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British Medical Journal

<em>Picture: Alex Anlicker</em>

Picture: Alex Anlicker

A Glasgow GP is warning consumers that they should “just say no” to those trying to urge them to drink more of a popular beverage.

The drink promotion which has raised the ire of Margaret McCartney concerns neither Buckfast nor strong cheap cider – nor indeed does it contain any alcohol at all. Rather, she has turned her fire on water.

Writing in the British Medical Journal, Dr McCartney has denounced the recommendation to drink six to eight glasses of water per day to prevent dehydration as “not only nonsense, but thoroughly debunked nonsense”.

Anyone who has worked in an office has seen the increasingly large bottles of water as regular fixtures on people’s desks – as seen in this Smack the Pony sketch on “water bottle envy”.

But Dr McCartney says there is no clear evidence of benefit from drinking increased amounts of water, although the “myth” that “we-don’t-drink-enough-water” has endless advocates, including the NHS.

She criticises the NHS Choices website for perpetuating this, and wonders at schools which insist that pupils are accompanied to school by a water bottle.

She also warns that many of the messages promoting the policy – and the research used to back it up – have come from those with vested interest, including marketers of bottled waters.

She cites the campaign Hydration for Health, which recommends taking 1.5 to 2 litres of water daily as “the simplest and healthiest hydration advice you can give” and says that “even mild hydration plays a role in the development of various diseases”. Hydration for Health was created by the French food company Danone, whose products include Volvic and Evian bottled water.

Dr McCartney argues that there is no high-quality evidence to support these claims and says there are studies which show no clear evidence of benefit from drinking increased amounts of water and which suggest there may even be unintended harms attached to an enforcement to drink more water.

“It would seem, therefore, that water is not a simple solution to multiple health problems,” she writes.

She quotes a paper from 2002, published in the American Journal of Physiology, which looked at the evidence around drinking increased amounts of water to prevent dehydration. “He concluded that ‘not only is there no scientific evidence that we need to drink that much, but the recommendation could be harmful, both is precipitating potentially dangerous hyponatremia [an electrolyte imbalance where the body’s concentration of sodium is too low] and exposure to pollutants and also in making many people feel guilty for not drinking enough’.”

An editorial in the Journal of the American Society of Nephrology, published in 2008, reached much the same conclusion, writes Dr McCartney.

Although she accepts that children in school should have access to water when they are thirsty, Dr McCartney disputes the suggestion (reported by the BBC in 2000) that increased water intake led to an improvement in test results. “The research has not been published in a peer reviewed journal and the water intervention seems to have been part of a raft of changes in school,” she says, and adds that data relating water drinking to better weight control in children were prone to bias.

There are some conditions that do benefit from drinking more water, such as recurrent kidney stones, but other evidence for preventing disease is conflicting. In other words, it’s a complex situation not easily remedied by telling everyone to drink more.

“There are many organisations with vested interests who would like to tell doctors and patients what to do,” Dr McCartney concludes. “We should just say no.”

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Barrier contraception: Not a staple of romantic fiction. <em>Picture: Robert Elyov</em>

Barrier contraception: Not a staple of romantic fiction. Picture: Robert Elyov

An agony aunt and broadcaster has hit out at romantic novels for the impact they have on women’s sexual health.

In a paper entitled: “He seized her in his manly arms and bent his lips to hers”, Susan Quilliam argues that the “rose-tinted” view of relationships in the likes of Mills and Boon publications makes itself felt in the problems which women bring to the consulting room.

In particular, she blames romantic fiction for dissuading women from using condoms, saying: “To be blunt, we like condoms – for protections and contraception – and they don’t.”

Ms Quilliam’s contention, published in the latest issue of the BMJ Group’s Journal of Family Planning and Reproductive Healthcare, is that women are in the “grip” of idealised love and sex “purveyed in romantic fiction”. Although she confesses a teenage addiction to Georgette Heyer’s Regency romances – and admits the books can be fun and enjoyable – she suggests the genre isn’t doing women any favours overall.

“I would argue that a huge number of the issues we see in our clinics and therapy rooms are influenced by romantic fiction,” she writes. “What we see is more likely to be influenced by Mills and Boon than by the Family Planning Association.”

Romantic fiction accounts for almost half the fiction titles bought in parts of the developed world, she says, and although it has come a long way in terms of depicting a more realistic view of the world, a “deep strand of escapism, perfectionism and idealisation runs through the genre”.

