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NHS Direct Health News

NHS Choices: Behind the headlines   + / -  
last updated: Sun, 19 Feb 2017 12:06:10 GMT

 Fri, 17 Feb 2017 16:28:00 GMT Inappropriate antibiotic prescribing by online pharmacies 'reckless'

"Scientists found antibiotics illegally available on 45% of websites they tested," the Mail Online reports.

This headline was prompted by research into 20 online pharmacies selling antibiotics to the UK public.

Researchers looked at whether the online pharmacy was properly registered – and therefore legal – as well as whether they required a prescription before selling the antibiotics and if safety information was provided.

The majority of sellers were not registered and therefore illegal. Most were thought to be based outside the UK, although half did not provide details on where they were based. Almost half did not require a prescription to purchase antibiotics.

The finding that the UK public are buying antibiotics from illegal unregistered prescribers is worrying, particularly when they can choose the specific antibiotic and dose themselves.

Because antibiotics have been overused and prescribed inappropriately, the drugs are losing their effectiveness at treating bacterial infections (antibiotic resistance). The more we use them, the greater the chance bacteria will become resistant to the drugs.

If the ticking timebomb of antibiotic resistance continues, we could end up in a world where previously trivial infections are untreatable.

It's important to use antibiotics in the right way – to use the right medicine, at the right dose, at the right time, for the right duration.

Always consult a GP or another health professional before taking antibiotics, and only take antibiotics and medication that has been specifically prescribed for you.

Where did the story come from?

The study was carried out by researchers from Imperial College Healthcare NHS Trust, the National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, and the UCL School of Pharmacy, all in the UK.

It was funded by the National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London, in partnership with Public Health England and Imperial College Healthcare NHS Trust and the Imperial National Institute for Health Research Biomedical Research Centre.

Three authors declared consulting for pharmaceutical companies, but state that the views expressed are their own.

The study was published in the peer-reviewed Journal of Antimicrobial Chemotherapy.

The UK media's reporting of the study was accurate.

Professor Dame Sally Davies, the government's chief medical officer, is quoted in the Mail Online as saying: "Clinicians across the country are making great progress in reducing inappropriate prescriptions, and this cannot be undermined by reckless illegal online pharmacies."

She added: "It is essential that we look after our antibiotics and only use them where clinically appropriate.

"Inappropriate use drives the development of drug-resistant infections, which could halt treatments and operations that we consider routine, such as hip operations, chemotherapy and caesareans." 

What kind of research was this?

This cross-sectional analysis of data aimed to look at the quality and legal status of online pharmacies selling antibiotics to the UK public.

It aimed to describe the processes for obtaining antibiotics online and look at the approach to promoting and monitoring the use of antimicrobials, including antibiotics, and examine patient safety issues.

Cross-sectional analyses are good at looking at the overall picture at a specific point in time. But they can't show trends over time, so can't tell us if the quality and legality of online pharmacies and the process of obtaining antibiotics online is getting worse or better.

What did the research involve?

This was an exploratory cross-sectional analysis of a representative sample of online pharmacies with the overall aim of understanding the current state of online antibiotic sales in the UK.

A search for "buy antibiotics online" was done on Google and Yahoo, as researchers said these were two of the most popular search engines in the world.

They took 20 websites in total, including the first 10 identified from each search engine, that were in English and selling to consumers within the UK. They then looked to identify the country the website was operating from.

The researchers aimed to understand the state of online antibiotic sales in the UK.

They reviewed the 20 websites by:

  • assessing the quality and legal status of these online pharmacies using registration status as an indication of quality and legal status
  • identifying any Antibiotic Stewardship or patient safety issues 
  • analysing the processes for purchasing online antibiotics, and if these were consumer-driven or prescriber-driven

Consumer-driven was described as whether the customer first selected an antibiotic of their choice to put in their online shopping basket.

Prescriber-driven was when the customer was directed through an online consultation after clicking on a specific illness, and an antibiotic was selected by the online prescriber if required.

What were the basic results?

