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Health News from NHS Choices

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NHS Choices News

  • No need for nightshift workers to avoid steak

    "Shift workers should avoid tucking into steak, brown rice or green veg at night," because these foods "disrupt the body clock," the Mail Online reports.

    But the research in question involved lab mice who were fed different amounts of dietary iron for six weeks to see what effect this had on the daily regulation of glucose production in their livers.

    The research found mice fed lower-iron diets tended to have better regulated glucose production pathways than those on the higher iron diets. The mice did not have disturbed sleep patterns.

    In a press release, the researchers raised the possibility their findings could have "broad implications" for people who do shift work, which could increase their risk of type 2 diabetes. This speculation has been mistakenly highlighted by the media.

    The results suggest sustained high iron intakes may compromise our glucose regulation in the liver, but we should interpret these results with caution. The results do not prove that high iron intake has any effect on the risk of type 2 diabetes, as diabetes outcomes were not examined.

    If you are concerned about diabetes, there are steps you can take to reduce your risk, such as maintaining a healthy weight (which is recommended whatever hours you work).

     

    Where did the story come from?

    The study was carried out by researchers from the University of Utah in the US and was funded by the Research Service of the Department of Veterans Affairs and the National Institutes of Health.

    It was published in the peer-reviewed medical journal, Diabetes.

    By taking the press release at face value, the Mail Online has overextrapolated the implications of this research, which has looked at how different dietary iron intakes in mice influence the daily regulation of glucose production in the liver.

    This study is not related to shift work – subheadings such as, "for people who work night shifts, it puts the liver's clock out of sync", are not supported by the evidence.

    The press department of the University of Utah appears to have misrepresented and overinterpreted the study in the hopes of hitting the headlines. While they have been successful in getting in the papers, they have perhaps done the science a disservice.

    In this study, all mice were kept on a 12-hour light/dark cycle. All that was altering was their iron intake, not their sleep/wake patterns.

     

    What kind of research was this?

    This was an animal study investigating the role that dietary iron has on the circadian (daily) rhythm of glucose metabolism in the liver.

    The researchers describe how the liver maintains a daily balance in regulating glucose, and point out that disruption of this rhythm is associated with type 2 diabetes.

    Dietary intake is one of the factors that influence the biological clock in our bodies, but little is said to be known about the role of specific dietary components.

    This research focused on dietary iron, as iron is an essential component of several proteins in the body concerned with electron transport and metabolism. Also, haem, the chemical compound containing iron, is necessary for the formation of several proteins involved in regulatory pathways.

     

    What did the research involve?

    In this study, researchers fed mice chow with different iron concentrations. They did this to create iron levels in the body tissues that would be within the range produced by a normal human diet.

    Three-month-old male mice were fed on diets containing low (35mg/kg), medium (500mg/kg) or high (2g/kg) amounts of iron. The upper 2g/kg level is said to be within the fourfold range of iron seen in human livers. The mice were fed on these diets for six weeks while they were maintained in a 12-hour light/dark cycle.

    After between six and eight weeks on these diets, the researchers also tested the effect of giving the mice three different chemicals in their daily drinking water.

    These chemicals either increased haem synthesis, inhibited haem synthesis, or acted as an antioxidant. They gave the mice these chemicals so they could work out how dietary iron was affecting glucose production in the liver.

    The mice were then given various tests, including glucose tolerance tests (GTT) and a variation on the GTT: the pyruvate tolerance test (pyruvate is one of the molecules involved in the production of glucose).

    The mice also had their blood levels of haemoglobin, red blood cell volume, insulin and glucagon (the hormone produced when blood glucose levels are low) measured. After death, the mouse liver was analysed in the laboratory.

     

    What were the basic results?

    The researchers found dietary intake influences the daily rhythm of glucose production in the liver.

    Mice fed the lower-iron diet had higher blood glucose levels in response to pyruvate injection than mice on the higher iron diets. This result suggests their livers had better regulated glucose production pathways than those who had been on the higher iron diets.

    The researchers found haem production varied with dietary iron intake, and haem influences the activity of an enzyme (Rev-Erbα) key to regulating the liver's daily rhythm. This Rev-Erbα enzyme regulates many aspects of glucose metabolism.

    To confirm that dietary iron was affecting haem production, the researchers looked at the effect of chemicals that either increased haem levels or blocked haem production. Treatment with either chemical caused the differences in blood glucose regulation seen to disappear.

