News briefs

Testing zero-gravity genomics in “vomit comet”

Nature reports that geneticists from Johns Hopkins University have successfully performed genetics experiments onboard NASA’s reduced-gravity aircraft — known as the “vomit comet” — to see whether astronauts will be able to sequence their own DNA during future long-term spaceflights. “The researchers tested two key tools in zero-gravity: one might aid long-term storage of genetic material; another is a small, transportable genetic sequencer”, known as a MinION. They also tried three pipetting methods on their flights — best results came when they used a small plunger inside the pipette, which touches the sample directly, ensuring that no air gets in. “And the pipette’s tip is small enough to avoid ruining the surface tension, which would let fluid escape up the tube.” One of the researchers, Andrew Feinberg said: “I really have to give NASA huge credit in allowing us to do this”, he says. “They’re very curious people. They really want to know.”

Taking off protective clothing spreads germs

A new study in JAMA Internal Medicine shows 46% of carefully removed protective clothing still showed contamination with a fluorescent lotion used to simulate germs or other dangerous matter, The Washington Post reports. “Researchers set up a simulation that involved asking doctors, nurses and other health-care personnel at four hospitals to put on their standard gowns, gloves and masks and smear themselves with [the lotion]. After the participants carefully removed the protective equipment as they usually would the researchers searched their bodies with a black light to see whether any lotion was transferred. Both participants and researchers were surprised to find contamination in a high number — 46% — of the 435 simulations.” The researchers recommended that “educational interventions that include practice with immediate visual feedback on skin and clothing contamination can significantly reduce the risk of contamination”.

Mexico’s soda tax produces drop in sales

Two years after it was passed into law, Mexico’s so-called “soda tax” is showing solid signs of reducing sales of sweetened drinks, reports The New York Times. “Preliminary data from the Mexican government and public health researchers in the United States finds that the tax prompted a substantial increase in prices and a resulting drop in the sales of drinks sweetened with sugar, particularly among the country’s poorest consumers. The long-term effects of the policy remain uncertain, but the tax is being heralded by advocates, who say it could translate [to other countries] … It cost bottlers a peso for every litre of sugar-sweetened drinks, which amounts to about a 10% price increase, a substantial jump. Because it was applied to distributors, any resulting increase would show up on list prices.”

Patient tweets give insights into hospital experiences

A study published in The BMJ collected more than 400 000 public tweets directed at the Twitter handles of nearly 2400 hospitals in the US between 2012 and 2013, FierceHealthcare reports. “They then tagged 34 735 patient experience tweets directed at 1726 hospital-owned Twitter accounts, and broke them down by sentiment (positive, neutral, negative) and then put them into topical categories, such as time, communication and pain.” Lead researcher Jared Hawkins from Boston Children’s Hospital said: “We were able to capture what people were happy or mad about, in an unsolicited way. No-one else is looking at patient experience this way because surveys ask very targeted questions. Unsurprisingly, you get back very targeted, narrow answers.” The data are “suggestive and highlight Twitter’s possible use as a way to supplement … surveys to improve quality.”

[Correspondence] How systematic reviews cause research waste

In the Lancet Series on Research, Iain Chalmers and colleagues1 argue that waste could be avoided if all research was preceded by a systematic assessment of the existing evidence. We agree in principle, but contend that many systematic reviews, by including small unreliable trials, increase waste by promoting underpowered trials.

[Perspectives] Moffat Nyirenda: investigating diabetes and other NCDs in Malawi

Privilege can be habit-forming. Stepping away from it takes willpower, even when it’s what you want to do. In his mid 40s Moffat Nyirenda was enjoying success as a consultant physician and a Medical Research Council clinician scientist at the Queen’s Medical Research Institute at the University of Edinburgh. His research had focused on a possible mechanism for developmental programming. Working with rats Nyirenda had shown that prenatal overexposure to glucocorticoids reduces birthweight and predisposes to diabetes later in life.

[World Report] Profile: Southern Africa Consortium for Research Excellence

That diseases need to be studied in their local environment, is not lost on Malawi-based clinician–scientist, Moffat Nyirenda, and director of the Southern Africa Consortium for Research Excellence (SACORE). At SACORE, he strives to strengthen the region as a robust research base so that communicable and non-communicable diseases (NCDs) can be rigorously studied in the local setting.

