more_vertThe Turnberg Fellowship has been helping medical researchers in the UK and the Middle East build long-term collaborations. It celebrates its achievements this week. Geoff Watts reports.
Preference: Statistics, epidemiology and research design
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[Articles] Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis
The literature indicates that both individual-focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians. Further research is needed to establish which interventions are most effective in specific populations, as well as how individual and organisational solutions might be combined to deliver even greater improvements in physician wellbeing than those achieved with individual solutions.
[Correspondence] Lessons from the controversy over statins – Editor’s reply
I’m grateful to Virginia Barbour for responding to the criticisms of the Committee on Publication Ethics (COPE). And I very much welcome her endorsement of the idea for an independent tribunal to consider allegations of research or publication malpractice. However, if she had quoted my words fully and fairly, I think she would have to agree that the claim that “COPE declined to act further” in response to “a direct request [to] conduct an independent investigation”1 was correct. COPE did decline to act further, and this refusal has led to the current exchange.
E-cigs a gateway to smoking for young: study
The AMA’s call for a cautious, evidence-based approach to the use of e-cigarettes has been underlined by research that ‘vaping’ can lead to heavy smoking among young users.
As debate rages over the effectiveness of e-cigarettes as an aid in avoiding or giving up smoking, a study published in the Journal of the American Medical Association has cast doubt on the idea that they can divert people from the deadly habit.
The longitudinal study involving 3084 public high school students in Los Angeles County found a “positive association” between the use of e-cigarettes and subsequent smoking, particularly when those taking up the vaping habit were non-smokers.
“In this study of adolescents,” the researchers said, “vaping more frequently was associated with a higher risk of more frequent and heavy smoking six months later.”
Furthermore, the positive association between baseline vaping and follow-up smoking frequency was stronger among baseline non-smokers than infrequent or frequent smokers, the research found.
The findings follow a United States Centers for Disease Control and Prevention investigation that found a large number of non-smoking middle and high school students had used an e-cigarette, and were twice as likely as those who hadn’t to report that they intended to start smoking tobacco cigarettes.
The findings back AMA concerns that e-cigarettes are undermining tobacco control efforts and should be subject to the same restrictions as on cigarettes, including a ban on sales to children and adolescents, and tight restrictions on their marketing and promotion.
In a Position Statement released late last year, the Association warned that many e-cigarettes were being marketed to appeal to young people, including through the use of flavourings, and voiced fears that they could act as a gateway for young people to progress to become smokers – a concern borne out by the JAMA study.
The AMA said the evidence that using e-cigarettes helped people to give up smoking was “mixed and low-level”, and the risk they posed meant governments should take a precautionary approach.
“Currently, there is no medical reason to start using an e-cigarette,” the Association said. “There are legitimate concerns that e-cigarettes normalise the act of smoking. This has the potential to undermine the significant efforts that have been dedicated to reducing the appeal of cigarettes to children, young people and the wider population.
“In fact, using an e-cigarette may significantly delay the decision to quit smoking,” the AMA warned, adding that the longer-term health implications of inhaling e-cigarette vapours produced by illegally imported and unregulated solutions were unclear.
The best approach, it said, was restrict their promotion and ban sales to young people until further evidence as to their safety and efficacy was available.
The AMA’s Position Statement, Tobacco Smoking and E-Cigarettes – 2015, can be downloaded at: position-statement/tobacco-smoking-and-e-cigarettes-2015
Adrian Rollins
GPs targeted in national plan to curb antibiotic resistance
GPs will be targeted over their antibiotic prescription practices as part of a national strategy to tackle the threat from rising antibiotic resistance.
Less than 10 days after researchers sounded the alarm over the arrival in Australia of a superbug capable of overcoming the last line of defence against salmonella infection, the Federal Government has detailed its plans to implement the National Antibiotic Resistance Strategy.
Health Minister Sussan Ley said the inaugural plan, covering the period 2015-19, had as one of its main targets reduced recourse to antibiotics by GPs.
“A particular focus will be Australia’s high use of antibiotics in general practice, which is 20 per cent above the OECD average,” Ms Ley said. “Bringing prescribing rates down is critical, as high antibiotic use is the number one driver of the increasing resistance to antimicrobials.”
Despite this focus Ms Ley, who launched the strategy in conjunction with Agriculture Minister and Deputy Prime Minister Barnaby Joyce, said the plan encompassed a broad “one health” approach which recognised the inextricable links between human, animal and ecosystem health.
“[This means] that combating resistance to antimicrobials requires action in all sectors where antimicrobials are used,” the Health Minister said.