    The researchers thought dietary iron may cause changes in haem synthesis through reactive oxygen species. This is because the protein that regulates the production of one of the enzymes involved in haem synthesis is regulated by reactive oxygen species, and iron creates reactive oxygen species.

    Reactive oxygen species are molecules containing oxygen. Depending on the specific context in which they are formed, reactive oxygen species can be both helpful and harmful to the cells of the body.

    To test the above hypothesis, mice were fed an antioxidant to mop up reactive oxygen species. This resulted in many of the differences seen between mice fed different diets to disappear.

    Iron intake had no effect on haemoglobin concentration or red blood cell volume.

     

    How did the researchers interpret the results?

    The researchers say their findings demonstrate that dietary iron affects the circadian rhythm and glucose production in the liver by modifying haem levels in the liver.

     

    Conclusion

    This animal research demonstrates how dietary iron intake affects the daily regulation of glucose production in the liver. Mice fed lower-iron diets tended to have better regulated glucose production pathways than those who had been on the higher iron diets.

    This happens because iron intake influences the production of the iron compound haem, which in turn influences the activity of an enzyme involved in regulating glucose production in the liver.

    Overall, it is difficult to draw any meaningful conclusions from these findings. The researchers suggest sustained high iron intakes may compromise our glucose regulation in the liver, but interpretations from this research should be made with caution. The results from this mouse study do not prove that a high iron intake increases the risk of type 2 diabetes.

    The results certainly do not have any immediate implications for shift workers. This leap seems to have been made because the study looked at daily rhythms of glucose production, but all mice in this study were maintained on the same light/dark cycle – only their iron intake was altered.

    The most effective method of reducing your diabetes risk is to achieve and then maintain a healthy weight. If you are struggling to get the weight off, why not try the NHS weight loss plan, a free evidence-based diet and exercise plan designed to deliver sustainable weight loss. 

    Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

    Links To The Headlines

    Why shift workers should avoid tucking into steak, brown rice or green veg at night: Iron-rich foods 'disrupt the body clock'. Mail Online, October 22 2014

    Links To Science

    Simcox JA, Mitchell TC, Gao Y, et al. Dietary Iron Controls Circadian Hepatic Glucose Metabolism through Heme Synthesis. Diabetes. Published online October 14 2014



  • Do dopamine drugs lead to compulsive shopping?

    “Drugs for restless leg syndrome cause gambling, hypersexuality and compulsive shopping,” Metro reports.

    Researchers in the US have looked at serious drug side effects reported to the FDA over a 10-year period. In particular, they were interested to see how often reports of impulsive behaviours such as gambling were linked to a group of drugs called dopamine receptor agonists.

    These drugs (such as pramipexole) mimic the effect of dopamine on the brain. They are most commonly used to treat Parkinson’s disease and other conditions such as restless legs syndrome.

    The drugs have sometimes been known to trigger extremely severe patterns of compulsive behaviours, so the researchers wanted to estimate exactly how common this side effect was.

    The study found that 710 events – just under half of all impulse control disorders reported during this 10-year period – were attributed to dopamine receptor agonists. Given the number of prescriptions of these drugs that are likely to be prescribed every year in the US, this would suggest that the compulsive side effect – or at least the reporting of it – is quite rare. We would expect to see a similar pattern in the UK.

    The risk of mental health-related adverse effects with these drugs, including impulse control disorders, is already recognised by the UK's medical profession. You or your carer should seek medical advice if there are any changes to your behaviour after taking a dopamine receptor agonist. 

     

    Where did the story come from?

    The study was carried out by researchers from The George Washington University and Harvard Medical School in the US, and University of Ottawa and Risk Sciences International in Ottawa, Canada. No sources of funding are reported. Two of the authors declare being consultant or expert witnesses in civil and criminal litigation involving many psychiatric drugs, though none involving the drugs that are at the centre of this research. This article is also reported to be based in part on data obtained under license from the National Prescription Audit.

    The study was published in the peer-reviewed medical journal  JAMA International Medicine.

    The Mail Online’s headline that, “Drugs for Parkinson’s disease can turn patients into gamblers, sex addicts and compulsive shoppers” is not justified by this study alone because – as the study authors acknowledge – the results did “not prove a causal relationship, only that such a relationship was suspected”. The study also only looked at one group of drugs, so the study results do not apply to all Parkinson’s treatments.

     

    What kind of research was this?