[Viewpoint] Cultivating and investing in clinical research in China

Biomedical research has taken off in China in recent years. From 2004 to 2011, medical research funding increased at an annual rate of 16·9%, from US$1·6 billion to 4·9 billion.1,2 The National Natural Science Foundation of China (NSFC), one of the major funding agencies that support academic research, alone awarded 1·1 billion RMB (US$0·18 billion) in medical research in 2009 and increased its funding to 4·4 billion RMB (US$0·71 billion) in 2013.3 Individual institutions such as universities and hospitals alike followed suit and established their own funds.

Good for the economy while good for your health

Prominent among the proposals for the future from Mr Turnbull as he assumes the prime ministership are ones that relate to economic growth. He seeks a more agile economy, one in which innovation is promoted and prized and where the negative forces of debt and deficit are dealt with by increasing productivity and growth. These aspirations are supported by stronger recognition in the new Cabinet of science and innovation.

Recently I have had cause to reflect on the place of health care in one piece of the Australian economy. Specifically, I was considering how much health care for the million citizens in western Sydney actually contributes to the economy. The answer is a lot. So, rather than portraying health care as a terrible drain on the national economy and incessantly saying we should cut our costs, we might express it differently.

We’re an investment, not a cost!
Our health care is based strongly on science and innovation. The revolution that has occurred in diagnostic and therapeutics due to new technology is profound. Procedures that once took days now take minutes. New drugs work wonders. CT and MRI have completely replaced the ghastly contrast-medium angiograms and pneumoencephalograms. The productivity of surgeons and other proceduralists has multiplied many times over.

So, if you are looking to grow an ‘industry’ through science and innovation, you could do no better than to look at health. It leads the way. Great efficiencies and immense amounts of suffering due to dreadful procedures have been banished by science and innovation.

In western Sydney, the health services provide care to nearly a million people. Public hospital and associated community services operate with a recurrent budget of nearly $1.4 billion per annum. That’s a lot of money pumped into the local economy. General practice likewise generates local expenditure in the millions.

Whether all this money is wisely or optimally spent is a separate and (I agree) an important question. But overlaying this concern is the fact that health care is a big contributor to the Australian economy.

What is the goal of the economy, we may ask? Surely it is to support the Australian community and enable us to compete in the world to maintain our prosperity and assist, as we see fit, to bring less-developed nations up to speed. Given that the segment of the global economy in which we compete is highly innovative and science-based, then we need to place emphasis on those attributes here Down Under.

As our future prosperity is unlikely to depend as heavily as it has in recent decades on ripping stuff out of the ground and selling it to China, inventing nothing, doing no innovation, making no scientific progress and then buying in all the creature comforts that we need from the US and Japan (and increasingly form China), we need to achieve self-sufficiency in innovation. That requires investment – in science, technology and education.

While it is hard to see these opportunities through the clouds of day-to-day slog in our hospitals and surgeries, investment in medical technological innovation, the education of smart scientists to develop even more and better equipment and drugs, the support of health research of all sorts – these things make an economy grow. These are the ways in which we develop economic agility and the nimbleness necessary to be able to adapt to change.

Health as a superior good

There is another important fact that tends to get in the way of clear perception of where health fits in the economy, and that is the complex notion that health is a superior good, something that we spend on almost without limit, constrained only by the extent of our discretionary income.

That is what makes trying to keep health costs under control so difficult. As affluence increases, ordinary goods such as food do not attract all that much additional expenditure. But health? We feel we can never get enough of it, and we are prepared as individuals and as a nation to keep on paying!

We have emerged from a period of economic discussion in Australia dominated by what many experts see to be an exaggerated concern for a relatively small deficit. The real economic challenge is the changing base of our revenue, away from minerals and coal toward service industries such as finance, education and health care. We need to be agile; we need to look for ways to increase our productivity through innovation and invention.

Health can help achieve those economic goals for the nation. Rather neatly, this can occur as a secondary outcome of our continued concentration on providing the best possible care for all Australians.

