In sickness and in health has moved

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World AIDS Day roundup

Today December 1st is World AIDS Day. As many as 33 million people worldwide are living with HIV, and there are 80,000 people with HIV in the UK. The aim of World AIDS Day is to raise awareness of the challenges and consequences of the epidemic - ultimately halting the spread of the HIV virus and improving the lives of people living with infection.

The UK theme for World AIDS Day 2008 is "Respect & Protect". Many people living with HIV face discrimination - this year's campaign hopes to highlight the responsibility everyone has to transform attitudes to HIV and encourage actions that stop its spread.> You can show your support for the campaign by wearing a red ribbon, which you can get your hands on in Gap, H&M, Selfridges and Levi's stores around the UK, as well as in Red Cross charity shops.

There is a whole selection of events and promotions worldwide to mark World AIDS day. For example, this weekend a flash mob descended on Glasgow town centre, "freezing" while handing each another red ribbons and condoms in the event organized by the British Red Cross.

South Africa is poised to grind to a halt for 15 minutes to talk about AIDS. This weekend the country received £15 million worth of support from the UK to tackle the HIV epidemic. In South Africa, 20–30% of the population is HIV positive and as many as 365,000 people have died unnecessarily thanks to the AIDS denialism of former president Thabo Mbeki.

Online, AIDS.gov has launched the “Facing AIDS for World AIDS Day” campaign. Participants are invited to take a photo of themselves wearing a red ribbon and, on World AIDS Day, put the photo on their social networking site, blog, Twitter page, or website. There is also a Flickr group and a Facebook group where supporters can upload their pictures.

Digital magazine (RED)Wire by Product (RED), the charity run by Bono to engage the private sector in AIDS programmes, launched today. For a monthly subscription fee of £4, half of which will go to the Global Fund to help people in Africa with HIV and AIDS, users can get world premieres of exclusive tracks from the likes of Elton John, Jay-Z and Coldplay.

Bloggers Unite, a movement that aims to "harness the power of the blogosphere to make the world a better place", has invited bloggers to dedicate their blog posts today to issues related to HIV/AIDS, with the aim of reminding people that HIV/AIDS is still a critical issue and to promote HIV testing. You can follow World AIDS day on Twitter with the tag #WAD08.

There is also a World AIDS day Musical Festival in Second Life, which will feature HIV/AIDS presentations and displays, tours, writing workshops, and virtual red ribbons and t-shirts.

• The Independent has an eyewatering but otherwise fascinating article about the use of circumcision in the fight against AIDS in Africa. The simple procedure has been shown to cut the risk of contracting HIV by about 60%.
• An editorial in the New York Times highlights a thought experiment published last week in The Lancet. The authors used mathematical modelling to predict what would happen if the majority of adults and adolescents were tested for HIV each year and treated immediately with antiretroviral drugs. This strategy could practically eliminate transmission of the virus within the space of a decade.

You've got mail... or chlamydia

The young people's sexual health charity Brook has teamed up with the NHS and the laboratory testing company Preventx to offer free chlamydia testing kits through the post.

By using the Freetest.me website, young people between the ages of 16 and 24 can order a postal home testing kit, return their urine sample or vaginal swab by post, and receive the results by text message, email or on the website's tracking service.

According to Brook, chlamydia is the most common sexually transmitted infection, with 1 in 10 people affected. Up to 75% of women and 50% of men with chlamydia have no symptoms, but left untreated the disease can cause serious health problems such as pelvic inflammatory disease and scarring of the reproductive system, and can lead to infertility.

Chlamydia can be treated easily with antibiotics, but these drugs can stop the contraceptive pill or patch from working.

'Two for the price of one' tactic improves outcomes after organ transplantation

A new study of more than a million transplant recipients has found that rejection rates are lower in patients who receive two organs at once than in those who receive a single organ.

The study, published in Annals of Surgery, found that the rejection rates for organs cotransplanted with a donor-specific liver, heart or kidney were significantly lower than those for organs transplanted alone.

It has been known for some time that transplanting a liver with another organ such as a kidney or a section of intestine reduces the likelihood of rejection of the primary organ, leading to the suggestion that liver allografts protect other organs from rejection. Combined liver and kidney transplantation is used in patients with hepatorenal syndrome - in which acute kidney failure occurs as a result of liver cirrhosis or fulminant liver failure - or in patients with end-stage renal disease who also have liver damage as a result hepatitis B or C virus infection. Simultaneous intestine and liver transplantation is used in patients with intestinal failure following the removal of a large section of intestine (e.g. because of a tumor) and end-stage liver disease, which may be due to receiving their meals intravenously following intestine removal (total parenteral nutrition).

The recent study by Rana et al. has revealed that heart and kidney allografts are also immunoprotective and are themselves protected when transplanted with another organ.

The authors searched the United Network for Organ Sharing database – which contains data about every transplant that has taken place in the US since 1986 – and identified all thoracic, kidney, intestine and liver transplant recipients over 18 years old.

In patients who simultaneously received heart and kidney transplants from a single deceased donor, the incidences of renal allograft rejection and cardiac allograft rejection at one year were lower than in patients who received either a heart or a kidney allograft alone. In addition, the rate of rejection-free survival at one year was higher in the combined organ recipients. Likewise, compared with patients who received a single organ, rejection of either organ and rejection-free survival were lower and higher, respectively, in individuals who received combined liver and kidney transplants.

On the other hand, cotransplantation of intestine or pancreas in patients undergoing kidney or liver transplantation did not lower the risk of rejection or improve rejection-free survival.

The authors suggest that combined simultaneous organ transplantation could be used more widely to reduce rejection rates and lower the need for immunosuppression in transplant recipients.
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Rana A et al. (2008) The Combined Organ Effect: Protection Against Rejection? Annals of Surgery 248 (5): 871-879 DOI: 10.1097/SLA.0b013e31817fc2b8

British Heart Foundation petition against cigarette machines

The British Heart Foundation has launched a petition to ban the sale of cigarettes from vending machines in the UK. The charity hopes that banishing cigarette vending machines will reduce the number of under 18s who take up smoking.

In the UK you need to be at least 18 years old to buy cigarettes from a shop and, technically, this old to get cigarettes from a vending machine. Vending machines aren't manned, however, making it easier for under 18s to circumvent this rule and get their hands on cigarettes. 66% of adult smokers started when they were under age, so stopping people from taking up smoking as teenagers is crucial to prevent a livelong addition to cigarettes.

