Sunday, 22 February 2015

Gong Xi Fa Cai! Medical news in the Year of the Sheep

Chinese New Year is upon us, with businesses closing up for a long holiday and most Chinese families looking forward to a reunion. But of course people still get sick at Spring Festival and the Chinese media has been full of stories praising the heroic and dedicated doctors and nurses who forego the holiday and put duty ahead of family to stay at work.  There are stories of doctors working solo for 24 hours to keep up with all the demand during the Spring Festival. From Hubei there is the story of the man bitten by his rabid pet dog who went to the hospital and was hugely relieved to find that the infectious diseases doctor was on duty to give him a rabies injection. At Fuzhou Hospital on New Years Eve the medical and nursing staff gather together to have the "big family banquet" that they would normally have with their families at home.  And there is even a story of the doctor at a Zhejiang leper colony who was urged by his ailing patients to go home and see his family rather than spend New Year on duty at the sanatorium.

Not all doctors have been heaped with praise at Chinese New Year, however. In Guangzhou there has been an uproar among the medical community after the city authorities sent anti-corruption teams in to raid hospitals just before Spring Festival. The city disciplinary affairs committee said the inspection teams were looking for evidence of bribes and 'hongbao' (red envelopes) given by patients to doctors. The raids have so far turned up little evidence of bribery, and doctors have been indignant at being suspected of corruption. They objected to having their everyday items such as snacks being documented - and also being questioned in detail about the origin of their possessions - and even for receipts for goods. Doctors said the actions of the inspectors went beyond their powers and the actions should have been a matter for the police. One doctor said a public hospital was not a place where bribes could be openly given or solicited among colleagues - and he was also indignant that many doctors had prepared hongbao or gifts for their families which were assumed by inspectors to be bribes from patients.

Chinese New Year is also a peak risk time for influenza in China. In Guangdong it has been reported there have been 53 cases and 13 deaths from  H7N9 avian influenza. In neighbouring Hong Kong there has also been a very severe flu season caused by the regular influenza H3N2 strain which has been causing as many as 18 deaths per day in the city. There have been reports of shortages of antivirals such as Tamiflu in Hong Kong, and the flu vaccine this year has been ineffective because the H3N2 strain of flu is a new mutation that is not covered by the vaccine. Of course influenza does not stop at the border, so we can only assume that the flu toll has been equally high in mainland China.

Another major infectious disease under the microscope this week is the recent outbreak of measles  affecting more than 1200 people in Beijing. Infectious disease specialists in the capital found that most of the cases originated in wholesale clothing markets popular with  locals and international visitors - so an MMR vaccination might be a pre-requisite if you are going to the Silk Market. The analysis found that many of the cases occurred in migrant workers who (unlike Beijing residents and tourists) had low levels of measles vaccination. The researchers recommended that outreach services be set up to vaccinate migrant workers in Beijing and "the offer of measles vaccine to workers as they register to live and work in the commodity markets might be a reasonable strategy to prevent future measles outbreaks."

In other news this week - the high demand for blood products in China is driving  a thriving black market in organised gangs of donors, organised by the so-called "blood heads" who are paid thousands of RMB for supplying blood. In the field of diabetes, some Chinese endocrinologists have been blasted in the pages of the Lancet for writing a review article that recommended the use of expensive new drugs as first line treatment for diabetes. Their critics say the endocrinologists failed to mention the more effective and cheaper drugs such as metformin - and the Chinese doctors also failed to mention their financial conflicts of interest with the Big Pharma makers of the expensive new drugs.

And finally, the quality of medical education in China has been questioned in several articles published this week. The Year of the Sheep is a milestone for China's medical educators in that they are now requiring a standard 5+3 medical degree + internship program be implemented nationally. However, some commentators have said that the new system will be no better than the current haphazard postgraduate 'Masters' programs if medical graduates receive insufficient clinical experience and supervision. They also say that the internship scheme should include 'exit examinations' to ensure that trainees have actually acquired the specialist skills they have trained in. Coincidentally this week Shanghai media report that trainee doctors get little experience in anatomy because there is a national shortage of donated cadavers. Chinese culture prohibits citizens from 'donating their bodies to science' as is done in the west. This means that Chinese medical graduates get all their anatomy learning from textbooks and have very little "hands on" experience. This is worrying for students going into specialties such as surgery - as they may never have practiced techniques such as cervical spine surgery before being asked to do the real thing. Not surprising then that a special anatomy cadaver training class at Shanghai's Fudan University was heavily oversubscribed.


Sunday, 15 February 2015

Research fraud and inappropriate treatment: my blog about medical news from China for Sunday 15 February.

Last week I blogged about how so many medical journal articles in China are simply "vanity publications", written by ghostwriters to satisfy the doctor's need to achieve a quota of published articles. However, this week we see that there are also major problems with 'serious' research clinical trials carried out in China. An article in JAMA this week by Charles Seife reveals that the FDA found serious problems with the Chinese clinical trials of apixaban, a novel anticoagulant.
 At one site the FDA concluded that patient records had been altered. When they investigated further the FDA inspectors declared that data from 23 other Chinese clinical trial sites was suspect and should be excluded from their evaluation of apixaban (Eliquis). We often hear that western pharma companies are shifting their R&D from the US and Europe to China. It may be cheaper but with reports like this you have to wonder if it is worth it in the long run.