High standards essential to sustaining patient trust

There is no professional relationship where trust is more intrinsic than the doctor-patient relationship.

Patients trust us when they are at their most vulnerable – when they are sick, hurt, confused, scared, when they are born, when they are dying. They trust us to care not only for them, but for their loved ones, to treat their bodies and their minds, to be honest, to be respectful, to protect their confidentiality, to put their health needs first.

If people do not trust doctors, they may seek care elsewhere, or not seek care at all – outcomes which may prove detrimental not only to their own health, but the wellbeing of the wider public.

The success of the doctor-patient relationship, as well as the wider profession-society relationship, depends on trust, which can be maintained through a strong adherence to medical professionalism.

Medical professionalism refers to the values and skills that the profession and society expects of individual doctors and the medical profession, encapsulating both the doctor-patient relationship and the wider ‘social contract’ between the profession and society.

Individual doctors are expected to uphold the core values of the medical profession such as respect, trust, compassion, altruism, integrity, advocacy and leadership, collegiality (among others).

The medical profession is expected to adhere to the social contract with society. The profession is granted a high level of autonomy and clinical independence because society values the profession’s highly specialised knowledge and skills in serving the public interest.

In return for this relative autonomy and independence, the medical profession is expected to use its unique expertise to set and maintain high standards of ethics, practice, competency and conduct through an open and accountable process of profession-led regulation.

More than anything, medical professionalism encapsulates the profession’s commitment to prioritise patient interests above all else.

But our ability to appropriately care and advocate for our patients is increasingly challenged by today’s often chaotic and demanding health care system.

We work in an environment of mounting costs; increasing bureaucracy, managerialism and regulation; changes to the structure and funding of the workforce; rising consumerism; and shifting perceptions of the medical profession.

While such issues may prove frustrating, demoralising, or even overwhelming at times, they should never undermine or compromise our commitment to our patients and the values of medical professionalism.

Through leadership, unity, solidarity and collegiality, the medical profession should adhere to and promote the values of medical professionalism to its own members, from medical students through to retiring doctors, from doctors who work in clinical practice to those who work in research, academia and administration. These qualities are fundamental to quality medical care.

*The AMA’s Position Statement on Medical Professionalism 2010 has been revised as part of the five year position statement review cycle. The Position Statement defines medical professionalism, sets out the core values of the profession and acknowledges the challenges that the modern, dynamic health care environment poses to putting patients’ interests first.

Medicare review taken off course

The AMA has demanded the Federal Government recast its approach to the Medicare Benefits Schedule Review as medical researchers have distanced themselves from claims doctors are routinely ordering ineffective and potentially harmful tests and procedures that are costing the nation cost the nation hundreds of millions of dollars each year.

The AMA has reasserted its support for the Medicare Benefits Schedule Review (and the accompanying Primary Health Care Review) as long as it not only about removing outdated services and procedures, but replacing them with items that reflect modern practice.

AMA President Professor Brian Owler told The Australian Financial Review the medical profession backed efforts to update the MBS but “we’re not going to have a Review that takes money away and puts it on the bottom line of the Budget, and the [Health] Minister [Sussan Ley] says that’s where it’s going. It takes services away from patients.”

The blame game

There has been mounting disquiet over the Government’s handling of the Review, including the depth of consultation with clinician representatives and claims that the vast majority of items were not backed by evidence, and around 30 per cent of all care was of little worth.

Fears about the direction the Government was taking were crystallised on 27 September when Ms Ley launched public consultations by arguing that only a tiny fraction of the 5769 items on the MBS had been assessed for effectiveness and safety, and “inefficient and unsafe Medicare services…cost the nation dearly”.

Issuing the call for consumers to participate in the Review, Ms Ley said that, “30 per cent of expenditure is not necessary, wasteful, sometimes even harmful for patients”.

Professor Owler said the claim was not only “factually incorrect”, but was being used by the Government and the Review Taskforce Chair Professor Bruce Robinson to try and frame the discussion around the idea that there were massive savings to be made because doctors were milking the system.