Of the 20 websites selling antibiotics:

  • 15 were not registered with the necessary bodies – the General Pharmaceutical Council (GPhC) in Great Britain or the UK Medicines and Healthcare products Regulatory Agency (MHRA), who also investigate websites suspected of operating illegally. Of these 15, three were operating from India, two from Cyprus, and the location was unclear for the rest. The five sellers registered with the GPhC and MHRA were all operating from the UK.
  • 16 of the 20 websites were consumer-driven regarding antibiotic choice, dose and duration. This meant people could put the medicine in their shopping basket straight away without having an online consultation or providing a prescription.
  • 9 of the 20 websites did not require a prescription before buying antibiotics.
  • 14 of the 20 websites did provide information before purchase on safety and possible side effects, or when to avoid using antibiotics.

At the end of the study, all online providers found to be illegally selling antibiotics within the UK were reported to the MHRA.

How did the researchers interpret the results?

The researchers concluded: "Wide variation exists among online pharmacies in relation to antibiotic practices, highlighting considerable patient safety and antibiotic stewardship issues.

"Improved education, legislation, regulation and new best practice stewardship guidelines are urgently needed for online antibiotic suppliers."

They added: "In order to promote patient safety and preserve antibiotic therapy, an efficient and operational multidisciplinary taskforce is needed to address the issues we have identified." 

Conclusion

Worryingly, most of the online pharmacies had no evidence of the registration required by current UK and European legislation.

This could be because some of the operators were based outside Europe – but regardless of where they are based, they are still subject to UK legislation if selling to the UK public.

The study raises concerns about the effectiveness of current UK legislation and the regulation of companies selling antibiotics over the internet.

This research does have some limitations, however:

  • Google and Yahoo searches are not identical when different browsers are used or when searches are performed at different times. This means other websites might have been identified at a different time.
  • Illegal sellers might change their name frequently to remain operational, so the same seller might have been identified more than once in this search under different names.
  • The researchers did not proceed to payment in their investigation of the sellers, so extra information on safety or prescribing might have been missed. Websites without information about requiring a prescription might have asked for one at a later stage or refused to prescribe antibiotics.

Aside from the clear safety issues, buying antibiotics online without a prescription can contribute to the growing problem of antibiotic resistance, where antibiotics are no longer effective against infections.

If you think you may need antibiotics, get advice from your GP or pharmacist. Your GP will prescribe medication, including antibiotics, if it is safe and appropriate to do so.

People can help fight the problem of antibiotic resistance by:

  • not buying antibiotics online
  • using antibiotics only when prescribed by a health professional
  • recognising that many coughs and colds, sore throats and stomach upsets are viral and do not need – and will not get better – with antibiotics
  • taking the full course of antibiotics as prescribed, even if you start to feel better
  • never sharing or passing on antibiotics to others

Sourcing antibiotics from a foreign country, especially without consultation with a GP, is not recommended.

Aside from the concerns mentioned above, the safety profile of the drug itself may not match the rigorous UK standards for pharmaceutical manufacturing.  

Links To The Headlines

Web chemists fuelling superbugs crisis by selling antibiotics without prescription and letting patients choose their own dosage. Mail Online, February 17 2017

Online pharmacies illegally handing out antibiotics are fuelling rise of superbugs. The Daily Telegraph, February 17 2017

Links To Science

Boyd SE, Moore LSP, Gilchrist M, et al. Obtaining antibiotics online from within the UK: a cross-sectional study. Journal of Antimicrobial Chemotherapy. Published online February 17 2017

 Fri, 17 Feb 2017 12:28:00 GMT Could brain scans be used to screen for autism?

"Brain scans could identify babies most at risk of developing autism, study shows," The Guardian reports.

Researchers think that looking for distinct changes in infant brains could identify some children with autistic spectrum disorder (ASD).

A small US study used MRI scans to look at the brains of around 150 infants – 106 were thought to be at high risk of developing autism because of their family history. Autism can run in families, with multiple siblings being affected.

