Doctors often ask for needless tests

Here's a warning from a medical expert you won't get too often: Do not follow your doctor's prescriptions blindly and question whether you really need to undergo the diagnostic tests he or she asks for. "On many occasions, doctors ask for tests that are unnecessary. Similarly, there are drugs that have become outdated or whose efficacy isn't proven. But doctors keep prescribing them. Unless there are standard guidelines on treatment of certain illnesses, such misuse will keep happening," said Dr Kameshwar Prasad, head of the clinical epidemiology unit at AIIMS. With the number of cases involving unwarranted prescriptions of surgical procedures, diagnostic tests and medication increasing, Dr Prasad said patients must ask their doctor about the pros and cons of the treatment offered before making a decision. To create awareness on the issue, AIIMS will hold an international meet — the first of its kind in the world — where experts will discuss how standard guidelines can be evolved for treating diseases. Dr Prasad said unnecessary diagnostic tests and surgical procedures not just put additional financial burden but also affect the patient's recovery. "We are also proposing that evidence-based treatment methodologies should be emphasized in medical schools," he said. AIIMS's neurology department recently screened prescriptions of 250 brain stroke patients referred from different hospitals. Many drugs, operations prescribed without need Doctors at AIIMS who recently screened prescriptions of 250 brain stroke patients referred from different hospitals said they found more than 48% of them were prescribed a particular drug which is not approved. "Either the doctor did not know about it or he used it despite knowing that it's not effective for the condition. In both cases, the patient had to suffer," the senior neurologist said. Experts said among the most misused procedures were hysterectomy (uterus removal), caesarean section and angioplasty for artery blockage. Among drugs, the most commonly misused were vitamins, steroids and antioxidants. According to Dr Paul Glaszious, former director of Oxford University's Centre for Evidence-based Medicine, MRI and CT scan are also being overused. "Vertebroplasty - a spinal procedure where bone cement is injected into fractured vertebra - has proved to be ineffective in many studies. Still, it is being used as a treatment method in patients complaining of backache," he said. In the case of angioplasties, experts said patients were most often not given time to decide whether they need to go for the procedure or not. For every patient with a blocked artery, there are three lines of treatment open - drug treatment, angioplasty and surgery. A recent study in US showed that only 36% of patients who had undergone non-emergency angioplasty to clear a clogged artery actually met the criteria for the procedure. In 50% of the cases, there was not enough evidence to show angioplasty would help and in 14%, the procedure was definitely not required. The study was published recently in the Journal of the American College of Cardiology. In the study, researchers gathered data from more than 24,000 angioplasty patients at 58 hospitals in New York State between 2009 and 2010, and measured how well the physicians stuck to the angioplasty guidelines advised by the American Heart Association and the American College of Cardiology. Said Dr Ashok Seth, chairman, cardiovascular sciences division at the Fortis Escorts Heart Institute, "Emergency procedures are not required in most cases, except for conditions such as heart attacks and unstable angina (chest pain) where a patient has to undergo stenting or surgery within 12 hours. In my view, anybody who can walk 500 metres without chest pain or exertion can wait. Patients must think over seriously and weigh the benefits of medicine versus surgery versus angioplasty before saying yes to any one treatment." "Every hospital should conduct an audit of various procedures carried out, say in a month. This would give us much-needed data about how prevalent each procedure is, and whether it is being misused," Dr Prasad said. He also urged patients to question their doctors constantly on their line of treatment and the tests prescribed by them.

Effectiveness of the combination of memantine plus vitamin d on cognition in patients with Alzheimer disease: a pre-post pilot study

