more_vertFor a quarter of a century, countless attempts have been made to produce an effective vaccine against Helicobacter pylori, a major cause of peptic ulcer disease and gastric adenocarcinoma.1 An effective vaccine against H pylori is needed most for prevention of gastric adenocarcinoma, the third leading cause of cancer-related death worldwide.2 However, efforts to produce such a vaccine have so far failed, and H pylori vaccine research has slowed in the past few years. The main reason for this might have been disillusionment, arising from the inability to produce a vaccine that completely protects against the infection.
Preference: Statistics, epidemiology and research design
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Smoking bans in prison: time for a breather?
Introducing a total smoke-free policy in prisons is not without problems
Successful public health campaigns have contributed to reducing daily smoking rates in the general Australian population from 24% in 1991 to 13% in 2013.1 However, this reduction has not been mirrored in prisons, where no downward trend is apparent and the rate remains stubbornly high at around 84%.2 High rates of community smoking persist in groups over-represented in the criminal justice system — the mentally ill (32% of current smokers had a 12-month mental disorder, compared with 16% of non-smokers),3 Indigenous people (44% of Indigenous v 16% of non-Indigenous Australians)4 and illicit drug users (37%).1
Smoking bans are becoming the norm in Australian prisons, driven mostly by concerns about the effects of second-hand smoke on non-smokers and potential legal action by non-smoking prison staff and prisoners. On 1 July 2013, the Northern Territory was the first Australian jurisdiction to implement a total smoking ban in prisons. Queensland followed suit with a total ban in May 2014, Tasmania from February 2015, and Victoria from July 2015. New South Wales implemented a full smoking ban in its prisons in August 2015; South Australia, Western Australia and the Australian Capital Territory will probably follow suit in the near future. Implementation of smoke-free polices in combination with smoking cessation interventions benefit prisoner health by reducing active smoking and second-hand smoke levels.5
Nevertheless, introducing a total smoke-free policy in prisons is not without problems. There is evidence that enforced prison smoking bans result in black markets in tobacco and other smokable substances.5,6 In one study, researchers reported that a smoking ban was unsuccessful because of low compliance; three-quarters of prisoners continued to smoke illicitly in prison after introduction of the ban.6 Despite imposing ever more severe penalties on the use of contraband goods and spending increasing sums of money on prohibition, very few jails and prisons in the United States, Australia and elsewhere have achieved completely drug-free (including tobacco-free) environments.
Further, fears have been raised that enforced smoking bans in prisons could lead to an escalation of violence. The recent riot at the Melbourne Remand Centre is believed to have been caused by the imminent ban on smoking.7 However, a literature review found little or no evidence of increased violence following the implementation of smoke-free policies in US jails and prisons.5
While banning smoking outright undoubtedly improves air quality8 and avoids possible litigation, another aim must be addressed if we are to tackle tobacco smoking in this population: sustained abstinence from tobacco use after leaving prison. Total smoking bans alone have been ineffective in reducing smoking rates in this population. Follow-up studies of prisoners after their release have found that 56% reported resuming smoking on their first day of release;9 84% had relapsed within 3 weeks,10,11 and 39% by a month after release.12 Another follow-up study found that 63% of former prisoners had relapsed on the first day of release, 82% by 1 week, 86% by 1 month, and 97% at 6 months.13
These findings indicate that this population is in need of interventions both inside prison and after their release to reduce their high rate of tobacco smoking. Few studies on smoking cessation interventions for this population during incarceration have been published. We are unaware of any published studies in Australia that have examined post-release smoking behaviours following a prison smoking ban, or of any post-release smoking cessation interventions for this population. However, a US study found that interventions can be effective in preventing smoking relapse after release from prison.14
Paradoxically, while public health professionals deplore tobacco smoking in the community, many have sympathy for those in prisons who smoke. This sentiment was expressed in 2010 at the National Summit on Tobacco Smoking in Prisons held by Public Health Association Australia. While smoking bans in prisons in Australia are inevitable, a targeted approach that recognises the unique characteristics of this population group is needed, and must involve support both in prison and in the community, recognising that imprisonment for most is only temporary.
[Correspondence] Public investment in biomedical research in Europe
Europe spends about 10% of its gross domestic product (GDP) on health care. Public spending on biomedical and health research in Europe is only about €42 per person per year, less than 2% of the health-care costs.1–3 The USA spends a much larger absolute and relative (compared with GDP) amount on health care (table). Several independent reports3–5 suggest that the USA also spends substantially more on public investment in biomedical and health research, up to 3 times more per person per year than in the EU.