    This was an analysis of adverse drugs events (more commonly known as side effects) reported to the US Food and Drug Administration (FDA) involving six FDA-approved dopamine receptor agonist drugs.

    These drugs are used in the initial treatment of Parkinson’s disease – a neurological condition with an unknown cause, where not enough of the chemical dopamine is produced in the brain. This causes the three classic symptoms of tremor, with stiff, rigid muscles and slow movements, as well as a range of other effects, including dementia and depression. While there is no cure, treatments that aim to control this dopamine imbalance are used to try and control symptoms.

    Dopamine receptor agonists act directly on dopamine receptors, effectively taking the place of dopamine and stimulating the receptor in the same way. There are a group of these drugs licensed in the UK, including drugs called pramipexole, ropinirole and rotigotine. Dopamine receptor agonists are a different group of treatments from the well-known Parkinson’s treatment Levodopa, which works in a different way.

    Dopamine receptor agonists are also sometimes used in restless legs syndrome if a person is having very frequent symptoms.

    The drugs are already known to be associated with a risk of adverse mental health issues. This study reports that severe impulse control disorders such as gambling, hypersexuality and compulsive shopping have been reported following the use of these drugs, in both case series and patient surveys. This study aimed to further investigate the potential link between these drugs and this side effect.

     

    What did the research involve?

    The researchers looked at all domestic and foreign serious adverse drug events concerning impulse control disorders reported to the FDA between 2003 and 2012. They looked at the number of impulse control disorder events that were associated with the use of dopamine receptor agonists, and with all other drugs, to look for differences.

    They specifically looked for 10 impulse control disorders as listed in the Medical Dictionary for Regulatory Activities:

    • pathological gambling
    • hypersexuality (experiencing extremely frequent sexual urges)
    • compulsive shopping
    • gambling
    • poriomania (wandering impulses)
    • binge eating
    • excessive masturbation
    • compulsive sexual behaviour
    • kleptomania (impulses to steal)
    • excessive sexual fantasies

    For the individual dopamine receptor agonists, they calculated the proportional reporting ratio (PRR).

    This involves calculating the frequency of impulse control adverse events for each dopamine receptor agonist drug, as a proportion of all adverse events reported for that drug.

     

    What were the basic results?

    Overall, the researchers identified 1,580 reports of impulse control disorders associated with any drug over the 10-year period. Gambling was the term mentioned in around half of these reports: pathological gambling in 628 (39.7%) and gambling in 186 (11.8%). This was followed by hypersexuality, which accounted for just under a third of impulse control events (465, 29.4%), and then compulsive shopping, which accounted for around an eighth (202, 12.8%).

    Just under half of all the impulse control events were related to dopamine receptor agonists (710, 44.9%) and the remainder to other drugs. The reports related to dopamine receptor agonists occurred in people with an average age of 55 years, and over half of whom were male. Most of these prescriptions had been for Parkinson’s disease (61.7%), with most of the remainder prescribed for restless legs syndrome.

    The six specific dopamine receptor agonists examined were pramipexole, ropinirole, rotigotine, bromocriptine, cabergoline and apomorphine – all of which are used in the UK.

    The PRR was significant for dopamine receptor agonists, meaning that the proportion of impulse control events was significantly higher than all other events with these drugs. For all dopamine receptor agonists, the PRR was 277.6. Most of the impulse control events associated with these drugs had occurred with pramipexole (410 events; PRR 455.9) followed by ropinirole (188 events; PRR 152.5). The number of reported impulse control events with the other four drugs was between 56 for cabergoline and 12 for apomorphine.

     

    How did the researchers interpret the results?

    The researchers say that their findings, “confirm and extend the evidence that dopamine receptor agonist drugs are associated with these specific impulse control disorders. At present, none of the dopamine receptor agonist drugs approved by the FDA have boxed warnings as part of their prescribing information. Our data, and data from prior studies, show the need for more prominent warnings”.

     

    Conclusion

    This study analysed serious adverse drug events reported to the US FDA over a 10-year period, and found that 710 events (just under half of all impulse control disorders reported during this period) were attributed to dopamine receptor agonists. Most of these disorders involved gambling, followed by hypersexuality and compulsive shopping.

    This group of six drugs are used in Parkinson’s disease (and a small number of other conditions) where there is a lack of the chemical dopamine. The drugs act directly on dopamine receptors, effectively taking the place of dopamine and stimulating the receptor in the same way.