The intensified treatment of breast cancer improves survival but has a price in terms of side-effects. The main side-effects, such as vasomotor symptoms and impaired sexual functioning, are related to premature menopause due to chemotherapy and/or anti-hormonal therapy. Though for some women these symptoms are bearable, for others they have a large impact on their quality of life. The paper discusses the menopausal symptoms most frequently reported by breast cancer survivors and current treatment options. METHODS: A literature review is presented of menopausal symptoms after breast cancer and management strategies, illustrated by two cases. SUMMARY: Vasomotor symptoms can be relieved by lifestyle adaptation, acupuncture and non-hormonal agents such as venlafaxine, gabapentin or clonidine. Impaired sexual functioning can be treated by couple-based sexual counselling or psycho-educational therapy. Painful intercourse due to vaginal dryness can be alleviated by vaginal lubricants and moisturizers, but is most effectively treated by vaginal estriol. Local estriol seems safe if used for a short period (less than six weeks). Because of proven increased risk of recurrence with hormone replacement therapy (HRT), it should not be prescribed for breast cancer survivors, although exceptions could be made of selected cases of fully informed BRCA mutation carriers after ER-negative breast cancer and with severe menopausal symptoms due to prophylactic oophorectomy at a young age and (preferably) after mastectomy. CONCLUSION: The management of vasomotor symptoms and impaired sexual functioning in breast cancer survivors should focus on lifestyle and, if necessary, non-hormonal pharmacological interventions.

Results of indirect and mixed treatment comparison of fracture efficacy for osteoporosis treatments: a meta-analysis

Network meta-analysis techniques (meta-analysis, adjusted indirect comparison, and mixed treatment comparison [MTC]) allow for treatment comparisons in the absence of head-to-head trials. In this study, conditional estimates of relative treatment efficacy derived through these techniques show important differences in the fracture risk reduction profiles of marketed pharmacologic therapies for postmenopausal osteoporosis. INTRODUCTION: This study illustrates how network meta-analysis techniques (meta-analysis, adjusted indirect comparison, and MTC) can provide comparisons of the relative efficacy of postmenopausal osteoporosis therapies in the absence of comprehensive head-to-head trials. METHODS: Source articles were identified in MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL) via Wiley Interscience; and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between April 28, 2009 and November 4, 2009. Two reviewers identified English-language articles reporting randomized controlled trials (RCTs) with on-label dosing of marketed osteoporosis agents and fracture endpoints. Trial design, population characteristics, intervention and comparator, fracture outcomes, and adverse events were abstracted for analysis. Primary analyses included data from RCTs with fracture endpoints. Sensitivity analyses also included studies with fractures reported through adverse event reports. Meta-analysis compared fracture outcomes for pharmacological therapies vs. placebo (fixed and random effects models); adjusted indirect comparisons and MTC assessed fracture risk in postmenopausal women treated with denosumab vs. other agents. RESULTS: Using data from 34 studies, random effects meta-analysis showed that all agents except etidronate significantly reduced the risk of new vertebral fractures compared with placebo; denosumab, risedronate, and zoledronic acid significantly reduced the risk for nonvertebral and hip fracture, while alendronate, strontium ranelate, and teriparatide significantly reduced the risk for nonvertebral fractures. MTC showed denosumab to be more effective than strontium ranelate, raloxifene, alendronate, and risedronate in preventing new vertebral fractures. CONCLUSIONS: The conditional estimates of relative treatment efficacy indicate that there are important differences in fracture risk reduction profiles for marketed pharmacological therapies for postmenopausal osteoporosis.

Risk of malignancies in patients with rheumatoid arthritis treated with biologic therapy: a meta-analysis

CONTEXT Concerns exist regarding the potential development of malignancies in patients with rheumatoid arthritis (RA) who are receiving biologic response modifiers (BRMs). OBJECTIVETo assess the risk of malignancy in patients with RA enrolled in randomized controlled trials (RCTs) of BRMs. DATA SOURCESElectronic databases, conference proceedings, and websites of regulatory agencies were searched for RCTs evaluating abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab, and tocilizumab in RA from inception through July 9, 2012. STUDY SELECTIONIndependent selection of studies included RCTs that compared the safety of any BRMs used in RA patients with placebo and/or any traditional disease-modifying antirheumatic drugs with a minimum of 24 weeks of follow-up. DATA EXTRACTIONIndependent reviewers selected studies and extracted data on quality and outcomes. Pooled estimates and 95% confidence intervals were calculated for each BRM. RESULTSSixty-three RCTs with 29,423 patients were analyzed. No statistically significant increased risk of developing malignancy was observed. Of the 29,423 patients, 211 developed a malignancy during the trial (118 solid tumors, 48 skin cancers, 14 lymphomas, 5 hematologic nonlymphomas, and 26 not specified). The incidence rate for any malignancy during the first year of therapy was very low in the BRM plus methotrexate group (0.77%; 95% CI, 0.65%-0.92%), the BRM monotherapy group (0.64%; 95% CI, 0.42%-0.95%), and the controls (0.66%; 95% CI, 0.52%-0.84%). Anakinra plus methotrexate showed lower odds compared with methotrexate alone (Peto odds ratio, 0.11; 95% CI, 0.03-0.45). No statistically significant risk was observed for specific cancer sites, although the Peto odds ratio for lymphoma was 2.1 (95% CI, 0.55-8.4) in patients receiving tumor necrosis factor inhibitors compared with controls. CONCLUSIONThe use of BRMs among patients with RA included in RCTs of at least 6 months' duration was not significantly associated with an increased risk of malignancy compared with other disease-modifying antirheumatic drugs or with placebo.