According to the BHF, 6% of children aged 11-15 are regular smokers and as many as one in six of these teenagers buy their cigarettes from cigarette vending machines. A 2007 study reporting on test purchases by young people found that teenagers were able to buy cigarettes from vending machines on more than four in ten occasions, with a number of councils reporting a 100% successful purchase rate. Using vending machines was the most successful way for young people to get hold of cigarettes - almost twice as successful as other ways tested such as purchasing cigarettes from a newsagent, off licence or petrol station kiosk.

Smoking is a leading risk factor for heart disease - of the 114,000 smokers who die as a result of smoking each year in the UK, one in four die from cardiovascular disease. Measures to help people quit smoking, or stop them from smoking in the first place, are thus a key part of the BHF's strategy.

• You can help put cigarette vending machines out of order for good by signing the BHF petition here.

Chronic kidney disease patients claim to know nothing about their condition

A study by Finkelstein and colleagues published recently in Kidney International has found that as many of a third of patients with chronic kidney disease (CKD) claim to know nothing about their disease or about their treatment options when their kidneys ultimately fail.

CKD encompasses many types of kidney damage and is characterized by the gradual loss of renal function, often with few symptoms bar raised blood pressure and nonspecific signs such as fatigue and reduced appetite. CKD is graded on a 5-point scale, with stage 1 being slightly diminished kidney function and stage 5 being established kidney failure. Despite treatment many cases progress, in some instances to the point of kidney failure, otherwise known as end-stage renal disease. Once a patient reaches end-stage renal disease, they have to regularly undergo life-saving treatment that mimics the roles performed by their now defunct kidneys. Some such treatments include dialysis and kidney transplantation.

In the study by Finkelstein et al., 676 patients with stage 3–5 CKD who had been receiving nephrology care for about 5 years completed a questionnaire to assess their knowledge of CKD and of renal replacement therapies. Only 23% of patients reported having a great deal or extensive knowledge about their CKD and 35% reported having very limited or no knowledge. When questioned about their knowledge of renal replacement therapy, 35% of patients reported knowing nothing about any end-stage renal disease treatment modality.

Various studies have shown that decent education about CKD can delay the onset renal failure, increase the likelihood of the patient choosing a less costly home-based therapy rather than elaborate hospital-based dialysis, and improve outcomes of patients after the start of dialysis.

The findings of the Finkelstein et al. study indicate that despite receiving specialized kidney care for several years, many patients with CKD feel they have little knowledge of their disease and are, therefore, ill equipped to make treatment decisions. In an editorial accompanying the research, Chester Fox and Linda Kohn of University at Buffalo, New York, suggest that, "A multidisciplinary team - including dieticians, social workers, nurse educators, and pharmacists - and access to transplant surgeons are necessary to improve patient knowledge and understanding about progression of CKD and treatment options."

Finkelstein FO et al. (2008). Perceived knowledge among patients cared for by nephrologists about chronic kidney disease and end-stage renal disease therapies Kidney International 74 (9): 1178-1184 DOI: 10.1038/ki.2008.376
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Another recent study, this time published in Archives of Internal Medicine, measured whether the introduction of early detection guidelines had improved the number of patients with CKD who were aware that they had the disease. The authors specifically asked 2,992 patients with stage 1-4 CKD whether or not they had been told that they had weak or failing kidneys. Between 1999 and 2004, awareness improved only in patients with stage 3 CKD. Patients with risk factors for CKD such as diabetes or hypertension were most likely to be aware of their disease.

Testosterone skin patches improve sex drive in postmenopausal women

A considerable proportion of women - between 25% and 53% in fact - suffer from sexual problems, with libido taking a nosedive after the menopause as estrogen levels drop. Although low libido isn't a health problem per se, it has been shown to have a negative effect on sexual relationships and overall wellbeing.

It has been known for several years that testosterone, administered as a skin patch, improves sexual function in postmenopausal women. Previous studies on sex drive in women have only looked at the effects of testosterone in females also taking estrogen therapy, as testosterone is thought to be ineffective without concurrent estrogen administration. Long-term estrogen therapy is, however, associated an increased risk of cardiovascular disease.

A recent study by Davis et al. has now shown that testosterone patches can improve libido in postmenopausal women taking no other hormone therapy. Sponsored by Procter & Gamble, the study found that use of the company's Intrinsa testosterone patches doubled the number of satisfying sexual episodes a month in women with low libido.

The study - conducted at 65 centers in the US, Canada, Australia, the UK and Sweden - enrolled 814 women who had undergone natural or surgical (e.g. through hysterectomy) menopause and who were concerned about decreases in their levels of desire and sexual activity. These women were randomly assigned to receive daily placebo, 150 micrograms of testosterone a day or 300 micrograms of testosterone a day, which was administered via patches applied to the abdomen.

After 24 weeks of treatment, the increase in the number satisfying sexual episodes per month was greater in women receiving 300 micrograms of testosterone a day than in women receiving placebo (an increase of 2.1 episodes vs 0.7 episodes). The increase seen in women receiving 150 micrograms of testosterone a day, however, was not markedly greater than that in women on placebo (an increase of 1.2 vs 0.7 episodes). Both testosterone therapy groups showed a greater increase in sexual desire than the placebo group and a more notable decrease in libido-related personal distress.

The number of reported side effects throughout the 52-week study period was similar in all three groups, although there was a higher incidence of unwanted hair growth in the women receiving 300 micrograms of testosterone a day. Four women receiving testosterone were diagnosed with breast cancer compared with none in the placebo group, but at least one case was thought to have developed before the initiation of testosterone therapy and the other cases were put down to chance.

Speaking to CNN, Dr Sheryl Kingsberg, one of the coauthors of the study, said, "Although the change in activity is modest, that's something that is appropriate and I think most women would be more than happy with it. They wanted to return to the level of desire they had in their premenopausal years, and that's what they got."

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Davis SR et al. for the APHRODITE Study Team (2008). Testosterone for Low Libido in Postmenopausal Women Not Taking Estrogen N Engl J Med 359 (19): 2005-2017 PMID: 18987368

November 14th is World Diabetes Day

Tomorrow the International Diabetes Federation (IDF) is leading World Diabetes Day, the primary global awareness campaign of the diabetes world.

World Diabetes Day is celebrated annually November 14th, the birthday of Frederick Banting, who in 1922, along with Charles Best, conceived the idea that led to the discovery of insulin.