The AMA President said the figure had been uncritically imported form the United States and there had been no evidence to support it in the Australian setting.

Instead, he said, the Government’s real intention was to use the Review to make Budget savings.

“They need to be upfront about what this process is and that it’s a budget preparation measure,” he told the AFR. “We’re having this conversation and it’s ‘No, no, this is not a cost saving exercise’. But, ‘Yes, the cost savings are going to the bottom line of the budget’. They say ‘Yes, we will reinvest’, but it’s going to be a very protracted, drawn out process to get any money back into MBS.”

Follow the evidence

A day after the Government launched the consultation process, ABC television’s Four Corners program aired claims that doctors were ordering tests and performing procedures that were of little or no benefit for patients and cost the nation hundreds of millions of dollars each year, including scans for lower back pain, spinal fusion surgery, knee arthroscopies and inserting stents in patients with stable angina.

Ms Ley seized on the program, which she said had exposed “real – not perceived – waste in health spending”, and demonstrated the need for the MBS Review.

The Minister said medical specialists and health researchers appearing on the program had “put their professional reputations on the line to provide important insight into billions of dollars being spent on unnecessary, outdated, inefficient and even potentially harmful procedures”.

But two researchers whose work was drawn on in the Four Corners program to help substantiate claims that doctors used inappropriate and unnecessary tests and procedures said their data had been misinterpreted and taken out of context.

Writing in Medical Observer, Associate Professor Helena Britt and Associate Professor Graeme Miller said that although their research showed GPs ordered imaging in about 25 per cent of new cases of low back pain, “conversely, we could equally state that 75 per cent of new cases were not sent for imaging”.

The researchers said that while they did conclude that the rate of imaging for back problems at the initial encounter was inconsistent with guidelines, this was only the case if there were no ‘red flag’ issues present, such as significant trauma, fever, weight loss, inflammatory conditions or advanced age.

“Unfortunately,” they said, “we cannot identify whether or not patients referred for imaging for back symptoms had any of these red flags, but the guidelines suggest that zero imaging for all cases would not represent best quality care.”

Ms Ley rejected claims the Government had launched an attack on the medical profession, and asserted that 97 per cent of MBS items had never been assessed for their clinical effectiveness or safety.

But Professor Owler said the Minister’s claim was “quite misleading”.

While just 3 per cent of items had been assessed through the Medical Services Advisory Committee process, the AMA President said, “but that doesn’t mean that there’s not evidence behind all of the other things that we do”.

He questioned the need for evidence-based reviews for performing life-saving operations: “I don’t need an evidence-based review to say that I should remove the tumour from a child that presents through the emergency department because I know they’re going to end up dead within the week if I don’t do it.”

“There are some things that, yes, we need to evidence-based review, but there are many on the schedule that don’t, and saying that 97 per cent doesn’t have evidence is quite misleading.”

MBS reviews nothing new

He said the medical profession had to be “vigilant” about the narrative being used to shape debate about the Review.

Professor Owler said the AMA not only supported the MBS reviews, but had been engaged with successive governments in undertaking them since 1990. He said in the last five years alone, the AMA had participated in reviews covering 26 areas of the MBS.

“Can we save money? Yes, and the AMA’s more than happy to engage in that process, but let’s actually go through and do the reviews and come up with the evidence before we actually pre-empt what the outcome is and what procedures might have conditions or be removed from the Schedule,” he said.

“The risks to patient care from an emasculated MBS are too great to allow this Review to go off the rails.”

Adrian Rollins

[Correspondence] China’s medical research integrity

The Lancet Editorial,1 entitled China’s Medical Research Integrity Questioned—which followed the retraction of more than 40 research articles, has been shocking for many in the Chinese medical research community. Although academic misconduct in China, including fabrication, falsification, plagiarism, ghost-writing, and especially ghost reviewers (causing the 43 retractions) led many to question China’s research integrity, we think one cannot focus on retractions to appraise China’s medical research integrity.