Treatment of the common cold in children and adults

The common cold, or upper respiratory tract infection, is one of the leading reasons for physician visits. Generally caused by viruses, the common cold is treated symptomatically. Antibiotics are not effective in children or adults. In children, there is a potential for harm and no benefits with over-the-counter cough and cold medications; therefore, they should not be used in children younger than four years. Other commonly used medications, such as inhaled corticosteroids, oral prednisolone, and Echinacea, also are ineffective in children. Products that improve symptoms in children include vapor rub, zinc sulfate, Pelargonium sidoides (geranium) extract, and buckwheat honey. Prophylactic probiotics, zinc sulfate, nasal saline irrigation, and the herbal preparation Chizukit reduce the incidence of colds in children. For adults, antihistamines, intranasal corticosteroids, codeine, nasal saline irrigation, Echinacea angustifolia preparations, and steam inhalation are ineffective at relieving cold symptoms. Pseudoephedrine, phenylephrine, inhaled ipratropium, and zinc (acetate or gluconate) modestly reduce the severity and duration of symptoms for adults. Nonsteroidal anti-inflammatory drugs and some herbal preparations, including Echinacea purpurea, improve symptoms in adults. Prophylactic use of garlic may decrease the frequency of colds in adults, but has no effect on duration of symptoms. Hand hygiene reduces the spread of viruses that cause cold illnesses. Prophylactic vitamin C modestly reduces cold symptom duration in adults and children.