The plan calls for, among other things, better support for doctors and vets in educating patients about the need for care in antibiotic use; the implementation of effective stewardship practices among health professionals; improved national surveillance of antibiotic use; better infection control measures; and intensified research efforts.
The plan has been developed amid mounting international alarm regarding the threat posed by antibiotic resistance. A recent British Government report warned the world was on track to a future in which even common infections and medical procedures could become potentially deadly because of the risk of infection.
The UK report estimated that antimicrobial resistance could kill 10 million a year by 2050, and cost the world a cumulative USD$100 trillion in reduced economic output without effective action to slow the rate of drug resistance.
The threat to Australia has escalated following the discovery by Murdoch University researchers of a strain of the Salmonella bug that is resistant to carbapenems, the drug used as the last line of defence against such infections.
The superbug was discovered in a pet cat admitted to Concord Veterinary Hospital in New South Wales with an upper respiratory tract infection that subsequently developed into a gut infection.
A sample of the infection sent to a team of researchers at the Concord Hospital identified a strain of Salmonella never before seen in the country. It was found to be carrying the highly resistant IMP-4 gene.
A further three animals at the veterinary clinics were also found to be infected with the superbug. The outbreak has been contained.
Dr Abraham said the identification and containment of the bacteria was “an example of Australia’s One Health capabilities, where animal and human health specialists work together to prevent the spread of infection”.
Adrian Rollins
[Comment] Offline: A barometer for trust in China
The Chinese Academy of Medical Sciences celebrated its 60th anniversary last week. 60 is commonly symbolised by a diamond. The word diamond (Greek, adamas) means “unbreakable” and “unconquerable”. Fitting. Because thanks to the organisation of health care in China, the Chinese public has been the beneficiary of some remarkable successes. Indeed, “health” has increasingly been emphasised in government manifestos since 1954, according to research presented at the second Lancet–Chinese Academy of Medical Sciences Health Summit held in Beijing this week.
Whooping cough booster faces axe
The Federal Government may axe the whooping cough vaccine booster for first year high school students as it pulls plans for an Australian Schools Vaccination Register.
An immunisation expert group has been asked to review the pertussis vaccine schedule, including the need for a booster currently being administered to children in secondary school.
The Government has announced that the Australian Technical Advisory Group on Immunisation (ATAGI) has been asked to “provide advice on the clinical place and effectiveness of the pertussis vaccine schedule, including the pertussis booster currently given in the first year of high school”.
Currently, it is recommended that infants receive a dose of the diphtheria-tetanus-acellular vaccine at two, four and six months of age, with further boosters at 18 months and four years. An additional booster is given between 12 and 17 years.
The review comes at a time when the number of whooping cough cases is in decline – about 16,000 cases have been notified so far this year, well down from the 22,500 infections reported in 2015.
But the decline has come not long after the country’s largest-ever recorded outbreak of the disease, between 2008 and 2012, including 38,732 notified cases in 2011 alone.
The National Centre for Immunisation Research and Surveillance said whooping cough was a “challenging” disease to control because immunity waned over time, and epidemics occurred every three to four years.
The Centre said declining immunity was a factor in the last major outbreak, during which 4408 people were hospitalised, including 1832 babies. Between 2006 and 2012, 11 died from pertussis, all but one of them infants less than six months of age.
The review of the pertussis vaccination schedule coincides with the decision not to proceed with the creation of the Australian Schools Vaccination Register.
The Health Department said it had discontinued the tender process for the creation of the Register following advice about the review of the pertussis booster vaccine for secondary school students and the end, in 2018, of the catch-up varicella vaccination program for adolescents.
The Register was announced in the 2015-16 Budget as part of the No Jab No Pay policy, and was portrayed as vital in helping to controlling infectious disease outbreaks by identifying areas where vaccination coverage was low.
But Health Minister Sussan Ley said it had now been “put on hold…pending further advice from independent medical experts on the vaccination needs of adolescents”.
The Health Department said it was possible that the Schools Register would only hold data on the human papilloma virus (HPV) if the pertussis booster for adolescents was axed and once the varicella catch-up vaccination program ends.
The Health Department said it was now looking at alternatives to the Schools Register, including the inclusion of such data in the whole-of-life Australian Immunisation Register which began operations on 30 September.
It is also in discussions with the Victorian Cytology Service about continuing the HPV Register in 2017.
Commonwealth Chief Medical Officer Professor Brendan Murphy was keen to assure that these changes would have “no impact on the health of adolescents because the full range of vaccination services are being delivered to the community, and will continue to do so”.
