The Lucky Iron Fish ™: a simple solution for a global problem

Fighting iron deficiency anaemia much better than tablets

The Lucky Iron Fish is a social enterprise dedicated to reducing iron deficiency rates around the world. Cooking with this specially formulated iron ingot can release up to 75% of a persons daily required iron intake.

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L’influence de la presse médicale sur les prescriptions des médecins

Facteurs influençant les prescriptions médicales…

image de médecin-lisant
Dans sa thèse, Etienne Lassalle montre que les prescriptions des médecins sont significativement majoritairement orientées dans la même direction que la ligne éditoriale des revues médicales que les médecins lisent… Image de Jonah.

Etienne Lassalle, dans sa THESE POUR LE DIPLOME D’ETAT DE DOCTEUR EN MEDECINE, a analysé le contenu de deux revues totalement différentes:

  • la revue Prescrire® (indépendante)
  • le Quotidien du Médecin (financé en partie par la publicité des médicaments)

La différence flagrante et importante entre les prescriptions des médecins lecteurs de ces deux revues montre qu’alors que nous sommes au lendemain de scandales sanitaires sans précédent – Distilbène® – Médiator® – ce sont bien les patients de ces lecteurs de revues qui bénéficieront ou non de prescriptions de qualité.

Pour reprendre l’expression du Docteur Philippe Foucras – président fondateur du Formindep – il est donc urgent qu’une très importante prise de conscience ait lieu en France sur ce facteur de risque sanitaire majeur.

En savoir plus:

  • THESE POUR LE DIPLOME D’ETAT DE DOCTEUR EN MEDECINE, voixmedicales, 12 mai 2015.
  • Influence de la presse médicale sur les prescriptions des médecins généralistes libéraux. Etude quantitative en Haute-Vienne (Thèse de Étienne Lasalle le 12 mai 2015), voixmedicales, 30 mai 2015.

The alarming tendency to overuse preventive health services

Is clinical prevention better than cure?

image of doctors-and-patients
In Europe, evidence shows an alarming tendency to overuse preventive health services . Seattle Municipal Archives.

” …if we want to prevent overdiagnosis and other potential harms related to excessive, not evidence-based, use of medical tests by healthy people, we should start designing strategies of communication to explain to our populations what is meant by potential harms, false positives, and overdiagnosis. Only by understanding these meanings and knowing the probabilities of being benefited or harmed, will the patient be able to make a shared decision and to avoid a consumeristic model of medical tests utilization. ”

Read Overuse of medical tests—a new health risk factor?
by Carlos Martins, 24 Apr, 2015.

Umbrella Trials and Bucket Trials explained

Never heard about Umbrella Trials or Bucket Trials? Watch this video

Never heard about Umbrella Trials or Bucket Trials? Watch Roche latest Drawn to Science video – published on 20 May 2015 – on clinical trials.

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  • As our understanding of disease advances, traditional clinical trial designs are becoming less and less viable. Two innovations in this area – the Umbrella trial and the Bucket (or Basket) trial – allow researchers to assess the safety and efficacy of new targeted drugs more efficiently. In addition, adaptive trial design offers the possibility to amend the clinical study protocol to reflect new insights or research data while the study is still ongoing. These innovations, which are all being used by Roche, allow us to bring new medicines to patients as fast and as efficiently as possible.
  • Watch more research videos on our YouTube channel.

One full pound extra daily gain for four months, 1956 DES Stilbosol advert

Stilbosol patenting turned the cattle feed industry upside down in the mid fifties with its phenomenal use by the farmers

1956-stilbosol-advert image
Stilbosol patenting turned the cattle feed industry upside down in the mid fifties with its phenomenal use by the farmers.
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The interactive effects of climate change and endocrine disrupting chemicals on population viability

Climate change could worsen effects of EDC pollution

Smokestacks-against-skyline
The study results indicate that higher temperatures associated with climate change can amplify the effects of EDCs.
Image by World Bank Photo Collection.

2014 Study Significance

Climate change impacts on wildlife populations are likely to be accentuated by pollution. Small (inbred) populations may be more vulnerable to these effects, but empirical data supporting these hypotheses are lacking. We present the first substantial empirical evidence, to our knowledge, for interactive effects on population viability of elevated temperature (climate); an endocrine disrupting chemical, clotrimazole (pollution); and inbreeding. Using the zebrafish (Danio rerio) as a model, we show these three factors interact to skew population sex ratios toward males and that this interaction can lead to increased risk of extinction. Our results suggest that climate change and pollution impacts are likely to pose significant extinction risks for small, endangered populations exhibiting environmental sex determination and/or differentiation.