The theme for this year and for 2007 is 'Diabetes in Children and Adolescents'. The incidence of type 1 diabetes in children is increasing at a rate of 3% each year and is increasing fastest in preschool children (a rate of 5% per year). Type 2 diabetes has been reported in children as young as 8 years old. Over half of all children with diabetes develop complications - such as heart disease and blindness - within 15 years.

The World Diabetes Day 2007-2008 campaign aims to:
• Increase the number of children supported by the IDF Life for Child Program, a international aid endeavor that provides life-saving medication to children with diabetes in developing countries.
• Raise awareness of the warning signs of diabetes.
• Encourage initiatives to reduce diabetic ketoacidosis.
• Promote healthy lifestyles to help prevent type 2 diabetes in children.

One of the key events of is the lighting of buildings and monuments in blue – the colour of the diabetes circle. In 2008, the aim is to encourage a total of 500 monuments and iconic buildings to light up to mark World Diabetes Day. The owners of the London Eye have already pledged to light up their monument; the Sears Tower in Chicago, Niagara Falls on the US/Canada border and the Alamo in Texas are also going blue. You can see pictures of buildings that were lit up in 2007 on the IDF Flickr page.

The global diabetes community is organizing a range of activities, including radio and television programmes, public information meetings, poster and leaflet campaigns, newspaper and magazine articles, events for kids, and walks, runs, and bicycle races.

Members of the public encouraged to show their support of diabetes awareness by lighting blue World Diabetes candles; a percentage of the sales of these candles will go to support children with diabetes on the Life for a Child Program.

The World Diabetes Day website includes lists of activities in various cities worldwide, so check it out and get involved!

Cardiologists circumspect on stellar JUPITER results

The publication this week in New England Journal of Medicine of the JUPITER trial - which found that the statin rosuvastatin reduces the risk of heart attack and other cardiovascular events in people with normal cholesterol levels - has cause quite a stir. The likes of the BBC and the Daily Mail squealed that statins should be prescribed to all healthy adults, but what did the study actually look at, and what do doctors think of the findings?

In patients with raised cholesterol levels, treatment with statins reduces the risk of cardiovascular events such as heart attack and stroke; however, nearly half of all first cardiovascular events occur in people whose cholesterol levels are below current thresholds for pharmacological therapy. The JUPITER trial investigated the benefits of treatment with rosuvastatin (also known as crestor) in 17,802 patients over 50 years of age who had normal blood levels of low density lipoprotein (LDL) cholesterol ('bad' cholesterol), but elevated levels of another marker of heart disease called C-reactive protein (CRP).

Compared with a placebo, statin treatment reduced the levels of both LDL cholesterol and CRP by considerable amounts (50% and 37%, respectively), and also almost halved the likelihood of a major cardiovascular event such as a heart attack or stroke. When the results were broken down, it was found that the risk specifically of heart attack was reduced by 54% and the risk of fatal or nonfatal stroke decreased by 48%.

CRP levels are not usually measured in people at risk of heart disease, yet statin treatment had a remarkable effect in people who were otherwise apparently healthy but had elevated levels of this marker. Doctors are now been asking whether measurement of CRP levels should be undertaken in all people at risk of heart disease, and whether statins should be prescribed as a preventative measure to a wider range of people, regardless of whether their cholesterol levels indicate that they should receive such treatment.

In an editorial in the same issue of New England Journal of Medicine, Mark A Hlatky from Stanford University School of Medicine in California goes through the trial with a fine tooth comb to decide whether or not doctors should change how they prescribe statins.

He notes that "JUPITER was a trial of statin therapy, not high-sensitivity CRP testing", and opines that "the evidence still favors [a] selective strategy for measuring high-sensitivity C-reactive protein, not routine measurement". Dr Hlatky also points out that the trial was only 2 years long, so could not assess the effects of long-term statin treatment, and that the cost of rosuvastatin is much higher than that of generic statins, so the benefits of broader prescription of rosuvastatin treatment need to be weighed up against these factors.

You don't have to just take Dr Hlatky's word though. New England Journal of Medicine are hosting an online Clinical Directions poll to find out directly from doctors whether they are likely to change how they practice on the basis of the JUPITER results.

So far over 1,500 doctors and medical professionals have voted in the poll, and only 53% believe that the approach to laboratory screening and therapeutic use of statins in apparently healthy adults should be changed. The comments on the poll are just as cautious - Greg Rice of Libby, Montana says "Certainly what this study clearly shows most is that there is a large cohort of high risk patients we are missing. However, simply giving them a statin is not a very cost effective way to reduce the risk of coronary disease", whereas Timur Timurkaynak of Ankara, Turkey states "I really wonder what have we learned from jupiter trial that we don't know before".

So it seems that the jury is going to being deliberating for some time as to whether apparently healthy people should have their CRP levels measured and should receive statins. The JUPITER trial seems to have thrown up more questions than it has answered, and it is clear that more research is needed before statins start getting dished out willy nilly.

• Nature News has a good run down of the JUPITER study and whether you should be heading straight to your doctor for preventative statin treatment
  

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Ridker PM et al. (2008). Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein New England Journal of Medicine DOI: 10.1056/NEJMoa0807646

The Nature Debate: Enhancing the Body

This evening I attended The Nature Debate: Enhancing the Body at King's Place in King's Cross, north London.

Today's discussion is the second of two panel events on "the risks, benefits and extent of how far research can extend our mental and physical abilities". Chaired by Kerri Smith, Nature Podcast Editor and presenter of Nature Neuroscience's NeuroPod, the panel comprised:

• Kevin Warwick, Professor of Cybernetics at the University of Reading and wannabe cyborg.
• Andy Miah, Reader in New Media & Bioethics at the University of the West of Scotland, Fellow of the Foundation for Art and Creative Technology and dapper dresser.
• Aubrey de Grey, Chairman of The Methuselah Foundation, an organization committed to accelerating progress toward a cure for age-related disease, and owner of a magnificent beard.

After a brief introduction and tongue in cheek incitement to "get physical" from Nature Managing Editor Nick Campbell, the panel members lay down their views on the subject of physical enhancement.

Aubrey de Grey begins by pointing out that all three panel members are advocates for physical enhancement and questions whether the discussion will really be a debate at all, then lays down his case, arguing that being against the concept of physical enhancement is "incoherent". Citing examples such as the beneficial effects of antibiotics and vaccines on the immune system, he illustrates that we humans have already taken measures to enhance ourselves physically.