Drawing a distinction between classic romances – where girl meets boy in the first chapter and is irrevocably committed to him by the last, with no diversions – from “chick lit”-style books like Bridget Jones (where unambiguous happy endings aren’t a must and where there are lots of diversions and sub-plots), she says some fans read a book every two days. This means that women are exposed to more of the romantic fiction’s vision than they are to formal sex and relationship education.

Common motifs in romances include non-consensual sex, female who are “awakened” by a man rather than being in charge of their own desires. The books also raise unrealistic expectations – for example, that heroines always achieve a life filled with multiple orgasms (without clitoral stimulation) and trouble-free – and frequent – pregnancies to “cement their marital devotion”.

“Clearly these messages run totally counter to those we try to promote,” she writes. “We don’t condone non-consensual sex. We want women to be aware of their own desires rather than be ‘awakened’. We aim to reassure our female clients that their first time may not be utterly joyful and that they may not gain reliable orgasms through penetration, but that they themselves are nonetheless existentially valid and that with affection and good humour things can improve immensely.”

We warn of the stresses of pregnancy and child-rearing and we discourage “relentless baby-making” as proof of a relationship’s strength, she adds. “Above all, we teach that sex may be wonderful and relationships loving, but neither are ever prefect and that idealising them is the short way to heartbreak.”

The condom issue is of particular concern, she says, with one study showing that only 11.5 per cent of romantic novels studied mentioned condoms – and even here, heroines typically rejected them, wanting “no barrier” between her and the hero.

“While the romance readers interviewed said that they knew that such episodes were diction, and that spontaneous sexual encounters are never risk-free, nevertheless there was a clear correlation between the frequency of romance reading and the level of negative attitude towards condoms and the intention to use them in the future.”

On the upside, other studies have suggested that reading romantic novels has encouraged women to have more sex, more adventurous sex and more experimental sex. Women also reported that they did not negatively compare their own real-life partners with fictional heroes unless the partnership was already rocky. Women might also use the books to nourish love and rekindle sex lives.

On the whole, however, she warns that if women start to believe the story that romantic fiction offers, then they store up trouble for themselves.

“If a woman learns from her 100 novels a year that romantic feeling is the most important thing, then what follows from that might be to suspend her rationality in favour of romanticism,” she says. This could mean she doesn’t want to use protection with a new man because she wants to be swept up in the moment as a heroine would. It could also mean she panics if sexual desire takes a nosedive after pregnancy or due to stress, causing her to think that the relationship has died with the romance.

“Sometimes the kindest and wisest thing we can do for our clients is to encourage them to put down the books – and pick up reality.”

<em>Picture: rumpleteaser</em>

Picture: rumpleteaser

Babies born outside normal “office hours” are at greater risk of dying because of a lack of oxygen (intrapartum anoxia), according to a study of more than a million births in Scotland.

Researchers used detailed data from Scottish national registers to determine that babies have a better chance of survival if they are born between 9am and 5pm, Monday to Friday.

Although the increased risk is small – and the overall number of deaths is very small – it is significant, the researchers say in today’s British Medical Journal, and should possibly prompt a rethink in the way that services are organised.

They suggest that the difference in death rates might be explained by variation in staffing at different times of the day, such as the total number of staff or the profile of staff, particularly the availability of senior clinicians. “It could also be related to access to clinical facilities, such as obstetric operating theatres,” they write.

They say that fatigue among clinical staff – often suggested as a cause of problems at night – is unlikely to explain the findings, as there was no excess risk of death among babies delivered during the night, compared with daytime at the weekends.

All births in Scotland between 1985 and 2004 were examined by the researchers, led by Professor Gordon Smith at the University of Cambridge. Many were excluded from the study for various reasons and the results were adjusted for factors such as deprivation and the type of hospital where the deliveries took place.

In all, 539 neonatal deaths (defined as deaths within four weeks of birth) were identified. The risk of neonatal death was 4.2 per 10,000 live births during the working week and 5.6 per 10,000 at all other times.

This represents a relatively small but significant risk of one to two extra deaths per 10,000 live births due to a lack of oxygen (intrapartum anoxia). The additional risk associated with delivering out of hours was estimated to account for approximately one in four of this type of death.

“Improving the level of clinical care for women delivering out of normal working hours might reduce overall rates of perinatal death,” the authors write.