This study found some shared signs of unusual brain overgrowth in 15 high-risk infants at 6 and 12 months old. All of the 15 then went on to be diagnosed with ASD at 24 months.

However, 15 children is too small a number to have confidence in these results. If the results could be replicated in larger studies, a screening method could perhaps be created for children thought to be at high risk of the condition.  

Even then, because of the complex nature of ASD, it's likely that further assessment using a combination of behavioural and psychological tests would still be required.

Early signs and symptoms of ASD in preschool children include delayed speech and language development, repetitive behaviour, not responding to their name being called, and little interest in interacting with others.

Visit your GP or health visitor if you're concerned about your child's development.

Where did the story come from?

The study was carried out by researchers from several institutions in the US, including the University of North Carolina, the University of Minnesota and New York University.

It was funded by a grant from the US National Institutes of Health, Autism Speaks and the Simons Foundation.

The study was published in the peer-reviewed medical journal, Nature.

The UK's media coverage on this research was generally poor. The Mail Online in particular reported that "scientists used MRI scan[s] to diagnose [the] condition in hundreds of babies under two years old", which is simply not true. ASD was not diagnosed by the MRI scans, it was diagnosed using traditional methods.

Differences in the MRI brain scans were only seen in 15 children out of 148, and we don't know if these changes are related to ASD or not.

What kind of research was this?

This was a proof of concept study that used brain scans and data from the Infant Brain Imaging Study (IBIS) to investigate whether ASD could be detected in six-month-old children at high risk of the condition before symptoms emerged.

Children with ASD tend to present with symptoms such as problems with social interaction and communication before the age of three.

Previous studies have shown that social deficits characteristic of ASD sometimes emerge in early childhood during the first and second years of life.

Small studies have also suggested there may be brain changes that start before 24 months of age, but these have not been validated.

ASD has been known to run in families. This study wanted to see if brain changes associated with the condition could be detected earlier in children at high risk of developing ASD. They also wanted to know if it could be detected early in children who were at low risk.

What did the research involve?

This analysis used data from the Infant Brain Imaging Study (IBIS), a network study that collected clinical data from four hospitals in the US.

IBIS enrolled children at both high and low risk of ASD. Children were defined as high risk if they had an older sibling clinically diagnosed with ASD.

Infants entered the study at six months of age, and the same children were followed up at 12 and 24 months.

The children were assessed using a brain MRI scan at each of these three time points. The MRI images were used to obtain brain tissue volumes and measurements of the surface area of the brain and cortical thickness.

Further tests measured cognitive development, adaptive functioning and behaviours associated with autism. The assessments were made using the Mullen Scales of Early Learning and the Vineland Scales of Adaptive Behaviour.

Autism-specific assessments included the Autism Diagnostic Interview-Revised, the Autism Diagnostic Observation Scale, and the Symbolic Behaviour Scales of Development Profile.

The final diagnosis of ASD was made by a clinician at 24 months of age using these tools.

This analysis looked at data for 106 high-risk individuals and 42 low-risk children. The researchers analysed the data to see if there were associations between diagnosis of ASD at 24 months and any clinical symptoms earlier in infancy.

What were the basic results?

There were noticeable brain changes in 15 infants below the age of 24 months who went on to be diagnosed with ASD at 24 months.

The changes seen were increased cortical surface area expansion at 6-12 months and brain overgrowth at 12-24 months. The emergence of social deficits characteristic of the condition became apparent during this time period.

There was no difference in total brain volume growth at 6-12 months between the high-risk and low-risk infants.

However, total brain volume growth rate was increased in the high-risk group during the second year of life, when compared with low-risk children. There was no difference between the groups in cortical thickness.

How did the researchers interpret the results?

The researchers concluded: "These findings demonstrate that early brain changes occur during the period in which autistic behaviours are first emerging.

"Our data suggest that very early postnatal hyper expansion of cortical surface areas may have an important role in the development of autism." 

Conclusion

This early-phase research suggests there may be brain changes associated with ASD, and MRI scans could potentially be used to aid earlier diagnosis.