Next up is Kevin Warwick, who compares humans to computers in order to demonstrate the limitations of our mental capacities. He cites a professor at MIT who claimed that all the memories of a 100-year-old person could fit on a single CD and states that machines can sense spectra like ultraviolet and X-rays, finally suggesting that by harnessing the power of computers in these areas we can enhance mental powers such as memory capacity and sensory perception. Warwick's most famous experiments represent the first steps along this path - in 1998 he implanted a chip under his skin and was able to open and shut doors via a computer, then in 2002 a new chip that interfaced directly onto his median nerve permitted him to move a robot arm in synchrony with his own actions.

The third panel member, Andy Miah, spoke about the value of human enhancement in elite sports. An asthmatic, he only recently began regularly using his inhaler and feels that his running capability has increased tremendously - where do these kind of measures fall in the debate about physical enhancement? Miah also discusses the case of the South African runner Oscar Pistorius, who is a double amputee and the proud owner of very high-tech carbon fibre transtibial artificial limbs. Pistorius successfully campaigned to compete with able-bodied athletes in the 2008 Beijing Olympics. His case raises interesting questions about the perception of disability and the purpose of enhancements.

Chair Kerri Smith picks up on this theme and asks the panel whether there is a difference between enhancing the physical capabilities of a disabled person in order to bring them up to the the capacity of a 'normal' individual, and physically enhancing a healthy person to give them abilities above the norm. Harking back to the case of Oscar Pistorius, Andy Miah opines that the definition of a 'normal' human and, therefore, what constitutes a physical enhancement is particularly difficult, especially in the paralympics. This issue then leads into a discussion of what constitutes an acceptable physical enhancement, with Aubrey de Grey suggesting that elite sport is 'the canary in the coalmine' of physical enhancement and may well prove to be the litmus test of what society considers acceptable.

Finally, the panel are asked what sort of physical enhancements are possible at this moment in time and how long it will be before one of their pet projects comes to fruition. Aubrey de Grey says that the aim in his field is "to solve the problem of aging faster than it catches up with us" and that he hopes the discipline of regenerative medicine will reach this point in 25-30 years. Andy Miah thinks that the first genetically enhanced athletes might appear in the 2012 Olympic Games, and acknowledges that genetic modification is already possible in animals and it is only ethical and safety concerns that prevent such techniques being used in humans today. Kevin Warwick cites his most recent experiments - in which rat neurons are interfaced with robot 'bodies' - as examples that enhancing physical capabilities through computers is technologically possible at the moment, and purports that it could only be 12-18 months before scientists start doing similar experiments with the human nervous system. On the other hand, there are many concerns relating to surgery, infection, and the ethics of such undertakings, meaning that linking human brains to robot bodies - Steve Martin brain-in-a-jar style - might not happen for up to 10 years.

So what of Nature's original question - "How should we respond to enhancement technologies?" The answer from the panel seems to be: "enthusiastically". The last word goes to Aubrey de Grey, who states "It is intellectually bankrupt to say that any enhancement per se is wrong".

Consumption of caffeine during pregnancy increases the risk of having an underweight baby

Caffeine has been proposed to have all sorts of effects on health, both good and bad. Just in the last few months, it has been reported that caffeine can help repair damaged blood vessels, protect against cataract formation, and even shrink women's breasts.

Now new research published in the British Medical Journal has found that consuming caffeine during pregnancy can increase the risk of giving birth to low-birth-weight baby. Underweight babies are more likely to be delivered early or by cesarean section, and are at a higher risk of having neurological disabilities.

The authors of this study devised a questionnaire on habitual caffeine intake that was administered before conception and twice during pregnancy in 2,635 women. They then looked at information on pregnancy complications and delivery details in the electronic databases of the two large UK maternity hospitals in which the study was conducted.

The mean caffeine intake during pregnancy in these women was 159mg a day - equivalent to approximately a cup and a half of filter coffee, three cups of tea, or about three cans of cola drink. Approximately 62% of the total caffeine ingested was in the form of tea, 14% was in coffee, 12% in cola drinks and 8% in chocolate.

Compared with women who consumed less than 100mg of caffeine a day, the risk of having a low-birth-weight baby was 20% higher in those who consumed 100-199mg per day and 50% higher in those who consumed 200-299mg per day. The size of the reduction in birth weight increased as caffeine intake increased.

Importantly, the magnitude of the association between caffeine consumption and baby size was similar to that seen between alcohol consumption and birth weight, i.e. caffeine consumption increased the risk of having a low-birth weight baby as much as alcohol consumption did.

The Food Standards Agency in the UK has now changed it's recommendations on caffeine intake during pregnancy on the basis of this research, lowing the limit from 300mg a day to 200mg a day.
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CARE Study Group (2008). Maternal caffeine intake during pregnancy and risk of fetal growth restriction: a large prospective observational study BMJ, 337 DOI: 10.1136/bmj.a2332

The sexual health of Great Britain

This week the Office for National Statistics released the results of their 2007/08 contraception and sexual health survey, which was undertaken as part of the National Statistics Omnibus Survey.

Over four months, 1,164 women aged 16-49 and 1,543 men aged 16-69 completed a questionnaire on contraception use, sexual health, and knowledge of sexually transmitted infections (STIs). The survey found that the majority of Brits are monogamous. Men still claim to have had more sexual partners than women but at least are mostly using condoms while they're playing the field. Women, on the other hand, prefer the pill to any other form of contraception. We're not too hot on emergency contraception but know our STIs better than we used to, gleaning most of our info from the TV.

As many as 75% of men and 78% of women reported having had only one sexual partner in the previous year. Within all age groups, a higher proportion of men than women reported multiple sexual partners and more women than men reported having had just one partner.

The pill was the most popular form of contraception, used by 28% of women employing such measures, and the condom was the second most popular method (24%). In total, 43% men and 50% of women had used a condom in the past year, with those who had had more than one sexual partner more likely to have used a condom than those who had only had one partner. More specifically, 80% of men and 82% of women who had multiple partners had used a condom in the past year.

Almost all women (91%) had heard of the morning after pill, but awareness of the emergency intrauterine device (IUD) had dropped from 49% in 2000/01 to 37% in 2007/08. Less than half (49%) of the women who had heard of emergency contraception knew that the morning after pill is effective up to 72 hours after intercourse, while less than 10% were aware that the emergency IUD was effective if inserted up to five days after sex. Only 6% thought that the morning after pill protected against pregnancy until the next period and less than 1% believed that it protected against sexually transmitted infections.