Although the costs of doing so might seem out of proportion to the potential benefit, the authors point out that it could also benefit those babies who survive a lack of oxygen but who suffer long term neurodevelopmental impairment – a group which also accounts for a high proportion of the NHS litigation bill. “Any interventions that improved outcomes out of hours would therefore be likely to have a greater effect than merely reducing the number of neonatal deaths,” they write.

“Furthermore, previous research has shown that interventions in early life provide better value in terms of the costs per years of life gained than interventions in later life.”

In an accompanying editorial, David Field and Lucy Smith from the University of Leicester say that it’s reasonable to assume that the results can be generalised to the rest of the UK and perhaps other countries, but that several questions – such as the factors that make the difference – remain unanswered.

They say that women should be made aware of the risks of giving birth in different settings – such as specialist hospitals or midwife-led units or at home – to enable them to make informed choices.

Neon sign of a tooth and toothbrush

Picture: Get Directly Down

People who don’t brush their teeth twice a day have a higher risk of developing heart disease, according to research based on Scottish data.

Those who do not brush their teeth as often have a 70 per cent extra risk of heart disease than those who brushed them twice a day, although the overall risk remained quite low, researchers say.

The findings could mean that asking people how often they brush their teeth could help doctors determine who is at risk of future cardiovascular disease, the researchers say.

It has already been established that inflammation in the body, including the mouth and gums, plays an important role in the build up of clogged arteries and, over the last two decades, there has been increased interest in links between heart problems and gum disease.

But this research, published on bmj.com today, is the first to investigate whether the number of times that people brush their teeth has any bearing on the risk of developing heart disease, the authors say.

The study, led by Professor Richard Watt from University College London, analysed information from more than 11,000 adults who took part in the Scottish Health Survey.

The data analysed covered lifestyle behaviours, such as smoking, exercise and oral health routines.

Oral health was generally good, with around 62 per cent of participants reporting regular (at least every six months) visits to the dentist, and 71 per cent reporting good oral hygiene (brushing teeth twice a day).

Participants who brushed their teeth less often were slightly older, more likely to be men and of lower socioeconomic status, and had a high prevalence of risk factors, including smoking, physical inactivity, obesity, hypertension and diabetes.

On a separate visit, nurses collected information on medical history and family history of heart disease, blood pressure and blood samples – these enabled the researchers to determine the levels of inflammation present in the body.

The information gathered from the interviews was then linked to hospital admissions and deaths in Scotland until December 2007.

Once the data were adjusted to take into account other risk factors for heart disease, such as family history, social class, obesity and smoking, the researchers found that participants who reported less frequent toothbrushing had a 70 per cent extra risk of heart disease compared to those who brushed their teeth twice per day.

People who had poor oral hygiene also tested positively for inflammatory “markers” in the body such as C-reactive protein and fibrinogen.

Prof Watt said that more work would need to be done to confirm whether poor oral health was a marker for cardiovascular disease, or whether it actually caused it. But he said: “Our results confirmed and further strengthened the suggested association between oral hygiene and the risk of cardiovascular disease – furthermore inflammatory markers were significantly associated with a very simple measure of poor oral health behaviour.”

But he says that a “simple self-report measure of toothbrushing” could give a good idea of a person’s future risk of cardiovascular disease.

“Given the high prevalence of oral infections in the population, doctors should be alert to the possible oral source of an increased inflammatory burden.

“In addition, educating patients in improving personal oral hygiene is beneficial to their oral health regardless of the relation with systemic disease.”

<em>Picyure: Waldo Jaquith</em>

Picyure: Waldo Jaquith

The “white coat” effect, which sees some patients’ blood pressure rise simply because a doctor is testing it, is even more dramatic than previously thought, according to a major study.

Researchers have found that patients with very high blood pressure can see increases of as many as 29 units if a doctor checks it, compared to 17 if it is tested by a nurse.

The study, published in the British Medical Journal, has led to calls for changed guidelines on the diagnosis of hypertension (high blood pressure), which affects around four in 10 adults in the UK.

One of the authors, Professor Arduino Mangoni, who recently joined Aberdeen University from Flinders University in Adelaide, said it was time for a rethink over how we approach high blood pressure – and criticised current methods for using a “one-size-fits-all” approach.

He called on clinicians to make more use of methods which measure blood pressure over a period of time, rather than a single test where people might feel stressed, affecting the results.