    Dopamine receptor agonists are known to have mental health-related adverse effects; impulse control disorders are already recognised.

    This study further highlights this risk, demonstrating that impulse control disorders account for more serious adverse events than all other events associated with these drugs that have been reported to the FDA.

    The study is based on US FDA data only, but it could give a good indication of the data reported to UK medicines regulatory authorities. The study also only covers adverse events that are formally reported, and it is unclear how many impulse control disorders may occur, but are not reported.

    As the researchers acknowledge, this study still cannot prove that it is the dopamine receptor agonist that has directly caused the adverse events reported.

    UK prescribing information for dopamine receptor agonists advises patients and prescribers of the risk of impulse control disorders. If symptoms develop, doctors are advised to reduce the dose or stop prescribing the drug until symptoms resolve.

    People in the grip of a compulsive pattern of behaviour are often unaware that their behaviour has changed and that they are acting strangely, so do not seek medical advice. Therefore friends, family members or carers can help by being vigilant for any strange changes in the behaviour of a person taking these drugs.

    Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

    Links To The Headlines

    Drugs for restless leg syndrome cause gambling, hypersexuality, and compulsive shopping. Metro, October 21 2014

    Drugs for Parkinson's disease can turn patients into gamblers, sex addicts and compulsive shoppers. Mail Online, October 22 2014

    Links To Science

    Moore TJ, Glenmullen J, Mattison DR. Reports of Pathological Gambling, Hypersexuality, and Compulsive Shopping Associated With Dopamine Receptor Agonist Drugs. JAMA Internal Medicine. Published online October 20 2014



  • Changes in 'Parkinson's walk' predict dementia

    "Subtle changes in the walking pattern of Parkinson's patients could predict their rate of cognitive decline," The Times reports after new research compared the gait of people with Parkinson's disease with those of healthy volunteers.

    Parkinson's disease is a condition with three classic features: a tremor, stiff rigid muscles and slow movements, notably a slow, shuffling walk. It also has other symptoms, including Parkinson's dementia, though it can be difficult to predict who will go on to develop dementia.

    Researchers wanted to see if comparing the differences in gait (walking pattern) and cognition (thinking) between 121 people newly diagnosed with Parkinson's disease and 184 healthy adults would provide any clues.

    As may be expected, the study found measures of both gait and cognition were poorer in people with Parkinson's compared with healthy adults.

    They then compared people with Parkinson's who mainly had gait problems with those who mainly had tremor problems.

    Though there was no difference in cognitive abilities between the two groups, in those who mainly had gait problems there was a link between this and their cognitive function. That is, if a person had more problems with gait, they tended to have more cognitive problems.

    This study will help doctors further understand how gait may be associated with cognition in people with Parkinson's. It suggests that progression in gait problems may be associated with cognitive decline.

    While there is currently no cure for dementia, knowing that someone is at a higher risk could help explain often upsetting changes in mood and behaviour, and enable early access to treatment.

     

    Where did the story come from?

    The study was carried out by researchers from Newcastle University and was funded by the National Institute for Health Research.

    It was published in the peer-reviewed open-access journal, Frontiers in Aging Neuroscience, so the article is free to access online.

    The Times' reporting is accurate. But the Daily Mail's coverage is misleading and confusing, as its headline asks, "Could your walk signal dementia?"

    This study is specific to Parkinson's disease and people with this condition who go on to develop dementia. It is not relevant to the population at large or to other types of dementia, such as Alzheimer's.

     

    What kind of research was this?

    This was a case-control study examining the differences in gait (walking pattern) and cognition (mental abilities) between people newly diagnosed with Parkinson's disease (the cases) and a comparison group of healthy older adults (the controls).

    Parkinson's disease is a neurological condition with an unknown cause, where not enough of the chemical dopamine is produced in the brain. This causes characteristic symptoms of:

    • a resting tremor – shaking when the person is relaxed
    • rigidity – stiff and inflexible muscles
    • slow movements – someone with Parkinson's classically walks with slow shuffling steps, and they are generally slower in all movements

    As well as these classic symptoms, there are a variety of others, and usually Parkinson's has some mental health effects, including dementia and depression.

    While treatments such as Levodopa can help improve symptoms, there is no cure for Parkinson's and the condition usually progresses.

    It has been observed that in people who have a predominant tremor (TD), symptoms progress more slowly than those with predominant postural instability and gait disorder (PIGD).