News briefs

New collaboration for NHMRC and Americans

The National Health and Medical Research Council (NHMRC) reports that it has opened a joint funding round with their American counterparts, the United States National Institutes of Health (NIH) as part of the United States Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative. Under this collaboration, the NHMRC will provide funding to support Australian researchers to participate in The BRAIN Initiative, which was announced by President Obama in 2013. “It is hoped that the research conducted through The BRAIN Initiative will lead to more effective treatments and methods of prevention for brain conditions such as dementia, autism, epilepsy, depression and Parkinson’s disease”, the NHMRC statement read. The NHMRC CEO Professor Anne Kelso said: “Both the NIH and the NHMRC believe that the ambitious goals of The BRAIN Initiative can best be attained by collaborating across both disciplinary and geographic boundaries. Over the past four decades Australian researchers have collaborated more with researchers in the US than in any other country.”

Missing microbes may point to asthma risk

NPR reports that a new study published in Science Translational Medicine shows that the composition of microbes living in babies’ guts may play a role in whether the children develop asthma later on. “The researchers sampled the microbes living in the digestive tracts of 319 babies, and followed up on the children to see if there was a relationship between their microbes and their risk for the breathing disorder … the researchers report that those who had low levels of four bacteria were more likely to develop asthma by the time they were 3 years old. To further test their theory, the researchers gave laboratory mice bred to have a condition resembling asthma in humans the four missing microbes. The intervention reduced the signs of levels of inflammation in their lungs, which is a risk factor for developing asthma.” The bacteria are from four genuses: Lachnospira, Veillonella, Faecalibacterium and Rothia.

“Predatory” journals publish 400k papers in 2014

Retraction Watch reports that a new analysis by BioMed Central shows that in 2014 so-called “predatory” open-access (OA) journals published around 420 000 papers, up from 53 000 in 2010, appearing in 8000 active journals. “Predatory” OA journals allegedly sidestep publishing standards in order to make money from article processing charges (APC). “Lately, most predatory journals are published by smaller publishers, which maintain between 10 and 99 titles”, Retraction Watch wrote. “The average APC was US$178, and most were published within 2–3 months after being submitted. Predatory journals have made the news — this year, The International Archives of Medicine was delisted from the Directory of Open Access Journals after it accepted a bogus study claiming chocolate had health benefits within 24 hours. In 2013, the same author behind that chocolate study, John Bohannon, tricked more than half of a sample of 300 OA journals to accept fake papers submitted under a fake name and institution. Last year, the Ottawa Citizen tricked a cardiology journal into publishing a paper with a garbled blend of fake cardiology, Latin grammar and missing graphs, for the price of US$1200.”

Cut and paste “tattoo” monitors health 24/7

An inexpensive wearable patch that continuously monitors vital signs for health and performance tracking has been developed by engineers in Texas, Futurity and Engadget report. The “tattoo” is manufactured via a repeatable “cut-and-paste” method that cuts production time from several days to only 20 minutes. “After producing the cut-and-pasted patches, the researchers tested them and discovered they picked up body signals that were stronger than those taken by existing medical devices, including an ECG/EKG, a tool used to assess the electrical and muscular function of the heart. The patch also conforms almost perfectly to the skin, minimising motion-induced false signals or errors. The wearable patches are so sensitive they may be worn to more easily maneuver a prosthetic hand or limb using muscle signals.”

Social network for doctors and their case photos

A new photo-sharing social network called Figure 1 is gaining popularity with doctors, nurses, paramedics and other medical workers, Wired reports. “Figure 1 is educational, engaging, and privacy-obsessed.” Anyone can join, but only health care professionals can comment on photos, which, says Wired, “keeps the discourse focused and professional”. The app is also heavily moderated. An image will be blocked if it doesn’t pose some kind of medical question. The app is very careful about patient privacy. “Every time anyone uploads an image, the first thing they do is fill out a consent form. Figure 1 has an algorithm that automatically obscures faces, and tools that let the user erase any pixels containing names, dates, or any other identifying details.” Figure 1 also strips away all the metadata before the picture gets uploaded. No data collection, over 500 000 users and so far, no ads. “Some of the pictures are straight up medical oddities. But just as often, users post because they are stumped and looking for a 2nd, 3rd, 4th, nth opinion.” The app is available from the iTunes App Store, Google Play and figure1.com.