High blood pressure, which is a major risk factor for heart attack, kidney disease and stroke, can be measured as a “one off” by a doctor or nurse at a GP surgery or hospital.

It can also by monitored by patients wearing a cuff on their arm which records blood pressure levels at regular intervals over a 24-hour period – called ambulatory blood pressure measurements.

The new study, involving 8,575 patients, shows that the higher the patients’ blood pressure, the bigger the difference between ambulatory monitoring and what is recorded by a nurse or doctor. The difference is particularly high when the blood pressure is measured by a doctor. The differences also vary depending on the sex and age of the patient.

But the study also found that the closer the patient’s blood pressure to normal levels, the less of a difference between measurements taken by ambulatory monitoring and those taken by a nurse or doctor.

Unlike existing published data, this study also provides a comprehensive range of differences between clinical and ambulatory blood pressure measurements for patients with a variety of profiles – for example, age, gender and whether the patient is suffering from other health conditions. This should allow for a far more tailored approach to taking blood pressure.

Prof Mangoni, executive member of the High Blood Pressure Research Council of Australia, said that hypertension could be a tricky condition for clinicians to diagnose, and may often be inadequately treated.

“High blood pressure is a contributory factor in cardiovascular diseases which account for 30 per cent of all deaths, and four million bed days each year, which is eight per cent of the total health capacity of the NHS.

“Yet current guidelines for the diagnosis and treatment of hypertension don’t pay enough attention to the role of ambulatory monitoring, often adopting a one- size-fits-all approach which doesn’t properly address different patient groups. ]

“Our new study will influence hypertension management guidelines worldwide as they take into account varying degrees of hypertension as well as treatment targets for patients of different genders, ages and with other existing conditions. We also hope they will encourage a wider use of ambulatory blood pressure monitoring by clinicians.”

PET scan of a human brain with Alzheimer's disease

PET scan of a human brain with Alzheimer's disease

Encouraging people in middle age to lead healthier lives could help stave off Alzheimer’s disease, researchers from Edinburgh believe.

Dr Tom Russ and Professor John Starr, experts in health and ageing at Edinburgh University, say that tackling risk factors such as obesity and high cholesterol could cut a person’s risk of developing dementia by about 20 per cent.

The most important areas are increasing levels of exercise across all age groups, and keeping obesity, blood pressure and cholesterol levels under control in middle age, they say.

Writing in the journal BMJ Clinical Evidence, the doctors add that the measures would also have positive effects on heart disease, diabetes and stroke.

The biggest risk factor for developing dementia is age. But there are steps which can be taken to cut other risk factors. The evidence suggests that, to be most effective, prevention has to begin earlier rather than later. For example, systematic reviews of research have suggested that there is no evidence that lowering blood pressure in later life is an effective strategy for preventing dementia, they write, while statins (cholesterol-lowering drugs) are not effective at preventing dementia in older adults.

“However, there is evidence that obesity, cholesterol and hypertension have effects on risk in midlife, rather than later life, highlighting the need for intervention in middle age to be sufficiently early to prevent dementia effectively,” they add.

“Modification of these risk factors at an appropriate age (ie early enough in life to have an effect) is everybody’s business and primary and secondary healthcare professionals, health promotion bodies, the voluntary sector and even employers will have to play a part for a national reduction in dementia incidence to occur.”

The alternative to such population-wide prevention initiatives would be targeting those at high risk of dementia. But they point out that this would be difficult. Even using cognitive tests, there is no reliable way of determining who is likely to progress to dementia, and who will not.

The paper is published in the same weeks as figures showing that the amount of anti-obesity drugs prescribed in Scotland grew by 2.8 per cent last year, costing the NHS around £4 million.

Dr Russ, co-author of the paper and an Alzheimer Scotland clinical research fellow, told the Caledonian Mercury he was not aware of evidence that anti-obesity drugs would help prevent dementia.

But he was not against the use of drugs per se in tackling high blood pressure and cholesterol: “The best advice is to lead a healthy lifestyle. That’s an individual responsibility, but we’re saying that it’s everybody’s business, including employers. Taking exercise across age groups is important, but drugs, such as those for lowering cholesterol, would form part of the standard clinical approach.”

Asked if Scotland’s general comparative poor health put its citizens at greater risk of developing dementia, Dr Russ said he didn’t look at it that way. “We’re saying it’s potentially possible to reduce that risk by taking action,” he added.