2014 Study Abstract

Endocrine disrupting chemicals (EDCs) are potent environmental contaminants, and their effects on wildlife populations could be exacerbated by climate change, especially in species with environmental sex determination. Endangered species may be particularly at risk because inbreeding depression and stochastic fluctuations in male and female numbers are often observed in the small populations that typify these taxa. Here, we assessed the interactive effects of water temperature and EDC exposure on sexual development and population viability of inbred and outbred zebrafish (Danio rerio). Water temperatures adopted were 28 °C (current ambient mean spawning temperature) and 33 °C (projected for the year 2100). The EDC selected was clotrimazole (at 2 μg/L and 10 μg/L), a widely used antifungal chemical that inhibits a key steroidogenic enzyme [cytochrome P450(CYP19) aromatase] required for estrogen synthesis in vertebrates. Elevated water temperature and clotrimazole exposure independently induced male-skewed sex ratios, and the effects of clotrimazole were greater at the higher temperature. Male sex ratio skews also occurred for the lower clotrimazole exposure concentration at the higher water temperature in inbred fish but not in outbred fish. Population viability analysis showed that population growth rates declined sharply in response to male skews and declines for inbred populations occurred at lower male skews than for outbred populations. These results indicate that elevated temperature associated with climate change can amplify the effects of EDCs and these effects are likely to be most acute in small, inbred populations exhibiting environmental sex determination and/or differentiation.

Sources and more information
  • Climate change could worsen effects of EDC pollution, chemtrust, MAY 7, 2015.
  • Climate change and pollution speed declines in zebrafish populations, E1237–E1246, doi: 10.1073/pnas.1416269112, January 26, 2015.

A Dose of Controversy: DateLine 2009 video

Exposed: Andrew Wakefield and the MMR-autism fraud

Brian Deer discusses early findings from his landmark Sunday Times investigation into the MMR vaccine crisis, launched from the UK. Video via vaccinevideos.

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DES Researchers Doctor Robert N. Hoover and Scientist Rebecca Troisi

The DCEG’s coprincipal investigators of the 1992 DES Follow-Up cohort study

Dr-Robert-Hoover
Dr. Robert Hoover and Rebecca Troisi, Sc.D., a staff scientist in EBP, have been DCEG’s coprincipal investigators of the 1992 DES Follow-Up cohort study.

Recognizing the need to continue observing DES-exposed mothers and their offspring, Dr. Robert N. Hoover reached out to several principal investigators at the various study centers and suggested reviving the cohorts and pooling the data to better answer the many questions that remained.

Dr. Hoover and Rebecca Troisi, Sc.D., a staff scientist in EBP, have been DCEG’s coprincipal investigators of the 1992 DES Follow-Up Study cohort study.

  • see the DES Follow-up Study Published Papers list.
  • watch Dr. Robert Hoover’s video interview.
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Choosing Wisely in the UK: an initiative to reduce the harms of too much medicine

Do I really need this test or procedure? What are the risks?
Are there simpler safer options? What happens if I do nothing?

This post content is published by The BMJ, aiming to lead the debate on health, and to engage doctors, researchers and health professionals to improve outcomes for patients.

A Malhotra and colleagues explain how and why a US initiative to get doctors to stop using interventions with no benefit is being brought to the UK.

The idea that some medical procedures are unnecessary and can do more harm than good is as old as medicine itself. In Mesopotamia 38 centuries ago, Hammurabi proclaimed a law threatening overzealous surgeons with the loss of a hand or an eye. In 1915, at the height of a surgical vogue for prophylactic appendicectomy, Ernest Codman offended his Boston colleagues with a cartoon mocking their indifference to outcomes and asking, “I wonder if clinical truth is incompatible with medical science? Could my clinical professors make a living without humbug?” Looking at the rates of tonsillectomy in London boroughs in the 1930s, John Alison Glover discovered that they were entirely governed by the policy of school doctors and bore no relation to need or outcomes. John (Jack) Wennberg established the science of outcomes research when in 1973 he described patterns of gross variation in the use of medical and surgical procedures in the United States, which lacked any clinical rationale but was closely related to supply.