[Perspectives] Alan Lopez: making everyone count
It’s difficult to squeeze Alan Lopez’s wide-ranging career into a resumé. A leading epidemiologist and global and public health researcher, he is Director of the Global Burden of Disease Group at the Melbourne School of Population and Global Health, University of Melbourne, and has worked for decades on the Global Burden of Disease (GBD) project with his longtime friend and collaborator Christopher Murray. Yet when they first met, in 1986, Murray began by remarking: “Everything you have written about mortality in Africa is wrong!” Far from being offended, Lopez took an instant liking to Murray.
Renowned clinician next MJA Editor in Chief
Influential medical clinician and researcher, Laureate Professor Nicholas Talley, has been appointed as the new Editor in Chief of the Medical Journal of Australia.
AMPCo Board Chair Richard Allely said Professor Talley, who is currently Pro Vice Chancellor, Global Research, at the University of Newcastle and a part-time staff specialist gastroenterologist at the John Hunter Hospital, came to the position with a wealth of local and international experience in medical research, practice and publishing.
“Professor Nick Talley is a clinician, educator, writer, author, researcher, and editor, with a strong track record in medical practice, medical education, and medical publishing, in Australia and overseas,” Mr Allely said.
As well as having authored 800 original and review articles in peer-reviewed academic journals, Professor Talley is currently Co-Editor in Chief of the international journal Alimentary Pharmacology and Therapeutics (a position he will relinquish soon after he takes up the MJA post on 1 December), and served for six years as Co-Editor in Chief of the American Journal of Gastroenterology.
“He brings significant experience, knowledge and expertise to the MJA, and is perfectly suited to guiding Australia’s leading medical journal at a time of rapid change, innovation and technological revolution in media and publishing,” Mr Allely said.
In addition to his ongoing academic, clinical and publishing work, Professor Talley is President of the Royal Australasian College of Physicians and Chair-elect of the College of Presidents of Medical Colleges.
He also holds several international adjunct appointments, including Professor of Medicine and Professor of Epidemiology at the Mayo Clinic, and Foreign Guest Professor at Stockholm’s Karolinska Institute.
Professor Talley’s appointment was announced soon after it was revealed that AMA Federal Councillor and former Australian Medical Students’ Association President Jessica Dean had been recruited to the Board of mental health organisation beyondblue.
beyondblue Chairman Jeff Kennett said Ms Dean’s experience as a young doctor would be “invaluable” for his organisation as it sought to work with medical students and practitioners at risk of experiencing depression and anxiety.
Ms Dean has been a member of beyondblue’s Victorian Doctors’ Mental Health Advisory Group, and earlier this year addressed a meeting of senior Victorian doctors, health officials and administrators about the mental health of medical practitioners and the culture in which they work.
Adrian Rollins
Lust for life, or another one bites the dust?
Patients might be forgiven for feeling a little unnerved if “The Final Countdown” is blaring from the speakers when they are wheeled into the operating theatre.
But is it helpful, or off-putting, for those doing the operating? Recent studies suggest both.
A small study, published in the Journal of Advanced Nursing, filmed 20 operations at two British hospitals to observe the music habits of surgeons.
Researchers placed multiple cameras at strategic points around the operating room to observe verbal and non-verbal communication between staff and found that, at times, playing music in the operating theatre can be disruptive and surgeons should think twice about pressing the play button.
Music was played in 16 out of the 20 operations observed, and usually senior doctors were in charge of the play list.
Dance music and drum and bass based music were often played fairly loudly, with popular tracks sometimes cranked up, making talking more difficult. In one operation, a scrub nurse asked the surgeon to turn the music down because she was finding it hard to count how many swabs had been used.
The UK Royal College of Surgeons said if music is played during surgery it must not be distracting.
Lead researcher Sharon-Marie Weldon said that music can be helpful to staff working in operating theatres where there is often a lot of background noise. However, she recommended that there be a considered approach based on discussion or negotiation about whether music was played, the type of music and the volume it was played at.
In a separate study, more than 80 per cent of theatre staff reported that music helped them while carrying out operations.
The study, published in the British Medical Journal late last year, found that music is played between 62-72 per cent of the time in the operating theatres. As with the Journal of Advanced Nursing study, songs were most often chosen by the lead surgeon.
Theatre staff reported that surgical performance was enhanced when music was played, and that it improved communication, reduced anxiety and improved efficiency.