Nearly all respondents correctly identified that chlamydia is an STI (85% of men and 93% of women), far more than in 2000/01 (35% and 65%, respectively), and nearly all men and women knew that gonorrhoea is an STI (92% and 91%, respectively).

Alarmingly, half of all respondents reported making no changes to their behaviour as a result of what they had heard about HIV/AIDS and other STIs, but thankfully more than a third of men and women said they had increased their use of condoms.

Most respondents got their information on STIs from television programmes (31%), followed by TV adverts (22%), and newspapers, magazines or books (20%). On the other hand, the internet was rarely used as a source of information about STIs, even by young people (3% of those aged 16-24).

The Lancet website relaunch

Today medical journal The Lancet relaunched a sleek and efficient new version of their website TheLancet.com.

The team at The Lancet consulted 100 authors, readers, doctors and clinicians - or 'development partners' - to find out what users wanted, and the result is a much cleaner and easier to use website. In the new design, The Lancet journals The Lancet, The Lancet Infectious Diseases, The Lancet Oncology, and The Lancet Neurology are now all accessible and searchable from a single website.

In a special podcast to accompany the launch, the Editor-in-Chief Richard Horton outlines his favourite features:

"The most exciting things about The Lancet's new site for me are first, we have the possibility for internet television ... in the YouTube would that we live in I think that's immensely important for communication, especially in health when you've got some pretty difficult concepts sometimes. And secondly, I think we're also able to convey the personality of The Lancet in ways that we've never been able to before: the idea that we're publishing research, educational material, and also opinion."

The new video functionality is showcast TheLancet.com Story, a very flashy and professional-looking production in which members of the journal staff and Dr Anne Szarewski, clinical consultant at Cancer Research UK and one of the development partners, discuss what the new website means to them. The Lancet hopes that in the future users will be able to submit their own medical videos to the site.

Richard Horton boasts that the website has "the best search engine in medicine", and certainly it's an awful lot faster than the search on the previous incarnation. Importantly, the search results include not only results from The Lancet family of journals, but also all relevant results in Medline, a life sciences and biomedical publication database run by the US National Library of Medicine.

Articles now include links to related material as well as social bookmarking tools, including parent company Elsevier's 2Collab social networking tool. In addition, online community features are planned, including social networking, debates, wikis and discussion boards.

On the editorial side of things, original research articles now include drop-down Editors' Notes within the table of contents - 2 or 3 sentences that summarize what is important about the research - while journal homepages feature three articles that represent the Editor's choice. The news aspect of the website has been expanded with the inclusion of 'This Week in Medicine', short paragraph-long summaries of what has been going on in medicine worldwide. Specialty-based online collections comprising content from across The Lancet family of journals will launch in the near future, one mooted project being a cardiology portal.

I think the new version of TheLancet.com is a vast improvement on the previous website, not least because it is so much easier to navigate and doesn't trip you up with sign-ins every 5 minutes. The site also looks far crisper, in stark contrast to it's cluttered forebear. I'm more into text than multimedia so I'm not fussed about using the new video content, but it's certainly very impressive and a new direction for The Lancet.

New Scientist cancer special

The latest issue of New Scientist is a cancer special titled 'Old killer, new hope'.

The main focus of the issue is a large article on genomics - 'Living with the enemy'. Instead of classifying tumors according to where in the body they appear, for example the prostate or the lung, scientists are now starting to groups cancers according to which molecular pathway the cancer uses in order to grow and spread.

New targeted therapies can act specifically on a particular molecular pathway, sparing the normal dividing cells that are often killed off in conventional forms of cancer therapy. For example, breast cancer patients with mutations that cause overproduction of the protein HER2 can be treated specifically with with an antibody called trastuzumab, better known as Herceptin, whereas those with receptors to the hormone estrogen can be treated with a drug called tamoxifen. An interactive graphic shows how these modern therapies work.

'Patients doing it for themselves' describes how powerful, well-funded patient groups are setting the agenda for cancer research. The article cites the example of the Multiple Myeloma Research Foundation, which amazingly donates as much money to research on multiple myeloma as the US National Cancer Institute.

The capacity of the immune system to hold tumors dormant is discussed in 'Tumors under lock and key'. Apparently about a third of breast cancer survivors still have tumor cells circulating in their blood after successful treatment, in cases up to 22 years after therapy. Finding out how the immune system keeps microtumors, which are thought to be responsible for these circulating tumor cells, from running amok could provide new strategies for fighting cancer.

The special issue also contains a list of expert tips for evading cancer and an editorial lamenting how patients and healthcare providers are ever going to be able to afford these fancy new treatments.

All these articles are currently available online for free, so go check them out.

Attitude has no effect on survival in women with breast cancer

Many patients with cancer feel that their attitude towards the 'fight' is an important part of beating the disease, but maintaining a positive perspective is pretty tough in the face of a life-threatening malignancy.

A large, population-based study published in the Journal of Clinical Oncology has now found that psychosocial factors such as fighting spirit and fatalism have no effect on survival in patients with breast cancer. The authors Phillips et al. emphasize that their results could allay the concerns of anxious women who believe that their mental attitude towards breast cancer will affect their likelihood of survival, and could in fact lift the burden of responsibility such women may feel.

Phillips et al. studied 708 Australian women diagnosed with nonmetastatic breast cancer before the age of 60 (average age 40 years old). At study entry approximately 11 months after diagnosis, all women completed an array of psychosocial tests that were designed to assess factors such as anxiety and depression, coping style, and social support. These women were then followed up for an average of 8.2 years.

In total, 33% of women experienced distant recurrence of their cancer and 24% died during follow-up. Once the patient data had been adjusted to take into account other factors that affect chances of recovery, such as tumour size, no associations could be found between psychosocial factors and either distant disease-free survival or overall survival.

The authors conclude that their study does not support the controversial theory that psychosocial factors influence survival after breast cancer. They state, "This should be reassuring for women, particularly those who experience substantial levels of psychosocial distress after their diagnosis."

It is important to note, however, that therapies that aim to reduce psychosocial stress in women with breast cancer should not be discounted, as such interventions do seem to improve quality of life.