The move to axe the Register has coincided with the release of Government figures showing that almost 200,000 children have had their vaccinations brought up-to-date following the introduction of the No Jab No Pay reforms.
The figures, reported in the Sunday Herald Sun, show that since the reforms were introduced on 1 January, 86,562 families, including 102,993 children, have been denied childcare payments, and $38 million of Family Tax Benefit A benefits have been suspended. Parents of 8896 children are still not meeting vaccination requirements.
But 183,000 children have had their vaccinations brought up-to-date as a result of the program, under which parents face losing Family Tax Benefit A and childcare payments if they let their child’s immunity slip.
Adrian Rollins
Introducing an accessible series on statistics for clinicians
For many clinicians, statistics is the equivalent of a foreign language: they may know a few words here and there from their travels, but they have never had the time to learn the language properly. As health care providers, we are increasingly being asked to engage in critical appraisal and sort through the large volume of research to help guide decision making. For many, this means reading mainly the abstract and the discussion, and glossing over the jargon in the methods and results. This is unfortunate, as the methods can obviously make or break the validity of the results and determine whether we decide that a study is valid and practice changing, or fatally flawed and pointless.
This is not a novel endeavour. The whole evidence-based medicine movement began with the Users’ guide to the medical literature series originally published in JAMA in the early 1990s and now compiled in a book.1 These articles focused mainly on study design and introduced a whole generation of practitioners to clinical epidemiology. However, with the rise of desktop statistical packages, such as SPSS, STATA and SAS, complex statistical methods have been put within the reach of many investigators. The results have generally been positive in that complex analyses can be performed by many more people, but the room for error has also increased tremendously. Therefore, the need for caution and critical appraisal is even more urgent. Many series on basic statistics for clinicians have been published — such as a primer for clinicians in the Canadian Medical Association Journal2 and the ongoing statistics notes in The BMJ3 — but we have decided to take a fresh look at this topic with the purpose of providing a concise and accessible overview of commonly used statistical tests. The series will cover a number of statistical ideas and methods commonly used in medical studies and will be published at regular intervals. It will build over successive articles, so it might be useful to read them in order (at least initially). We have chosen not to cover some topics that have already been comprehensively discussed in the literature (eg, randomised controlled trials), and to cover others that may be less familiar (eg, receiver-operator characteristic curves). Our hope is that, by the end of this series, you will have grown in practical knowledge and will be reading the methods and results of research articles and feel empowered to come to your own conclusion about the wheat and the chaff in medical literature. We welcome suggestions from readers or contributions from other authors that will help to expand the series.
News briefs
Can assisted reproduction lower birth defects for older mothers?
Research from the University of Adelaide suggests that babies born to women aged 40 and over from assisted reproduction have fewer birth defects compared with those from women who conceive naturally at the same age. Published in BJOG: An International Journal of Obstetrics and Gynaecology (doi: 10.1111/1471-0528.14365) the research, led by Professor Michael Davies from the Robinson Research Institute, was based on data of all live births recorded in South Australia from 1986-2002, including more than 301 000 naturally conceived births, as well as 2200 births from in vitro fertilisation (IVF) and almost 1400 from intracytoplasmic sperm injection (ICSI). The average prevalence of a birth defect was 5.7% among naturally conceived births, 7.1% for the IVF births, and 9.9% for the ICSI births, across all age groups. In births from assisted reproduction, the prevalence of birth defects ranged from 11.3% at its highest for women less than age 30 using ICSI, down to 3.6% for women aged 40 and older using IVF. For natural conceptions, the corresponding prevalence across age groups was 5.6% in young women, increasing to 8.2% in women aged over 40 years. “There is some aspect of IVF treatment in particular that could be helping older women to redress the maternal age issues we see among natural conception, where we observe a transition at around the age of 35 years toward a steadily increasing risk of birth defects,” Professor Davies said. “We don’t know what that is quite yet – it could be an aspect of hormonal stimulation that helps to reverse the age-related decline in control of ovulation. More research is desperately needed in this area to understand why this is occurring, and whether it could be adapted to both fertile and infertile women in future to prevent birth defects, which continue to be a major cause of death and disability in the first year of life globally.”