    These people who predominantly have problems with walking and balance tend to demonstrate greater decline, not only in terms of movement, but also cognition.

    This study aimed to quantitatively measure the differences in movement and cognition between cases and controls. The researchers expected to see a specific association between movement and cognition in people with the different predominant type of Parkinson's.

     

    What did the research involve?

    The researchers included 121 people (average age 67) who had been diagnosed with Parkinson's disease in the past four months. They were matched by age and sex to 184 healthy controls, who were able to walk independently and had no specific cognitive or mental health problem.

    The Movement Disorder Society (MDS)-revised Unified Parkinson's Disease Rating Scale, which is a well-validated scale, was used to measure disease severity. It was also used to determine which features were predominant – TD (53 people) or PIGD (55 people).

    Gait was measured by asking people to walk at their comfortable walking pace for two minutes around a 25m oval walkway. Researchers observed five variables: pace, rhythm, variability in step, asymmetry and posture.

    Separately, a range of validated assessment scales were used to measure six domains of cognitive function: global cognition, attention, visual memory, executive function, visuospatial function and working memory.

    A range of other tests were performed, including a timed chair stand to assess slow movements and muscle strength. This involved participants being asked to stand up from a seated position with their arms folded across their chest and sit down five times, as quickly as possible.

    Balance was measured using the activities balance self-confidence scale, and physical fatigue and depression were also measured.

     

    What were the basic results?

    All gait variables were significantly different between healthy controls and people with Parkinson's.

    People with Parkinson's walked more slowly, walked less symmetrically, made shorter steps, and overall had a more variable gait.

    The only measures that were not different were step velocity variability, swing time and step width. As expected, gait measures were poorer for those with Parkinson's characterised as PIGD compared with TD.

    When looking at cognition, cognitive outcomes were significantly poorer for people with Parkinson's compared with controls, with the exception of a measure of attention (choice reaction time).

    Cognition was no different between the TD and PIGD types of Parkinson's, with the exception of one measure of executive function (semantic fluency), which was poorer in people with PIGD.

    The researchers found some association between gait and cognition in both people with Parkinson's and controls. In the group with Parkinson's, four measures of gait (pace, rhythm, variability and postural control) were correlated with measures of cognition, such as poorer measure of gait and poorer cognition.

    Two of these measures (pace and postural control) were also associated with cognition in controls. In both people with Parkinson's and the controls, the strongest association was between pace and attention.

    Looking at the different types of Parkinson's, associations between measures of gait and cognition were evident in people with PIGD, but not TD.

     

    How did the researchers interpret the results?

    The researchers say their observations provide a basis for understanding the complex role of cognition in Parkinson's gait.

     

    Conclusion

    Parkinson's is a neurological disease with characteristic features of tremor, rigidity and slow movements, as well as a variety of other classic symptoms, including Parkinson's dementia.

    This case-control study demonstrates how measures of both gait (walking) and cognition are, as would be expected, poorer in people newly diagnosed with Parkinson's disease compared with healthy controls.

    The study also demonstrates that in Parkinson's disease, people with a predominant postural instability and gait disorder (PIGD) unsurprisingly have poorer measures of gait than people with predominant tremor disorder (TD).

    Though there was little difference in cognitive measures between people with PIGD and TD, in those with PIGD there was a correlation between measures of their gait and cognitive function.

    This suggests that progressive gait problems may be associated with progressive cognitive decline in people with Parkinson's disease, though the specific biological mechanisms behind this link were not investigated by this study. The researchers now plan to investigate this link further.

    The researchers also acknowledge several limitations with their study, including the relatively small sample size – involving only around 50 people with each subtype of Parkinson's. This means these are small numbers on which to base firm conclusions about the differences between the two subtypes.

    There are also other measures the study may not have been able to take into account, including the influence of medication (some had started Levodopa, some not) and depression.

    Overall, this study helps doctors to further understand how gait may be associated with cognition in people with Parkinson's, and that predominant gait problems may also be an indicator of more cognitive problems.

    While there are no current preventative or treatment implications of these findings in terms of Parkinson's, early recognition of people who may be at risk of dementia is likely to be beneficial.

    Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

    Links To The Headlines

    Walking pattern offers clues to speed of brain decline. The Times, October 22 2014

    Could your walk signal dementia? Scientists find link between subtle changes to a person's gait and their brain function. Daily Mail, October 22 2014

    Links To Science

    Lord S, Galna B, Coleman S, et al. Cognition and gait show a selective pattern of association dominated by phenotype in incident Parkinson's disease. Frontiers in Aging Neuroscience. Published online October 21 2014



  • NICE wants tooth brushing to be taught in schools

    “Children should get their teeth brushed at school, says NHS watchdog,” The Daily Telegraph reports.

    The headline follows the publication of guidance by the National Institute for Health and Care Excellence (NICE) on ways for local authorities to improve the oral health of their communities. The new guidelines have been welcomed in some parts of the media, but others have accused NICE of creating a “supernanny state”.

    The guidance follows a recent Public Health England survey that demonstrated the wide disparity in oral health across the country, particularly among younger children and vulnerable socioeconomic groups.

    Overall, across the country, 12% of young children were found to have tooth decay, but this varied – from more than a third of children in Leicester, to just 2% in other parts of the country.

    As NICE says, dental problems such as tooth decay and gum disease can have a wide range of effects, not only causing pain and the need to remove decayed teeth, but affecting a person’s ability to speak, eat, smile and socialise.

    The recommendations aim to help authorities commission health, social care and educational services that promote and protect oral health. This includes advice on ways to improve oral hygiene, such as reducing the consumption of sugary food and drinks, alcohol and tobacco, increasing the availability of fluoride, and encouraging people to get regular dental check-ups.

    Among these recommendations are those focused towards improving oral health among young and school-age children, including considerations for nurseries and primary schools to supervise tooth brushing in children at high risk of tooth decay.

     

    What does NICE recommend?

    Essentially, NICE wants action to promote and protect oral health by:

    • improving diet and reducing consumption of sugary food and drinks, alcohol and tobacco
    • improve oral hygiene
    • increase the availability of fluoride
    • encourage people to go to the dentist regularly
    • increase access to dental services

    Public services

    Among the recommendations targeted towards public action, they advise that:

    • Public services (including leisure centres, community or drop-in centres, nurseries and schools) make plain drinking water freely available and provide a choice of sugar-free food and drinks, including vending machines on site.
    • All health and wellbeing policies and services for adults, children and young people should include advice and information on nutrition and wellbeing, and how tooth decay and gum disease are preventable; this includes educating people on the importance of regular tooth brushing and tooth brushing techniques, the importance of fluoride toothpaste and regular dental check-ups, and the links between high-sugar diets, alcohol and tobacco, and poor oral health.

    Advice for parents

    Specific to younger children, NICE recommends that all early years services (including midwives and health visitors, children’s centres, nurseries and childminding services) should have a requirement to train staff in giving oral health advice.

    This advice should include:

    • promoting breastfeeding and healthy weaning
    • promoting food, snacks (such as fresh fruit) and drinks (water and milk) that are part of a healthier diet
    • explaining that tooth decay is a preventable disease and how fluoride can help prevent it
    • promoting the use of fluoride toothpaste as soon as teeth come through
    • encouraging people to regularly visit the dentist from when a child gets their first tooth
    • giving a practical demonstration of how to achieve and maintain good oral hygiene and encouraging tooth brushing from an early age
    • advising on alternatives to sugary foods, drinks and snacks as pacifiers and treats
    • using sugar-free medicine
    • giving details of how to access routine and emergency dental services
    • explaining who is entitled to free dental treatment
    • encouraging and supporting families to register with a dentist

    Schools and nurseries

    A recommendation that has stimulated the most comment and debate in the newspapers is that nurseries and primary schools in areas where children are at risk of poor oral health should consider supervising children in tooth brushing.

    Such schemes would include having a requirement to get consent from parents or carers, and provide free toothbrushes and fluoride toothpaste – one set for the premises and one to take home.

    In high-risk nurseries and primary schools, where supervised tooth brushing is not possible, a fluoride varnish programme should be considered. This involves coating the teeth with a film of the chemical fluoride, which has a protective effect against decay. At least two applications of fluoride varnish a year would be needed.

    NICE also includes recommendations to raise awareness of the importance of oral health during a child’s school years. This includes similar policies to above, of having healthy food and drink choices available, ensuring that opportunities are found in the curriculum to teach the importance of maintaining good oral health and highlighting how it links with appearance and self-esteem.

     

    What has been the response to the recommendations?

    Some newspapers have accused NICE of promoting a nanny state agenda, such as the Mail Online stating that: “Now nanny state wants lessons in brushing teeth! Schools told they must help halt decay caused by children's sugary diets.”