Recently the Alzheimer’s Research Trust estimated that dementia currently costs the UK economy £23 billion per year, much more than previously thought. It is expected to increase as the population ages.

eyeDoctors have warned that liquid capsules of fabric detergents should be kept out of reach of young children following a wave of eye injuries.

The capsules accounted for four in ten cases of chemical eye injury in children aged under five who attended a London hospital, according to a letter in this week’s British Medical Journal.

Ophthalmologists Rashmi Mathew and Melanie Corbett, from the Western Eye Hospital, Imperial College Healthcare NHS Trust, warn that the capsules can cause burns to the cornea of the eye, and that the effects can be life-long.

They also report that Guy’s and St Thomas’ Poisons Unit received 192 enquiries related to the capsules during 2007-08 and 225 in 2006-07, a fifth of which related to eye exposure.

The cleaning industry produced liquid capsules for fabric detergents in 2001, the researchers say. Although there are warnings on the packaging, this has not been enough to prevent eye injuries.

They looked at the cases of 13 children, nine of them girls, aged between 14 and 34 months. In 12 children, corneal burns were resolved with no complications. But one child, whose eyes were not washed out with sterile water (corneal irrigation) until arrival at hospital, suffered serious burns to both corneas.

The capsules are more dangerous than initially perceived, say the authors (who include senior chemist Katherine Kennedy) because, when dissolved in water, they give an alkaline solution. Alkali injuries are the most severe form of ocular chemical injury and can cause irreversible damage to the eye.

Specialist registrar Rashmi Mathew told The Caledonian Mercury that she would like to see parents and manufacturers take action. “Parents should know that if a child gets a chemical in the eye, it’s important to wash it out immediately with lots of liquid. They should also ensure that concentrated cleaning products are kept out of reach of children.

“But the manufacturers have a role to play as well, in making the products safer.”

The researchers say that some manufacturers have made hazard labels more prominent, after discussions with Guy’s Poisons Unit.

But Ms Mathew, who instigated the research after seeing a number of patients with detergent capsule-related injury, said the effects of such injuries could stay with children for the rest of their lives. “Fortunately all the children we saw made a complete recovery, including the girl with total burns to both eyes. But in some children, the injuries may never heal, or it may heal, but leave a scar behind.”

She repeated that the most important thing to do if someone gets a chemical in their eye is to wash it out with lots of water and then, if it doesn’t settle, seek medical attention.

A stethoscopeA new test designed to widen access to medical schools still favours males and those from privileged backgrounds, including private school pupils, according to a study published today.

More action is needed if we are to choose our future medics based on the personal qualities that would make them good doctors, rather than on good school exam results and background alone, the findings suggest.

Places at medical and dental schools are notoriously competitive and the applications process must be transparent, say the authors of the study, which is published in the British Medical Journal.

Universities also find it difficult to discriminate between applicants with equally impressive school exam results – especially amid claims of A-level ‘inflation’.

The UK Clinical Aptitude Test (UKCAT), which is aimed at increasing diversity and fairness in the application process, was introduced at a limited number of universities in 2006, amid fears that medicine was becoming a more elitist profession, open only to the privileged.

It appraises skills such as verbal reasoning and decision analysis and is designed to ensure that candidates have the most appropriate mental abilities, attitudes and professional behaviours to be doctors and dentists.

Professor David James, Foundation Director of Medical Education at the University of Nottingham Medical School, and colleagues, analysed data from the first group of applicants who sat the UKCAT in 2006 and who achieved at least three passes at A-level in their school leaving examination.

The test was found to have a modest correlation with A-level results, confirming that it can be used as a reasonable proxy for exams in the selection process.

But although it is subject to less bias than school exam results alone, it still favours males and those from a higher socioeconomic class or from independent or grammar schools, the researchers found.

The authors of the study say the findings “lead us to be cautious about the use of the UKCAT and the value of any one specific sub test within an admissions policy”. They conclude there is need for further research.

In an accompanying editorial, Professor David Powis from the University of Newcastle in Australia, says that measuring cognitive ability is a step in the right direction, but that it doesn’t tackle widening participation, or the admission of people from lower socioeconomic groups or those ‘whose education has been compromised by attending poorer schools’, he says. “And neither does UKCAT yet provide selectors with information on the non-cognitive characteristics and personal qualities that are fundamentally essential (and those that are undesirable) in the generic good doctor. This challenge remains for the future.”