Growing association between obesity and cancer
A new literature review by the International Agency for Research on Cancer published in the New England Journal of Medicine (doi: 10.1056/NEJMsr1606602) has concluded that “having lower overall body fat lowers the risk of developing eight tumor types: cancers of the gastric cardia, liver, gallbladder, pancreas, ovaries, and thyroid, in addition to multiple myeloma and meningioma”, according to a commentary published in the Journal of the National Cancer Institute (doi: 10.1093/jnci/djw243). The review brings the list to 13 following the IARC’s 2002 report which found evidence that the risk of being diagnosed with colorectal cancer, adenocarcinoma of the oesophagus, renal cell carcinoma, postmenopausal breast cancer, and uterine cancer was lower among non-overweight people. “The association between obesity and cancer is still not common knowledge. When people think of obesity, they think of diseases such as diabetes and cardiovascular issues,” said one of the IARC authors.
Is the NHMRC funding process fair?
Last week’s announcement of funding from the National Health and Medical Research Council (NHMRC) provoked mixed reactions.
Australia’s leading biomedical research funding agency allocated A$190 million for a range of projects, including centres of excellence to find a solution to alcohol-related health problems in Aboriginal populations, and research into stillbirth, a devastatingly sad end to many pregnancies.
Outstanding young researchers, within two years of completing their PhDs, received NHMRC fellowships to train in prestigious laboratories and to bring their new skills back to the Australian community.
The funding decisions follow a highly competitive and intense selection process that took up months of research time; applicants crafted the best application possible to convince panels of scientists that their research deserved funding more than a competitor’s.
However, after each round of funding announcements some researchers are left questioning how the NHMRC chooses which research to fund. Others question whether the very process of how funding applications are assessed gives some types of researchers or research an unfair advantage.
Peer review for grants and fellowships
The process of awarding grants and fellowships is based upon a rigorous and thorough peer review process.
A fellowship or grant review panel scores and ranks applications, with help from external assessors, the top experts in their fields.
To assess the research proposals, the NHMRC has established rigorous scoring criteria to ensure it chooses the best ones.
These criteria rely heavily on:
- the feasibility of success, judged by reviewing supporting scientific data
- the innovative aspect of a project
- the number and the prestige of the scientists’ publications in specialised journals.
The NHMRC then funds the best-ranked applications.
Do some researchers have an unfair advantage?
Sadly, since 2010, the success rate of all funding project applications has steadily declined, which has a considerable impact on the way reviewers evaluate research proposals for funding.
Over the same time, the number of high-quality applications has increased. Applicants now spend months, if not years, of hard work allocating large resources to ensure they have a large volume of preliminary data for the proposal. They must publish in prestigious scientific journals to convince their peers the research is feasible and worth funding.
Sadly, the peer review system now punishes researchers with innovative projects that may be risky, but could be highly successful.
Well established investigators with mature projects produce large amounts of preliminary data for applications. However, younger researchers (who completed their PhD less than 15 years previously) with new research programs or groundbreaking research, struggle to generate similar volumes of data; their teams are smaller and have less funding; they take more risk and this leads to lower success rates in obtaining funding.
Female researchers taking parental leave or sick leave, or who have a child with disabilities, are also adversely affected as they lose years of research time, thus being less competitive than their male peers. The NHMRC takes these disruptions of a researcher’s research output and productivity into account, but they only allocate an extra year of publications to the CV of the researcher. Yet often these types of leave affect a researcher for many years.
Seducing the assessors
Many worthy and high-quality applications are submitted. But to receive funding, the proposal must seduce the independent referees and review panel.
This leaves a major flaw in the system – the chance that randomly allocated assessors may not like the proposal and the project won’t be funded simply because of the influence of one or two key people.
This means that new, groundbreaking projects from young researchers are often overlooked in favour of research that has proved successful in the past, but may no longer yield exciting outcomes. Young and/or female researchers tend to be sifted out as assessors favour “safe” research projects.
The NHMRC knows all this
The NHMRC is aware of the shortcomings of the review process and is conducting a structural review of the entire grant program. Researchers hope the review will lead to better distribution of research funds.
However, many young and highly talented researchers have already left academia or are working overseas.
Nobel Prize-winning astrophysicist Brian Schmidt has openly discussed the importance of ensuring that younger researchers receive research money, as they are often the ones who conduct groundbreaking research. Sadly this is not happening in the current system.
The government established Medical Research Future Funds to support medical research and innovation in Australia to notably address these issues.
However, the NHMRC’s investment in basic medical research is absolutely crucial if we want innovative approaches that address health related problems. The NHMRC deserves better support as part of this government’s innovation agenda.
Gaetan Burgio, Geneticist and Group Leader, The John Curtin School of Medical Research, Australian National University
This article was originally published on The Conversation. Read the original article.
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