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K.-A. Phillips, R. H. Osborne, G. G. Giles, G. S. Dite, C. Apicella, J. L. Hopper, R. L. Milne (2008). Psychosocial Factors and Survival of Young Women With Breast Cancer: A Population-Based Prospective Cohort Study. Journal of Clinical Oncology 26 (28): 4666-4671 DOI: 10.1200/JCO.2007.14.8718

Would you like a defibrillator with your coke sir?

Authorities in Japan have taken an interesting approach to improving the dire survival rates after out-of-hospital sudden cardiac arrest (SCA), i.e. heart attack in the home or in a public place rather than in a ward on a hospital.

Nature Clinical Practice Cardiovascular Medicine reports that automated external defibrillator devices (AEDs) are being placed in vending machines and advertising hoardings in public spaces in Japan. Members of the public can then use these devices to provide defibrillation at the scene of a SCA, saving precious minutes before emergency services arrive.

The American Heart Association estimates that 166,200 people die in the United States each year from out-of-hospital SCA and only 6.4% of patients who are admitted to hospital for SCA survive until discharge.

Early medical response is crucial for people who suffer an out-of-hospital SCA. For every minute that passes between collapse and defibrillation, survival from witnessed SCA falls by 7-10%. In most cases it is the emergency services who provide defibrillation, but time is lost waiting for paramedics to arrive at the scene.

An obvious way to shorten the time between SCA and defibrillation is for lay witnesses to perform the procedure. In fact, studies have found that defibrillation by members of the public considerably improves survival after SCA.

The Japanese government authorized the lay use of AEDs in July 2004. Subsequently, a study by the Japanese Fire and Disaster Management Agency in 2006 found that 32.1% of the 140 SCA victims who were defibrillated by a member of the public were still alive at 1 month, compared with 8.3% of the 18,180 people who did not receive defibrillation from a lay person.

In most countries public-access AEDs can only be used by trained individuals, be they members of the public, first aiders, paramedics and so on; however, what is interesting in Japan is that no training is necessary in order to use these devices. In addition, the Japanese government has formally declared that the liability of an individual who uses an AED is limited, irrespective of the outcome of resuscitative efforts.

Another interesting point about public-access AEDs in Japan is that rather than being directed by the government, the positioning of AEDs in public places is being spearheaded by commercial companies. As Nature Clinical Practice Cardiovascular Medicine reports:

"The cost of keeping an AED in a vending machine is primarily covered by the revenue from drink purchases and is shared by the manufacturer of the drink, the provider of the machine, the distributor of the AED, and the proprietor who provides the space and electricity. Allowing paid advertising on a display panel above a box housing an AED is another method of funding public access AEDs. Again, the proprietor has only to provide the space and electricity. These creative efforts are surely effective in keeping down AED dissemination costs."

Although Japan was a little behind other countries when it came to introducing public-access AEDs, the creative approaches to accessibility undertaken by the Japanese are in a class of their own.

Last night the Bee Gees saved my life

The Bee Gees' disco smash 'Stayin' Alive' is more appropriately titled than anyone could have realized - the 1977 hit is the ideal speed at which to perform chest compressions in heart attack victims. Having practiced cardiopulmonary resuscitation (CPR) with the song, participants in a recent study could maintain the ideal rhythm weeks later by simply thinking of the tune as they performed the procedure.

Dr David Matlock, an author of the study, said many people were put off performing CPR as they were not sure about keeping the correct rhythm. CPR can more than double the chance of survival after cardiac arrest, if performed properly.

The research from the University of Illinois, which will be presented during the American College of Emergency Physicians' scientific assembly in Chicago this month, found that at 103 beats per minute, Stayin' Alive is almost the same pace as the American Heart Association's recommendation of 100 compressions per minute for CPR.

In this study, 15 students and doctors first performed chest compressions on mannequins to the beat of Stayin' Alive. Five weeks later, they performed the same procedure without the music but were told to think of the song while doing compressions. The average number of compressions the first time was 109 per minute; the second time it was 113.

Dr Matlock acknowledged that the pace kept in the second round was a little fast, but stated that when it comes to trying to revive a stopped heart, a few extra compressions per minute is better than too few. "It drove them and motivated them to keep up the rate, which is the most important thing," he told the Associated Press.

According to the BBC, a spokesman for the American Heart Association said that the organization had been using Stayin' Alive as a training tip for CPR instructors for about two years.

Diabetes gonna get you

About 10 days ago Diabetes UK launched their biggest ever UK public awareness campaign - Beware the silent assassin. I first got wind of the campaign when I spotted this arresting poster at Old Street tube station in east London.

The campaign has been launched on the back of research by Mori showing that people tend to underestimate the severity of the complications associated with diabetes; for example, only 29% of adults are aware of the link between diabetes and heart disease, and only 46% appreciate that diabetes shortens life expectancy. Diabetes UK says, "This research tells us that the public see diabetes as rather mild and easily managed – something of an inconvenience rather than the serious condition it can be."

In addition, an estimated 500,000 people in the UK have the condition but are not aware of it, so are at risk of being diagnosed too late to prevent the complications of diabetes. “Dealing with the diabetes time-bomb is a matter of urgency if we want to prevent millions of people from facing a grim future of ill-health," said Douglas Smallwood, Chief Executive of Diabetes UK.

The 'hard-hitting campaign' launched by the charity aims to spook the public into realizing that diabetes is serious condition that can potentially cause heart disease, stroke, amputations, kidney failure and blindness.

The images, which will appear on outdoor posters as well as in newspapers and magazines, feature an ominous ghostly figure - the specter of undiagnosed diabetes presumably - pouncing on unsuspecting members of the public. The ads also include secondary warning messages such as:
- Diabetes causes more deaths than breast and prostate cancer combined.
- The death certificate will say heart attack. It was really diabetes.
- Diabetes causes heart disease, stroke, amputations, kidney failure and blindness.
So far so portentous.

The campaign also encourages people at risk of developing type 2 diabetes, i.e. the overweight, to make changes in their lifestyle to avoid a future of chronic disease. As the blurb states, "With early diagnosis and by leading a healthier lifestyle and improving diabetes control, the risk of developing these serious complications can be minimised. "

The adverts refer readers to a microsite developed especially for the campaign, which has quizzes to help users establish their risk of developing diabetes and gives information and support on managing the condition.

I personally feel that these adverts suggest that diabetes could to strike you dead on the spot - assassinate you - the way heart disease might, but is this really the case? On the other hand, a campaign educating our increasingly overweight population that diabetes is a serious and mostly preventable disease is certainly needed, and it is quite likely that striking adverts such as these will get people thinking more seriously about their health.