    Just a few weeks before, the same newspaper was reporting that: “One in 8 three-year-olds has rotting teeth… and [sugary] fruit juice is to blame.”

    Early intervention at a young age, through education on effective dental care both at home, and reinforced at school, could make a lifetime’s worth of difference.

    As Elizabeth Kay, foundation Dean for the Peninsula Dental School, Plymouth, says: “Around 25,000 young children every year are admitted to hospital to have teeth taken out. Given that we know how to prevent dental disease, this really should not be happening.

    “If there were a preventable medical condition which caused thousands of young children (mostly around five years old) to end up in hospital to have body parts removed, there would be an outcry.

    “These guidelines offer local authorities an opportunity and evidence as to how they can stop the most vulnerable children and adults in their areas from suffering from the pain, trauma and lifetime negative effects of tooth decay.”

    The director of the centre for public health at NICE, Professor Mike Kelly, further explains: “Children as young as three are being condemned to a life with rotten teeth, gum disease and poor health going into adulthood. Many children have poor diets and poor mouth hygiene because there is misunderstanding about the importance of looking after children’s early milk teeth and gums. They eat too much sugar and don’t clean their teeth with fluoride toothpaste. As a society, we should help parents and carers give their children the best start in life and act now to stop the rot, before it starts.”


    Analysis by
    Bazian. Edited by NHS Choices. Follow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

    Links To The Headlines

    Children should get their teeth brushed at school, says NHS watchdog. The Daily Telegraph, October 22 2014

    Schools should check kids brush teeth, says NICE. BBC News, October 22 2014

    Now nanny state wants lessons in brushing teeth! Schools told they must help halt decay caused by children's sugary diets. Mail Online, October 22 2014

    Schools Urged To Supervise Brushing Of Teeth. Sky News, October 22 2014

    Nursery-age children ‘should get tooth-brushing lessons’. The Independent, October 22 2014

    Stop the rot with lessons on brushing teeth, schools told. The Times, October 22 2014



  • Paralysed man walks again after pioneering surgery

    "World first as man whose spinal cord was severed WALKS," the Mail Online reports. In pioneering research, transplanted cells have been used to stimulate the repair of a man's spinal cord.

    The headlines are based on a scientific report describing a 38-year-old man whose spinal cord was almost completely severed in a knife attack. The man had completely lost feeling and movement below the injury and was paralysed from the chest down.

    Researchers injected the man's damaged spinal cord with cells taken from parts of the brain involved in interpreting smell signals from the nose to the brain. This treatment was combined with a graft from one of the nerves in his lower leg to reconnect the stumps of spinal cord severed by the injury. 

    After surgery, the man had improved trunk stability, partial recovery of the voluntary movements of the lower extremities, and an increase of muscle in one thigh, as well as improvements in sensation. According to an accompanying press release, the man is now able to walk using a frame.

    While previous techniques have managed to "re-route" nerve signals around a damaged section of the spinal cord, this is the first time that damage to the cord has been directly repaired.

    These results are very encouraging, but, as the researchers note, the findings will need to be confirmed in other patients with similar types of spinal cord injury.

     

    Where did the story come from?

    The study was carried out by researchers from Wroclaw Medical University, the Polish Academy of Sciences, Karol Marcinkowski Medical University, the Neurorehabilitation Center for Treatment of Spinal Cord Injuries AKSON in Poland, the Medical University of Warsaw, the University Clinical Hospital and the UCL Institute of Neurology in the UK.

    It was funded by the Wroclaw Medical University, the Nicholls Spinal Injury Foundation and the UK Stem Cell Foundation.

    The study was published in the peer-reviewed journal Cell Transplantation and has been made available on an open access basis, so it is free to read online.

    The news was widely reported by both the UK and international media. Coverage was accurate, if uncritical. The lead author's claim that this research was "more impressive than man walking on the moon" seems to have been accepted without question by the media.

    However, other experts are less impressed. For example, Dr Simone Di Giovanni, Chair in Restorative Neuroscience at Imperial College London, is reported by the Science Media Centre as saying, "One case of a patient improving neurological impairment after spinal cord knife injury following nerve and olfactory cell transplantation is simply anecdotal.

    "Extreme caution should be used when communicating these findings to the public, in order not to elicit false expectations on people who already suffer because of their highly invalidating medical condition."