However, we don't know if these changes are present in all children with ASD. Much larger studies would be required to see if this is the case.

The researchers suggest these findings may have implications for the early detection of and intervention for ASD.

However, any such test would need to have a high degree of accuracy to avoid over- or under-diagnosis of ASD in infants. Even if this test was well validated, it would probably be just the start of a process of diagnosis.

Early signs of ASD in preschool children fall into four main categories:

  • problems with spoken language
  • failing to respond to others
  • problems with social interaction
  • unusual behaviour

See your GP or health visitor if your child is showing symptoms of ASD or you're worried about their development.

If appropriate, your GP can refer you to a healthcare professional or team who specialise in diagnosing ASD.

Links To The Headlines

Autism detectable in brain long before symptoms appear. BBC News, February 15 2017

Accurate test for autism? Scientists use MRI scan to diagnose condition in hundreds of babies under 2 years old. Mail Online, February 15 2017

Brain scans could identify babies most at risk of developing autism, study shows. The Guardian, February 15 2017

Links To Science

Cody H, Hongbin Hm Brent G, et al. Early brain development in infants at high risk for autism spectrum disorder. Nature. Published online February 15 2017

 Thu, 16 Feb 2017 16:00:00 GMT 'Add vitamin D to food to prevent colds and flu', say researchers

"Adding vitamin D to food would reduce deaths and significantly cut NHS costs," The Guardian reports.

A review of existing data estimates that supplementing food with vitamin D would prevent millions of cold and flu cases, and possibly save lives.

Researchers looked at data from 25 previous studies where vitamin D was compared with a placebo.

The studies explored the effect of vitamin D in preventing acute respiratory tract infections. These are infections of the body's airways, such as colds, flubronchitis and pneumonia. More than 10,000 people were involved in total.

Their analysis suggests daily or weekly vitamin D supplementation was useful in preventing respiratory tract infections. Perhaps unsurprisingly, supplementation was particularly beneficial for people who had very low levels of vitamin D.

The researchers concluded that these results add to the body of evidence that fortifying widely eaten foods with vitamin D would improve public health.

But this opinion is not shared by all experts in the UK. Professor Louis Levy, head of nutrition science at Public Health England (PHE), said: "The evidence on vitamin D and infection is inconsistent, and this study does not provide sufficient evidence to support recommending vitamin D for reducing the risk of respiratory tract infections."

As this debate is ongoing, it would seem sensible to stick to the relatively new guidelines about vitamin D – that is, everyone should consider taking supplements during the winter months.

Where did the story come from?

The study was carried out by researchers from a number of institutions, including Queen Mary University, Winthrop University Hospital in the US, and the Karolinska Institutet in Sweden.

No manufacturers of vitamin D supplements were involved in this research. Funding was provided by the National Institute for Health Research.

The study was published in the peer-reviewed British Medical Journal on an open access basis, so it's free to read online.

The findings of this research have been widely covered by the UK media, and the reporting has been accurate.

A number of quotes are provided from experts across all media sources to provide both sides of the argument for vitamin D supplementation and the reaction to this particular review.

The British Medical Journal itself includes an editorial from independent experts arguing that food should not be routinely fortified with vitamin D.

What kind of research was this?

This systematic review and meta-analysis investigated the use of vitamin D supplementation as a way of preventing acute respiratory tract infections such as flu, bronchitis and pneumonia.

This type of review is the best way of gathering all available evidence on a topic – but the findings can only be as reliable as the studies included. The researchers therefore only included high-quality evidence from randomised controlled trials (RCTs).

What did the research involve?

The researchers searched four literature databases and two clinical trial registries to identify RCTs that looked at the overall effect of vitamin D supplementation on risk of acute respiratory tract infection.

To be included in the review, studies had to compare vitamin D3 or D2 with a dummy pill (placebo).

They also had to be double blind, meaning that neither the participant nor the doctor knew which pill they were taking.

Finally, the trial needed to set out to look at the rates of respiratory infection, rather than this being an incidental finding.