Herbal remedies and acute kidney disease

Nature Clinical Practice Nephrology has recently published a review by Luyckx and Naicker highlighting the link between traditional medicines and kidney injury.

Traditional and herbal remedies are widely used worldwide, with as many as 80% of people in some populations using such treatments. The use of herbal remedies becoming increasing common in Western countries, as shown by a 2002 survey that found that 36% of people in the US use alternative or complementary medicines.

Herbal therapies all pass through the kidney on their way out of the body; consequently, many have been associated with acute kidney disease. Luyckx and Naicker report that "folk remedies account for up to 35% of cases of acute kidney injury and mortality rates for acute kidney injury range from 24% to 75%."

The herbal remedies most commonly used in the US include echinacea, which is used as an immunostimulant, and St John’s wort, which is used to treat depression among other things. Echinacea, however, has been associated with acute kidney injury and St John's Wort with kidney transplant rejection.

Various factors besides direct toxicity of the agent can contribute to kidney injury, such as contamination of the preparation or incorrect administration. In addition, the type of nephrotoxicity experienced by an individual taking a herbal remedy is dependent on which part of the kidney is affected, and the authors discuss these factors in more detail in their review.

Luyckx and Naicker do point out that the effects of herbal remedies are something of an unknown quantity; for example, some studies have shown that cranberry decreases the risk of kidney stones, whereas other studies find that cranberry increases this risk.

The review concludes by saying "The incidence and prevalence of acute kidney injury associated with the use of traditional remedies is unknown and probably varies greatly from place to place. Since the use of traditional remedies is common worldwide, it is probably safe to assume that the incidence of acute kidney injury is not high. Individual morbidity, however, can be considerable."

Skin test to detect Parkinson's disease

A recent study published in the Journal of Neuropathology & Experimental Neurology has shown that neural signs of Parkinson's disease can be identified by taking a simple skin sample.

Parkinson’s disease is a progressive neurodegenerative disease that affects about 1 in every 500 people in the UK. There is no biochemical test to definitively diagnose Parkinson's disease; diagnoses are instead made on the basis of various clinical assessments. Parkinson's disease is, however, characterized by the presence of Lewy bodies (LBs) - tiny protein deposits in nervous tissue.

LBs can only be identified from a tissue sample, which is then stained and examined under a microscope (see right). These proteins tend to accumulate in the central nervous system and in the sympathetic ganglia, nervous tissue that runs like train tracks down either side of the spine - places that are nearly impossible to get biopsy samples.

In this study, the authors looked for LBs in various tissues in 279 patients undergoing autopsy. A total of 85 patients had evidence of LBs in their central nervous system, so were diagnosed as having had a LB disease (LBD) - Parkinson's with or without dementia, dementia with LBs or LB-related progressive autonomic failure.

The authors then examined skin biopsy samples taken the patients with proven LBD and found that 20 (23.5%) patients showed LB pathology in the cutaneous nerves of skin samples. None of the 194 individuals who did not have LBD showed evidence of LBs in skin samples; therefore, the skin test didn’t mistakenly identify any patients as having LBD.

More specifically, LBs were found in the skin of 70% of patients who had Parkinson’s disease with dementia and in 40.4% of those who had dementia with LBs. On the other hand, LB pathology was found in the skin of only 20% of patients who had subclinical LBD, i.e. patients who would have had few symptoms of LBD but not enough signs to meet all the criteria for a diagnosis. This skin biopsy test might not, therefore, be a useful test for early diagnosis in individuals suspected of having LBD.

When the authors looked at the clinical records of the patients that they had autopsied, they found that LBD patients who had evidence of LB pathology in their skin were more likely to have been bedridden and unable to walk independently before they died than were those patients with LBD who did not have cutaneous LB pathology (P<0.001 style="font-style: italic;">P=0.065, respectively). This finding suggests that skin biopsy testing could be used to predict which patients’ physical functioning might be affected most seriously by their disease, and physiotherapy could be prescribed accordingly.

Ikemura et al.’s study is the first to find evidence of LB pathology in the skin of patients with LBD; however, their results do not support the use of skin biopsy as an early diagnostic test. Testing for LBs in the skin could be used to confirm the diagnosis in a patient with clinical Parkinson’s disease or dementia with LBs and to predict the effect the disease might have on their physical functioning, both of which could help clinicians tailor treatment.

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Ikemura M, Saito Y, Sengoku R, Sakiyama Y, Hatsuta H, Kanemaru K, Sawabe M, Arai T, Ito G, Iwatsubo T, Fukayama M, Murayama S (2008). Lewy Body Pathology Involves Cutaneous Nerves. J Neuropathol Exp Neurol, 67 (10), 945-953 PMID: 18800013

From homeopaths to psychopaths

To celebrate the launch of the book Medical London: City of diseases, city of cures, the Wellcome Collection is hosting a selection of events in the city. Written by Richard Barnett and Mike Jay, Medical London offers "a unique ... view of the roles played by diseases, treatments and cures in London's sprawling story". Yesterday I took part one of the Wellcome events - a walk around west London titled From homeopaths to psychopaths.

We started out in Sloane Square, where leader Max Décharné, author of King's Road, gave us a bit of background on the area. Throughout the 16th and 17th century, the Chelsea region served as a rural outpost of London, the clean air and clean water of the village a welcome reprieve for the visitors looking to recuperate from the filthy mêlée of the east end.

First stop was the statue of Hans Sloane, which stands outside of the Duke of York's Headquarters (Photo: Matt from London on Flickr). Sloane, born in 1660, was physician to Queen Anne, George I and George II and was the first medical practitioner to receive a peerage, given the title Baron in 1716. In clinical practice, Sloane promoted innovations such as inoculation against smallpox and the use of quinine (a treatment for malaria). He was also a president of the Royal College of Physicians and succeeded Sir Isaac Newton as President of the Royal Society.

As well as being a proficient doctor, Sloane was an avid collector of pretty much anything and everything, and on his death his vast collection of natural history specimens and antiquities was sold to the nation at a knock-down price and housed in the newly created British Library, and later at the Natural History Museum.

We next passed through Chelsea Walk, which was originally built by William III and intended as a wide boulevard linking the newly-built Royal Chelsea Hospital with Kensington Palace, but actually only extends from the hospital to King's Road.