     

    What kind of research was this?

    This was a case report, which often report unusual medical findings in a single person. They often describe rare diseases, strange symptoms or untypical responses to treatment.

    The results of this case report will need to be confirmed in a larger group of patients with similar types of spinal cord injury before such stem cell transplants can be said to be an effective treatment for spinal cord injuries.

    Even if the treatment proves effective, it may not be safe in all cases. Because of its complexity, neurological surgery has a higher rate of complications than most other types of surgery.

     

    What did the research involve?

    The case report describes a 38-year-old man whose spinal cord was damaged in a knife attack, leading to his spinal cord being almost completely severed. The man had completely lost sensory (feeling) and motor (movement) function below the injury, resulting in paraplegic paralysis (where both legs and the lower body are paralysed).

    The researchers removed one of his olfactory bulbs, the parts of the nervous system that normally transmit information on smell from the nose to the brain.

    They then grew cells from the man's olfactory bulbs in the laboratory. They were interested in two cell types: olfactory ensheathing cells and olfactory nerve fibroblasts. Both of these cell types have been shown to mediate regeneration and the reconnection of severed axons (nerve cells).

    The researchers transplanted the cultured cells by injection into the man's spine above and below the injury. 

    To fully bridge the gap and reconnect the stumps of spinal cord severed by the injury, they also combined this treatment with a graft of small strips of nerve taken from one of the nerves in the man's lower leg (the sural nerve).

    The man received intense neurorehabilitation through exercises and other interventions designed to help recovery from a nervous system injury or compensate for its effects.

     

    What were the basic results?

    The man seemed to have no adverse effects in the 19 months following the operation.

    From five months after the operation, the man had improved neurological function. By 19 months after surgery, he had improved trunk stability (sometimes known as core stability), partial recovery of the voluntary movements of the lower extremities, and an increase in the muscle of one thigh, as well as improvements in sensation (feeling).

    According to accompanying media reports, the man is now able to walk using a walking frame.

    Interestingly, removal of one of the olfactory bulbs did not cause the man to permanently lose his sense of smell on one side, as might have been expected.

     

    How did the researchers interpret the results?

    The researchers conclude that to their knowledge, "This is the first clinical indication of beneficial effects of transplanted autologous bulbar cells."

     

    Conclusion

    Overall, these results demonstrate the first person with a severed spinal cord to have regained movement and sensation in his lower limbs following a cell transplant. Specifically, this involved a combination of cells taken from the olfactory bulb and a graft from nerve cells in the leg, which were used to reconnect the severed sections of spinal cord.

    These results are very encouraging, but, as the researchers note, these will need to be confirmed in a larger group of patients with similar types of spinal cord injury.

    Further research is also required into how best to access the olfactory bulb. In this study, it was accessed by craniotomy – a surgical operation where a bone flap is temporarily removed from the skull to access the brain. As the researchers also state, there remains a possibility that sources of other, more readily obtainable reparative cells may be discovered.

    Though this treatment has given good recovery of movement and sensation, there has not yet been a full recovery in terms of bowel, bladder and sexual function. These functional effects of spinal cord injury can of course have an equally devastating effect on a person as loss of movement or sensation.

    The results will undoubtedly give hope to many people affected by paralysis as a result of spinal cord injury. However, while very promising, there are still many steps to go until a new treatment is found that gives complete functional recovery from severe spinal cord injury.

    Analysis by Bazian. Edited by NHS Choices
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    Links To The Headlines

    World first as man whose spinal cord was severed WALKS: Fireman paralysed by knife attack recovers after UK scientists use nose cells to re-grow nerve cells in his spine. Mail Online, October 21 2014

    Paralysed man walks again after cell transplant. BBC News, October 21 2014

    Paralysed man Darek Fidyka walks again after treatment by British doctors on brink of 'cure'. The Independent, October 21 2014

    Paralysed man Darek Fidyka walks again after pioneering surgery. The Guardian, October 21 2014

    Paralysed man helped to walk again. The Daily Telegraph, October 21 2014

    Paralysed man walks again: ‘It’s incredible — like being reborn’. The Times, October 21 2014

    Links To Science

    Tabakow P, Raisman G, Fortuna W, et al. Functional regeneration of supraspinal connections in a patient with transected spinal cord following transplantation of bulbar olfactory ensheathing cells with peripheral nerve bridging. Cell Transplantation. Published online October 21 2014