The studies included in the analysis were all considered to be high quality according to a validated assessment using the Cochrane risk of bias tool, which assesses bias and skewed reporting.

The primary outcome of the meta-analysis was incidence of acute respiratory tract infection of any location.

When analysing the pooled data, the researchers adjusted for the potential confounding effects of age, sex and duration of the study.

They also performed subgroup analyses, where a data set is split into smaller groups to check for possible patterns, to see if other factors such as asthma and body mass index affected the results.

But the researchers weren't able to analyse the results according to whether people had chronic obstructive airways disease (COPD) or if they had been given a flu vaccine.

What were the basic results?

In total, 25 RCTs from 14 countries, including the UK, were included. These involved a total of 11,321 participants, aged from 0-95 years.

After pooling the findings, vitamin D supplementation was found to reduce the risk of acute respiratory tract infection by 12% (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.81 to 0.96).

By splitting the participants into smaller subgroups, a statistically significant protective effect was seen for those who had daily or weekly vitamin D supplementation without large one-off doses (aOR 0.81, 95% CI 0.72 to 0.91) but not for those receiving one or more large one-off doses (aOR 0.97, 95% CI 0.86 to 1.10).

Among those receiving daily or weekly vitamin D, protective effects were stronger for those with lower vitamin D levels at the start of the study and people with asthma. 

There were no serious adverse events or deaths linked to supplementation.

How did the researchers interpret the results?

The researchers concluded: "Our study reports a major new indication for vitamin D supplementation: the prevention of acute respiratory tract infection.

"We also show that people who are very deficient in vitamin D and those receiving daily or weekly supplementation without additional bolus doses experienced particular benefit.

They added: "Our results add to the body of evidence supporting the introduction of public health measures such as food fortification to improve vitamin D status, particularly in settings where profound vitamin D deficiency is common." 

Conclusion

This was a systematic review and meta-analysis investigating the use of vitamin D supplementation as a way of preventing acute respiratory tract infections such as flu, bronchitis and pneumonia.

The study found vitamin D supplementation to be useful in the prevention of acute respiratory tract infection. People who are very deficient in vitamin D and those receiving daily or weekly supplementation without additional large one-off doses had a larger benefit.

This study has both strengths and limitations. It is very well designed and includes high-quality evidence. The researchers made efforts to reduce the risk of bias and investigate possible areas where bias may exist in their study.

They provided the following limitations:

  • Analysis suggests the results may have been subject to some degree of publication bias, so some small trials showing adverse effects of vitamin D may not have been included.
  • The study was not adequately powered to detect effects of vitamin D supplementation in some subgroups, such as people with COPD.
  • Data relating to adherence to supplementation was not available for all participants.

PHE guidelines published in the summer of 2016 recommend adults and children over the age of one should consider taking a daily supplement containing 10 micrograms (mcg) of vitamin D, particularly during autumn and winter.

People who have a higher risk of vitamin D deficiency are being advised to take a supplement all year round.

But PHE currently does not recommend the routine fortification of common foodstuffs with vitamin D.

In the words of Professor Louis Levy, head of nutrition science at PHE: "The evidence on vitamin D and infection is inconsistent, and this study does not provide sufficient evidence to support recommending vitamin D for reducing the risk of respiratory tract infections."

Another way to protect yourself during the winter is to make sure you have the seasonal flu jab if you're vulnerable to the effects of flu.

Read more about who should have the seasonal flu vaccination.

Links To The Headlines

Adding vitamin D to food reduces deaths, say scientists. The Guardian, February 15 2017

Vitamin D pills 'could stop colds or flu'. BBC News, February 16 2017

Put vitamin D in milk and bread: 'Three million people a year would escape colds and flu' if it was added to food. Daily Mail, February 16 2017

Vitamin D pills 'key to beating colds and flu' says study. ITV News, February 16 2017

Vitamin D supplements could prevent colds and flu, according to a new study. Metro, February 16 2017

Links To Science

Martineau AR, Jolliffe DA, Hooper RL, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ. Published online February 15 2017


 

 
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