The Royal Chelsea Hospital itself was commissioned by Charles II for the "succour and relief of veterans broken by age and war" (Photo: stevecadman on Flickr). Until the 17th century injured or elderly soldiers were not provided for in any way by the state. Many were kept on regimental rolls and still took part in duties so that they could continue to receive payment as there were no pension provisions. Charles II recognized that the state owed a debt to these soldiers, marking a shift from the tactic of previous kings who often left the poor and infirm to fend from themselves. The hospital was built by Sir Christopher Wren and completed in 1692, with the first 479 in-pensioners in residence by the end of the year. The hospital is still a home to elderly or injured British soldiers, and is also the site of the annual Chelsea Flower Show.

On the way to the hospital we passed Bram Stoker's house on St Leonard's Terrace, who, despite writing rather morbid literature, has an interesting health connection. In 1882 Stoker was awarded a Royal Humane Society Bronze Medal for attempting to save the life of a man who had jumped into the River Thames.

At this point I sadly had to abandon the walk as I had been totally soaked through by the torrential rain. I was particularly disappointed to miss the trip to Chelsea Physic Garden, not least because for many years I thought it was called Chelsea Psychic Garden and was hoping for some horticultural glimpse into my future (incidentally, the word ‘physic’ refers to the science of healing, not the science of matter and forces. So much opportunity for confusion). The garden was founded in 1673 as a site to train apothecary apprentices in the art of identifying plants and still hosts the Garden of World Medicine, a special collection of plants used for medicinal purposes by different cultures around the world.

Not so Ignoble

On Thursday the Ig Nobel prizes were awarded at Harvard University. Sponsored by the Annals of Improbable Research, these prizes are an irreverent alternative to the Nobel Prizes, which will be awarded over the next ten days, and aim to "celebrate the unusual, honor the imaginative -- and spur people's interest in science, medicine, and technology".

This year the winners of the medicine prize were Dan Ariely of Duke University, Rebecca L Waber of MIT, Baba Shiv of Stanford University, and Ziv Carmon of INSEAD (Singapore), who demonstrated that high-priced placebos are more effective than low-priced placebos.

In their study, published in the Journal of the American Medical Association no less, 87 healthy, paid volunteers were told that they were receiving a new opioid analgesic; however, one group of patients was told that they were receiving a drug at its regular price of $2.50 per pill, whereas the other patients were told that they were receiving a discounted medication priced at $0.10 per pill. All patients then received a series of electric shocks before and after taking the placebo, supposedly to test the efficacy of this treatment. More patients in the regular price group than in the discounted price group said that the electric shocks were less painful after taking the drug.

Rather than being frivolous, this study sounds like it may be of some importance. Patients switching from expensive branded medications to generic drugs have a tendency to perceive that the generic equivalents are less effective, and some might actually experience reduced efficacy thanks to a negative placebo effect (or nocebo response). Healthcare providers could, therefore, incur unnecessary costs by keeping patients on brand drugs on the basis of perceived efficacy. Doctors could prevent this problem by playing down potentially deleterious commercial factors when discussing treatment options with their patients; for example, steering clear of terms like 'low-priced' and 'generic'.

To be fair, the overarching aim of the Ig Nobels Prizes is to "honor achievements that first make people laugh, and then make them think". The study by Ariely et al. certainly meets both criteria, as do several of the winning pieces of research.

Read more: Nature News has a blow-by-blow account of the raucous ceremony, while The Guardian celebrates Britain's double win.

Irresponsible reporting of clinical trials by the news media

It is important for journalists to highlight any potential bias in medical research so that patients and physicians alike can judge how valid clinical trial findings are. Today the Journal of the American Medical Association published a study showing that almost half of news stories on clinical trials fail to report the funding source of the trial. In addition, two-thirds of news articles refer to study medications by their brand names instead of by their generic names.

The authors Hochman et al. reviewed papers published between 1st April 2004 and 30th April 2008 in the top five medical journals (New England Journal of Medicine, JAMA, the Lancet, Annals of Internal Medicine and Archives of Internal Medicine) to find pharmaceutical-company-funded studies that evaluated the efficacy or safety of medications. They then searched 45 major US newspapers (for example New York Times and USA Today) and 7 US-based primary news websites (including ABC News, CNN and MSNBC) for news stories that reported these clinical trials.

A total of 358 company-funded clinical trials were identified, and 117 of these yielded 306 distinct news stories. Of the 306 news stories, 42% did not report the funding source of the clinical study. A total of 277 of these news articles were about medications that had both brand names and generic names, but 67% of stories used brand names in at least half of the references to the medication and 38% used only brand names.

By using a brand name in news articles instead of a generic name, journalists are inadvertently favouring one pharmaceutical company over another. For example, the cholesterol lowering drug atorvastatin (generic name) is manufactured by several different pharmaceutical companies who all give it a different brand name - Pfizer call it Lipitor, whereas Merck until recently marketed a version called Zocor. Drugs are often referred to by their brand name because these titles tend to be better known - you've probably heard of paracetamol but not of acetaminophen; fair enough, maybe, but this practice still represents biased reporting.

Hochman et al. also surveyed 94 newspaper editors to find out whether these individuals thought that their publication accurately reported clinical trials. Interestingly, 88% of editors stated that their newspaper often or always reported reported company funding in articles about medical research, and 77% said that their publication often or always referred to medications by their generic names.

It seems that news outlets think they are reporting funding sources in medical articles when actually they're not. Academic journals have strict policies for disclosing funding and potential conflicts of interest, so why don't newspapers follow suit?

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M. Hochman, S. Hochman, D. Bor, D. McCormick (2008). News Media Coverage of Medication Research: Reporting Pharmaceutical Company Funding and Use of Generic Medication Names JAMA: The Journal of the American Medical Association, 300 (13), 1544-1550 DOI: 10.1001/jama.300.13.1544

And while we're talking about patient privacy...

Today Pulse reports that pharmaceutical companies are directly approaching NHS staff to try to get their grubby paws on patient-identifiable data. The story reports that "two staff members had been approached by a pharmaceutical company while at a conference in London, given access to a website and asked to upload patient-identifiable data".

A spokesperson for Poole Hospital NHS Foundation Trust went on to say: "For some time the trust has been concerned about the lengths to which pharmaceutical companies, or companies working on their behalf, will go to seemingly bypass the research governance route and encourage staff to release person-identifiable data onto third-party databases. A number of attempts have been thwarted by the trust." So it seems that for some time pharmaceutical companies have been trying to weasel patient information out of NHS employees.