Steven Moffat

Today marks the 50th anniversary of the first credited single release by The Beatles - who would feature in Doctor Who in stock footage in The Executioners (episode 1 of The Chase) - and if he had a time machine Matt Smith would love to see the Fab Four: "I'd go see music - the Beatles at their height, or Woodstock, or Kurt Cobain live. I'd love to see Arcade Fire in a room somewhere. And Sinatra when he was with Dean Martin." [Bust Magazine via Yahoo, 2 Oct 2012] (DWN note: Perhaps Matt got his time trip after all, if this photo that was circulated earlier in the year is to be believed!) Alex Kingston is to appear in the 10th season of NCIS as a "woman of questionable morals". The actress is to play a character named Miranda Pennebaker, and is described by series boss Gary Glasberg as someone who "deals in everything from high-end weapons sales to priceless gems. Her connections go all the way up the ladder of D.C. politics, and [Major Case Response Team leader Supervisory Special Agent Leroy Jethro] Gibbs needs her for this very disturbing, emotional case." [TVLine, 3 Oct 2012] Author and long-term fan A. L. Kennedy has expressed an interest to write for Doctor Who: "To go back to things that you are completely open to as a child, and which you allow to be very deeply part of who you are, as an artist, is to get back to that bit of yourself. And Doctor Who is very deeply there in my own work. Every crazy person, lots of the sense of humour, my viewpoint on what human beings are, absolutely. If I wasn’t going to be a writer I was going to be an anthropologist, because that was my thing: what are human beings?" The author will also be talking about Doctor Who when she appears at the Wigtown Book Festival on Sunday 7th October. [Scotsman, 1 Oct 2012] A rare opportunity to see Sarah Sutton in one of her earliest TV roles is coming up. The BFI is screening the BBC's 1973 adaptation of Alice Through The Looking Glass, which stars Sutton as the eponymous heroine, at its Southbank venue in London on Saturday 17th November as part of its Beyond the Fourth Wall – Experiments in TV Drama season. Directed by James MacTaggart, who was keen to exploit the possibilities offered by the then-new technique of colour separation overlay, the 65-minute play was the BBC's official entry to the Prix Italia competition. Also appearing in it are Geoffrey Bayldon (White Knight), Bruce Purchase (Walrus), and Stephen Moore (Haigha). Tickets go on sale to the public on Tuesday 9th October. Mark Gatiss will be at the BFI Southbank on Sunday 28th October for a question-and-answer session following a preview of his feature-length BBC Four documentary Horror Europa With Mark Gatiss, which explores European horror cinema and is a follow-up to his BBC Four series A History of Horror. Again, tickets go on sale to the public on Tuesday 9th October. The 90-minute documentary will air on BBC Four towards the end of October. Billie Piper is moving to Los Angeles with husband Laurence Fox after they both finish their current theatre stints, according to a newspaper interview with Fox, who is appearing with Arthur Darvill in Our Boys at The Duchess Theatre in London until Saturday 15th December. Piper is in The Effect at The Cottesloe, which opens on Tuesday 6th November and runs until Wednesday 23rd January 2013, meaning that for a few weeks their performances will overlap. However, Fox said the two of them didn't compete over their careers. "It's not competitive but I feel like I've got to raise my game a bit. She's really good so it would be nice if I was really good too," he said. [i, 3 Oct 2012] Meanwhile, Matt Smith and David Tennant bumped into each other at the press night for Our Boys. Also there was Billie Piper to give her support to her husband. [Mail Online, 4 Oct 2012] Comedian and TV presenter Frank Skinner has told of his failed bid to secure a role in the current series of Doctor Who. In an interview with Absolute Radio, he said: "I got my manager to phone up the Doctor Who people when I heard this series was being filmed. He never mentioned it again so I take it that he couldn't break it to me." [i, 3 Oct 2012] Comic book writer and playwright Grant Morrison, who penned stories for Doctor Who Magazine in the 1980s, told the MorrisonCon audience in Las Vegas that despite his desire to write for the show and apparent initial interest by Steven Moffat and Mark Gatiss in him doing so, nothing more had been forthcoming. "Moffat had been getting a lot of tweets from people who were saying, 'You should have Grant write Doctor Who', and I'd really love to write Doctor Who," he said. He added that a friend who had worked with Moffat and Gatiss suggested it to the pair and told him the duo wanted to hear from him. "We tried it four or five times, and he never wrote back," said Morrison. [Comic Book Resources, 1 Oct 2012 - NB: Article contains strong language elsewhere.] In a two-page feature in the new Radio Times, Steven Moffat describes how he struggled to find the proper ending for Amy and Rory. "How and why would they leave? And would they live or die? I wrote and rewrote. I had a completely different ending and threw it away. So many times over those mad few days, the fate of the Ponds changed. Alive, dead, alive, dead . . . Nothing felt right. Nothing felt inevitable." [Radio Times, 3 Oct 2012] Sheridan Smith - companion Lucie Miller to the Eighth Doctor in the Big Finish audio dramas - is the latest signing to BBC In-House Comedy's production of Mr Stink. As previously reported, the children's novel by David Walliams stars Hugh Bonneville as the eponymous tramp and has been adapted by Walliams and Simon Nye. Smith, who will play the overbearing mother of lonely 12-year-old Chloe who befriends Mr Stink, said: "David is such a brilliant writer, and the character just jumped off the page when I read it." [BBC Media Centre, 4 Oct 2012]

Doctor Who dominated the listings for the BBC iPlayer for September, with over 8 million accessing the programme at some point during the month.

Top of the list was the series opener, which has been available for almost the entire month, Asylum of the Daleks with over 2.2 million requests. It was by far the most requested programme on the iPlayer for September. The next three episodes, availble for fewer days, took the next three places in the chart with Dinosaurs on a Spaceship having 1.8 million requests, A Town Called Mercy having 1.4 million requests and The Power Of Three having 1.3 million accessing the episode. The highest rated non Doctor Who programme was Citizen Khan, which has less than half of the requests for Asylum of the Daleks with just over 1.0 million accessing the programme. The last Doctor Who episode before the mid-series break, The Angels Take Manhattan, was 7th in the list, with 0.92 million requests, despite only being available for the last 28 hours of the month. Asylum of the Daleks currently stands as the fifth most accessed programme of the year. All Doctor Who episodes are available on the BBC iPlayer until later this evening.