The researchers said that critics often argue that music consumes cognitive bandwidth, reduces vigilance, impairs communication, and proves a distraction when anaesthetic problems are encountered. However, they encouraged surgeons to embrace music in the operating theatre whenever the situation allowed it.
Kirsty Waterford
Warm temperatures put heat on ED
Heat-related emergency department visits and deaths surge when the mercury rises above 23 degrees Celsius, according to a US study.
Researchers at Brown University and the Rhode Island Department of Health undertook a detailed statistical analysis of emergency department visits, deaths and weather data, and included possibly confounding factors, such as ozone, to assess the effect of rising temperatures on presentations at hospitals. The ED records included information about whether doctors thought a patient’s condition was related to heat or dehydration.
The study suggested that if the population were living with the sort of temperatures the world is expected to reach because of climate change, there will be an appreciable increase in emergency department visits and deaths.
Lead author Samantha Kingsley said the primary finding was that as temperatures increase, the number of emergency room visits and deaths increase. But, she said, people were going to the hospital for heat-related reasons at temperatures below what would typically be considered extreme.
The researchers found that while the rate of heat-related ED visits jumped 3.3 per cent on days when the temperature reached 23 degrees compared with those with a high of 18 degrees, they jumped almost 24 per cent when the mercury reached 29 degrees compared with days when the high was 23 degrees. Overall, temperature began to play an independent role in increasing ED visits when the mercury reached or exceeded around 23 degrees.
Senior author and Associate Professor Gregory Wellenius said that people should be aware that heat represents a significant public health threat that needed to be taken seriously, even when authorities did not issue heat warnings.
Interestingly, the researchers found that 18 to 64 year olds made the most heat-related emergency department visits, rather than infants and the elderly, who are considered to be the most vulnerable to heat-related health problems. The researchers were unsure about the reason, but speculated it may be because people in this age group were more likely to be outdoors working or playing sport, and may pay less heed to heat warnings.
Previous studies have linked higher temperatures to increased hospital visits and deaths, but in heat waves the elderly have been most at risk. Earlier this year a heat wave killed about 2000 people in India, many of whom were elderly.
The researchers warned that their finding that ED visits and deaths are greater on warmer days, even if temperatures are only in the 20s, suggests that distress from the heat may become even more common as temperatures rise as a result of global warming.
Kirsty Waterford
Fish oil key in preventing pre-term babies
Taking fish oil supplements can extend pregnancy and reduce complications, according to new research.
While exploring a theory that fish oil might aid brain development in the foetus, South Australian researchers stumbled upon the finding that fish oil extends gestation by an average of two days.
The South Australian Health and Medical Research Institute is now looking to recruit a further 5500 pregnant women to take part in a wider study to test this initial finding.
While the discovery might see reluctant full-term babies requiring come coaxing by induction or caesarean section, it has major implications for preventing pre-term births.
The original study was designed to look at whether omega 3 fats were needed in supplement form during pregnancy to help reduce the risk of post-natal depression and improve developmental outcomes for babies.
Lead researcher, Professor Maria Makrides, said that, “what we found was that it didn’t seem to do that, but the really interesting data we found was that we saw this shift in the mean duration of gestation that resulted in a halving of the number of babies born at less than 34 weeks”.
“It [fish oil] reduced the proportion of births at less than 34 weeks by about 50 per cent – they are the infants that are most likely to need intensive care, and most likely to suffer morbidities of being born pre-term,” Professor Makrides told the Adelaide Advertiser.
“They often can’t breathe properly, and sometimes do have developmental problems as they grow, so the burden on the child, family, and society if often quite large.
“If we are shifting the gestation then this is a really important outcome.”
The study also found that more women required obstetric intervention because their pregnancies were continuing too far beyond term.
The new study will ask women to take a supplement daily, with some women given fish oil and others vegetable oil. Once the women reach 34 weeks gestation they will be taken off the oil.
Professor Makrides said stopping the supplements at 34 weeks will hopefully allow women to get the full benefit of avoiding early prematurity, without extending gestation beyond the expected delivery date.
“This is a safe and cheap potential solution that can easily be applied to everyone,” Professor Makrides said.
Pregnant women interest in taking part of the study can call 08 81617458.
Kirsty Waterford
Tobacco cuts a deadly swathe through China
While tobacco companies and their deadly products are under siege in Australia and many other developed countries, the death toll from cigarettes in emerging markets is soaring as they make huge inroads into markets like China and Indonesia.