Diagnosis drives treatment, and in recent years the term overdiagnosis has been used to describe various situations where diagnoses lead to unnecessary treatment, wasting resources while increasing patient anxiety. Overdiagnosis can be said to occur when “individuals are diagnosed with conditions that will never cause symptoms or death” often as a “consequence of the enthusiasm of early diagnosis.” Overtreatment includes treatment of these overdiagnosed conditions. It also encompasses treatment that has minimal evidence of benefit or is excessive (in complexity, duration, or cost) relative to alternative accepted standards. A recent report by the Academy of Medical Royal Colleges argued that doctors have an ethical responsibility to reduce this wasted use of clinical resource because, in a healthcare system with finite resources, one doctor’s waste is another patient’s delay.

Choosing Wisely in the NHS

Even before the inception of the NHS, the British tradition has generally been one of late adoption and cautious use of new medicines, procedures, and technologies. Nevertheless, the UK shows similar patterns of variation in use of medical and surgical interventions to those in the US, though less extreme in absolute terms. The National Institute for Health and Care Excellence (NICE) was set up in 1999 in part to address these unwarranted variations in clinical practice and has identified over 800 clinical interventions for potential disinvestment. However, engaging clinicians with stopping familiar or ingrained practices requires a different approach to that for introducing new treatments.

An initiative recently developed in the US and Canada called Choosing Wisely aims to change doctors’ practice to align with best practice by getting them to stop using various interventions that are not supported by evidence, free from harm, and truly necessary, including those that duplicate tests or procedures already received. Choosing Wisely asks medical organisations (such as medical royal colleges in the UK) to identify tests or procedures commonly used in their specialty, the necessity of which should be questioned and discussed. These are compiled into lists, and the “top five” interventions for each specialty should not be used routinely or at all. So far, more than 60 US specialist societies have joined in the Choosing Wisely initiative. It has also been adopted by other countries, including Australia, Germany, Italy, Japan, Netherlands, and Switzerland—a clear sign that wasteful medical practices are a problem for all health systems.

The Academy of Medical Royal Colleges, which represents all medical royal colleges in the UK, is launching a Choosing Wisely programme in collaboration with other clinical, patient, and healthcare organisations. Participating organisations will work together to develop top five lists of tests or interventions with questionable value. The academy, royal colleges, and partners, including The BMJ, will then promote dissemination of this information and Choosing Wisely conversations between clinicians and patients. These new conversations will rebalance discussions about the risks and benefits of tests and interventions, such that doctors and patients will be supported to acknowledge that a minor potential benefit may not outweigh potential harm, the minimal evidence base, and substantial financial expense and therefore that, sometimes, doing nothing might be the favourable option.

Tackling the underlying causes of overtreatment

A culture of “more is better,” where the onus is on doctors to “do something” at each consultation has bred unbalanced decision making. This has resulted in patients sometimes being offered treatments that have only minor benefit and minimal evidence despite the potential for substantial harm and expense. This culture threatens the sustainability of high quality healthcare and stems from defensive medicine, patient pressures, biased reporting in medical journals, commercial conflicts of interest, and a lack of understanding of health statistics and risk.

The system has no incentive to restrict doctors’ activity; the NHS in England has a system of payment by results, which in reality is often a payment by activity and encourages providers to do more both in primary and secondary care. General practice is increasingly pressured to focus less on open dialogue with patients about treatment options and more on fulfilling the demands of the Quality and Outcomes Framework (QOF, a pay for performance instrument) and adhering to local commissioning decisions.

The quality measures in both primary and secondary care are based on guidelines produced by NICE, but doctors should not consider these as tramlines because decisions need to be made with reference to individual patient circumstances, the wishes of the patient, clinical expertise, and available resources. Some people would choose to take a hypothetical pill with no side effects daily, even for a few weeks’ gain in life expectancy, whereas others would prefer not to, even if they were told it would add 10 years to their lifespan. It is instructive to note that a large and comprehensive longitudinal study recently concluded that higher reported achievement incentivised under QOF has not reduced premature death in the population.

We suggest that guideline committees should increasingly turn their efforts towards the production of tools that help clinicians to understand and share decisions on the basis of best evidence. Rather than prespecifying the outcome of such dialogue, and trying to get medicine “just right,” they should try to ensure that decisions are based on the best match between what is known about the benefits and harms of each intervention and the goals and preferences of each patient.

More informed decision making can also alleviate, perhaps disproportionate, fears for those patients who may not want treatment. A recent study revealed that when patients were told the lack of prognostic benefit for angioplasty, only 46% elected to go ahead with the procedure versus 69% who were not explicitly given this information. Responding to similar concerns about getting patients’ consent for elective coronary angioplasty in the UK, NHS England’s cardiology lead, Huon Gray, stated, “It is important that doctors are clear with their patients about this.”

