48 hours.9 n nThere is a risk of deliberate misuse. For example, Independent columnist Johann Hari admitted in September this year to maliciously editing articles about people he disliked. These amendments introduced allegations of anti-semitism, homophobia and drunkenness.10 Similar cases have been reported on a number of occasions8 and raise the possibility of unscrupulous parties editing healthcare-related articles. However, a Nature survey of Wikipedia articles concluded that such high profile incidents are an exception rather than the rule.4 n nAlthough considered an unsatisfactory authority for doctors and medical students, Wikipedia cannot be disregarded because of its perceived credibility deficit. It is currently the seventh most frequently visited website on the Internet11 and appears within the top 10 search results when users search for specific medical terms.12 n nThere is a growing literature to suggest patients and their relatives use the Internet to answer health concerns.13 These online information seekers depend on the accuracy of resources such as Wikipedia which, in turn, rely on the knowledge, conscientiousness and objectivity of its contributors. One risk of clinicians disengaging from Wikipedia is that only contributors motivated by personal experience (e.g. patient anecdote) or vested interests (e.g. individual clinicians, institutions or companies promoting their own ideas and products) will remain. Legitimate authorities would be discouraged from contributing to healthcare articles online. This risks crippling a significant online information resource and missing an opportunity to provide accurate and reliable health information to millions worldwide. n nMost reports suggest that initial skepticism about Wikipedia by the academic community may have been over-stated. There are now many examples of researchers engaging constructively with this resource, including graduate students earning credit from updating articles.14 n nRecent work has proposed that members of the ‘Net Generation’ naturally engage with user-created resources such as Wikipedia.15 The evidence suggests that Wikipedia can have legitimate educational uses for individuals. These include a quick resource for finding general information and as an instrument for preliminary literature searching.1 The uncertain providence of information on Wikipedia should remind doctors to exercise caution when receiving established ‘fact’ from any source, whether online, published, or spoken by a senior colleague. If medical professionals can be encouraged to actively engage with Wikipedia, they may become involved in correcting errors as they are identified. Wikipedia is a rare opportunity for doctors to interact with an educational resource while helping develop an important public health information tool.

A negative association between condom availability and incidence of urethral discharge in a closed Malawian community

Condom promotion in sub-Saharan Africa has been accused by some conservative groups of encouraging promiscuity. This study explored the relationship between condom availability and sexually transmitted infection (STI) incidence in a closed Malawian community. An audit of clinic records charted the changing availability of condoms and the concurrent incidence of patients presenting with STI-associated urethral discharge (UD). When condoms first became available, their distribution steadily increased and the UD incidence declined. During a three-month period of unavailability, this previously uninterrupted decline was reversed and UD incidence increased. Once condoms again became available, UD incidence resumed its decline. This association was found to be statistically significant (Spearmans correlation coefficient, −0.499; P = 0.035). In a small community largely isolated from neighbouring towns, condom distribution appeared to negatively correlate with the number of patients presenting with UD. This may challenge the local belief that condoms have a damaging effect on sexual health in Malawi.

Inequalities in access to total hip arthroplasty for hip fracture: a population-based study

Abstract Background In June, 2011, the National Institute for Health and Care Excellence (NICE) recommended that total hip arthoplasty (THA) should be offered to a defined group of patients with displaced intracapsular hip fractures. We sought to determine whether national practice was consistent with national recommendations, or whether systematic inequalities exist in accessing THA for hip fracture. Methods Data for this observational study came from the UK National Hip Fracture Database (NHFD), which records data from all hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland. Included were all patients within the NHFD who were aged over 60 and received operative treatment for a non-pathological displaced intracapsular hip fracture between July 1, 2011, and April 30, 2015. Provision of THA to patients eligible under criteria published by NICE were analysed with recursive partitioning and logistic regression. Findings 114 119 patients with hip fracture were included, of whom 11 683 (10%) underwent THA. Recursive partitioning showed that NICE eligibility criteria did not optimally explain THA. Among patients satisfying NICE criteria, logistic regression demonstrated that access to THA was restricted by higher age (odds ratio 0·88, 95% CI 0·87–0.88), lower Abbreviated Mental Test Score (1·44, 1·34–1·54), higher American Society of Anesthesiologists score (0·74, 0·66–0·84), male sex (0·85, 0·77–0·93), walking with a stick (0·32, 0·28–0·35), and quintiles of increasing socioeconomic deprivation (1·0 [referent]; lowest vs highest quintile 1·30, 1·13–1·51). Patients treated during the week were more likely to receive THA than those treated at the weekend (1·12, 1·04–1·21). Interpretation There are wide disparities in access to THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those requiring surgery at the weekend are less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimum treatment for older adults with hip fractures can depend on where and when they present to hospital. Funding National Institute for Health Research.

Subarachnoid Haemorrhage with Pituitary Adenoma

Pituitary apoplexy is an uncommon syndrome typically resulting from ischaemic or haemorrhagic necrosis of an existing pituitary adenoma. Patients classically present with sudden-onset severe headache, reduced consciousness, and meningeal irritation. For this reason, the clinical picture is frequently mistaken as being caused by aneurysmal subarachnoid haemorrhage (SAH). It is necessary to distinguish preoperatively between pituitary apoplexy and SAH as there are reports of inappropriate craniotomy being performed with a view to clipping nonexistent aneurysms. Importantly, transsphenoidal excision of a pituitary adenoma risks rupture of an unidentified intracranial aneurysm. This is particularly significant given the established association between pituitary adenoma and development of intracranial aneurysms. This chapter reviews the epidemiology and pathophysiology underlying the relationship between pituitary tumours, intracranial aneurysms, and SAH. It also makes evidence-based recommendations for the investigation of patients with suspected pituitary apoplexy to identify associated conditions preoperatively and manage the risk of iatrogenic aneurysm rupture.