A study in the peer-reviewed journal Cancer has highlighted the heavy human cost that has resulted, reporting that smoking now causes almost a quarter of all cancers in Chinese men.
The authors of the study said that since the 1980s there had been an explosion in the number of men in China who smoke, to the point that the vast Asian country now produces and consumes around 40 per cent of all the world’s cigarettes.
Already, smoking is estimated to cause 435,000 new cancers each year in China (83 per cent of them in men), and researchers warn this will be only the tip of the iceberg as the effects of increased smoking rates now feed through in coming decades.
“The tobacco-related cancer risks among men are expected to increase substantially during the next few decades as a delayed effect of the recent rise in cigarette use, unless there is widespreasd cessation among adult smokers,” the research team, led by Professor Zhengming Chen of Oxford University and Professor Liming Li of the Chinese Academy of Medical Sciences, said.
The team analysed the results of a survey of more than 510,000 Chinese men and women conducted between 2004 and 2008, and a follow-up survey conducted after seven years found around 18,000 new cancers among those interviewed.
Underlining the dangers of tobacco, the survey found 68 per cent of men smoked, and they were at 44 per cent greater risk of developing cancer than non-smokers, particularly cancer of the lung, liver, stomach and oesophagus. The increased risk accounted for 23 per cent of all cancers found in people aged between 40 and 79 years.
But, in a result that should spur efforts to get people to quit the habit, the study found the excess risk of cancer had virtually disappeared 15 years after a smoker stubbed out their last cigarette.
Professor Zhengming said getting smokers to dump cigarettes would be the most potent and cost-effective strategies to avoid cancer and premature death “over the next few decades”.
The results came as Assistant Health Minister Fiona Nash dismissed complaints by tobacco companies about an increase in the excise charged on their products in Australia, and reaffirmed the nation’s commitment to defend the country’s world-leading plain packaging laws against legal challenge in international forums including the World Trade Organisation.
Senator Nash said the heavy tobacco excise had helped reduce the proportion of Australians who smoke daily to an all-time low of 12.8 per cent.
Cigarette manufacturers have complained that plain packaging, the hefty excise and other Government measures are fuelling an illegal trade in tobacco, but the Minister said such “scaremongering…[was] no reason to roll back sensible health policies”.
Adrian Rollins
Pain, pregnancy or Pilates – there is plenty to peruse
Paracetamol has been under the microscope a lot recently. A new review of oral non-steroidal anti-inflammatory drugs (NSAIDs) versus other oral analgesics for acute soft tissue injury continues this trend. Sixteen trials involving more than 2100 mostly young adults with various strains, sprains and bruises evaluated a range of drugs, including paracetamol and opioids. The review found low-quality but consistent evidence that NSAIDs and paracetamol are similar with respect to pain relief, swelling and return to function but, as you might expect, there is evidence that NSAIDs result in slightly more gastrointestinal side effects (doi:10.1002/14651858.CD007789.pub2).
Meanwhile, the rising tide of allergies in children has spawned an ocean of research. A recent review of eight trials of over 3350 women asks whether giving pregnant women or breastfeeding mothers marine omega-3 supplementation prevents allergies in their young children. The short answer is possibly for some allergies, notably food allergies, but probably not for other conditions such as allergic rhinitis or asthma (doi:10.1002/14651858.CD010085.pub2).
If too much sitting around over this year’s cold winter has brought on extra cases of low back pain, it’s good to know that Pilates can be added to the list of exercise interventions effective for relieving pain and improving function. A review of 10 studies involving over 500 adults with chronic low back pain also compared Pilates with other forms of exercise but found no conclusive evidence that it is superior (doi:10.1002/14651858.CD010265.pub2).
Making sense of the burgeoning evidence included in multiple systematic reviews has become an exercise in itself. Cochrane’s response is to publish overviews. In recent issues, assisted reproductive technology (ART), bronchiectasis and dressings for foot ulcer have all been given the overviews treatment. The ART overview, for example, synthesises the findings of 59 Cochrane reviews categorising 19 interventions as effective, 13 as promising and 14 as ineffective or possibly ineffective (doi:10.1002/14651858.CD010537.pub4). The evidence is less clear-cut when it comes to dressings for treating foot ulcers in people with diabetes. There is no shortage of systematic reviews but a paucity of included studies in these reviews makes drawing robust conclusions an ongoing challenge (doi:10.1002/14651858.CD010471.pub2).
For more on these and other reviews, check out www.cochranelibrary.com.