It is easy to misunderstand health statistics, and doctors can find themselves needing to manage unrealistic expectations of patients who may find it difficult to obtain reliable information. Communicating relative risks as opposed to absolute risk or numbers needed to treat can often unintentionally mislead. As Gerd Gigerenzer, director of Harding Centre for Risk Literacy in Berlin, summarised in 2009, “It is an ethical imperative that every doctor and patient understand the difference between absolute and relative risks, to protect patients against unnecessary anxiety and manipulation.”

Doctors’ health illiteracy is well documented. Misunderstanding of statistics often leads to a belief that screening is more beneficial than it actually is and, in some cases, to no acknowledgment of its potential harms. In a study of 150 gynaecologists, one third did not understand the meaning of a 25% risk reduction from mammography. Many believed that if all women were screened 25% of women (or 250 fewer out of every 1000) would die of breast cancer, when actually the best evidence based estimate is actually one less death per 2000 women (from Cochrane’s analysis of randomised studies including 500 000 women).

Both medical and surgical overtreatment can place patients at high risk of adverse events. Shared decision making can help to reduce this overtreatment and may be particularly beneficial to disadvantaged groups, significantly improving health outcomes and reducing health inequalities.

Potential limitations

One of the major concerns about the development of top five lists in the US is the potential for individual societies to choose low hanging fruit. For example, the American Academy of Orthopaedic Surgeons included the use of an over the counter supplement but no major procedures, despite evidence of wide variation in elective knee replacement and arthroscopy rates among Medicare beneficiaries. Currently, there is also no evidence that lists reduce use of low value medical practices. One crucial and relevant marker of success would be universal awareness of the Choosing Wisely programme among doctors and patients. However, despite much publicity in the medical literature, a random telephone survey of 600 US doctors recently conducted by the American Board of Internal Medicine found that only 21% had heard of Choosing Wisely. The level of public awareness of the campaign, which is a fundamental component to its progress, has not been assessed.

Reducing wasteful and harmful healthcare will require commitment from both doctors and patients, in addition to objective evidence of effectiveness. The NHS already has good systems for evidence appraisal and health technology assessment, but better and simpler tools are needed to facilitate informed discussion in clinical settings. Without such robust and easily shared decision aids, systematically updated without bias, patients may be swayed by potential exaggerated claims in the media when new drugs or procedures are introduced. Lastly, shared decision making does not guarantee lower resource use; greater involvement of patients in deciding their care will require a new set of consultation skills as well as a better range of decision aids.

Call to action and next steps

To ensure the development of a Choosing Wisely culture in clinical practice, the academy suggests:

  • Doctors should provide patients with resources that increase their understanding about potential harms of interventions and help them accept that doing nothing can often be the best approach
  • Patients should be encouraged to ask questions such as, “Do I really need this test or procedure? What are the risks? Are there simpler safer options? What happens if I do nothing?
  • Medical schools should ensure that students develop a good understanding of risk alongside critical evaluation of the literature and transparent communication. Students should be taught about overuse of tests and interventions. Organisations responsible for postgraduate and continuing medical education should ensure that practising doctors receive the same education
  • Commissioners should consider a different payment incentive for doctors and hospitals

Support from the media and medical publications will be vital because the public education campaign is crucial to the programme’s success. The academy will ensure that the programme is thoughtfully implemented and rigorously evaluated by demonstrating a reduction in wasteful practices within a fixed time scale. It will begin by asking specialty organisations to compile top five lists. All lists will be accompanied by an implementation plan and will be evaluated and monitored to assess their effect on reducing low value healthcare.

The academy has set up a steering group to provide policy advice and direction for the project. The group comprises individual experts, patient groups, college representatives and key stakeholders. It is time for action to translate the evidence into clinical practice and truly wind back the harms of too much medicine.

Sources and more information
  • Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine, BMJ 2015;350:h2308, 12 May 2015.
  • Doctors urged to stop ‘over-treating‘, BBC News Health, 13 May 2015.

Things you’ve always wanted to ask a Trans Person… but probably shouldn’t

Things NOT to say to a trans person | Breaking the mould

BBC Free Speech asked Paris Lees, Fox Fisher, Veronica Blades, Adeleh Sasansara, Munroe Bergdorf, Dani Gibbison and Harry Taylor to pick out questions they often hear. BBC Three asked, so you don’t have to! Video published on 21 May 2015.

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