China is also trying to make a name for itself in high tech areas such as stem cell transplantation. An announcement in the Shanghai media said the city was to build the world's largest hospital for 'blood diseases'. This seems to be a reference to  hematopoietic stem cell transplant procedures for patients with blood diseases such as leukaemia. This is a highly specialised and expensive form of treatment for a small niche of patients (and often of limited benefit), so it is odd that a city that can't even meet demand in its emergency departments  is pushing ahead with a hospital for rare diseases. perhaps the explanation is that the project is being run by the China Stem Cell Group Co Ltd. This may be more about making profits than providing needed health facilities.

China's love of high tech for its own sake is  also manifest in the move by a Guangdong hospital to set up 1000 telehealth stations in pharmacies to provide online consults. The move by the Second People's Hospital of Guangdong to set up the Guangdong Online Hospital will reportedly include 200 doctors providing services via videolink. All sounds very modern, but how exactly does a doctor do a physical exam, order tests and imaging and provide 'hands on' care over a video link? It might be of limited value in follow up counselling consultations and for repeat prescriptions, but it sounds like a gimmick to me.

Online hospitals are supposed to help address the problem of overcrowded hospitals. I'm not sure how they will help the cancer patients who need a bed but can't get one. In places such as Changsha in Hunan the hospital bed shortages are so acute that patients have to make do with 'cancer hotels' instead. Patients with cancer who require treatment but who are on the waiting list pay 1100 yuan a month to stay in hotels adjacent to the cancer hospitals so they can go into outpatients for treatment. Locals say that about half the hotels near the hospital are occupied by patients, who face 1-2 month waits for a bed.

Breast cancer is an increasing concern in China, but rates are still not as high as in the west, perhaps due to dietary and lifestyle factors. Screening for breast cancer is also not part of the Chinese health system, although there has been some use of mammography. However ultrasound has been favoured by some Chinese clinicians, reportedly because it is more suitable to the smaller and more dense breast tissue of Chinese women. Now a study has confirmed that ultrasound is a more effective screening method for breast cancer in Chinese women. A study of more than 12,500 women who underwent either or both found that of the 30 cancers detected, five were in the mammography group and 11 in the ultrasound group, and 14  in the combined group. Ultrasound was more sensitive had the same specificity and positive predictive value as mammography. It was also considerably cheaper, costing $7876 to detect one cancer compared to $45253 for mammography.

In other clinical news, metabolic syndrome (a highly dangerous combination of abnormal cholesterol, high blood pressure and pre-diabetes) was found to occur in 27% of Chinese people. A study of 15,477people in NE China found that 28% of men and 26% of women had metabolic syndrome. The condition was more common in Chinese on high incomes, those who ate more rice and those who did less physical activity - in other words, 'to get rich is glorious' but it also comes at a price of this disease of affluence. 

However, Chinese people might be forgiven for thinking twice about going for a jog, given the terrible air pollution in many cities. This has now been confirmed by Dr Liu Yu of the Key Laboratory of Exercise and Health Sciences at Shanghai University of Sport. This week he published an article in the BMJ which warned that the harms of ambient air pollution on the cardiovascular and respiratory systems might outweigh the benefits of exercise. He estimated that air pollution probably caused more than a thousand deaths a year in the city.

It's not all bad news from China, though. A paper published by the WHO this week shows that Chinese healthcare workers have had great success in reducing deaths from HIV using a simple 50c antibiotic, co-trimoxazole. Their study showed that giving the antibiotic at the same time as antiretroviral reduced HIV deaths by 37% - a staggering achievement. If routinely use in China for HIV patients  this could save thousands of lives among HIV positive people, the researchers sai.d Unfortunately, however, antibiotic use if often missed in this patient group.

Sunday, 8 February 2015

My weekly medical news blog for 7th February

There have been few takers for GP training places in Nanjing. The city's community health centres need to recruit 110 family doctors to fill their positions but have only had 49 applicants. Under new health ministry regulations, all doctors including GPs must have the 5+3 education and training (5 years undergraduate and 3 years postgraduate.) However, despite offering a masters degree and a one month placement with GPs in Taiwan, most medical graduates have given the GP training scheme the cold shoulder. The reason is the low status and poor pay of 'community doctors'. After eight years training, GPs can expect to earn only about 80,000 yuan (US$13,000) a year, which is much lower than hospital-based specialists earn. Also there is no chance of promotion or career progression and GPs are expected to move around many clinics in suburbs and villages. Health educators say the Chinese government needs to put more emphasis and resources into primary care if it is to develop a healthcare gatekeeper system similar to those used successfully in developed countries.

Most of the 'research' published by China's doctors is rubbish and there's a simple reason for this - the publish-for-promotion system. To gain promotion (and often just to stay in the job) all China's doctors have to meet a certain quota of  papers published in medical journals. The problem is that most of China's doctors are way too busy treating patients to be doing research and writing up papers. Many are simply not interested. The result is a thriving industry in academic fakery and plagiarism. It is common knowledge that doctors hire 'publishing agents' and ghostwriters to source the articles that will be published under their name. Ironically, many of the articles are written by medical students, and so there is an inverted system whereby the most knowledgeable and experienced clinicians are publishing articles written by the least knowledgeable. The going rate is about 3000-4000 yuan for a good paper - payment on publication, of course. Experts say the system has become a wasteful farce, and they are calling for reform of the one-size-fits-all quote system, to divide doctors into three categories: 'craftsmen' (no research, just treating patients), physicians (some research) and medical scientists (more  research, fewer patients).

The government says it expects to see a dramatic increase in uptake of private medical insurance before 2020, with new policies encouraging Chinese citizens to take out private cover. Ma Xiaowei, deputy head of the health ministry, the National Health and Family Planning Committee, told a news conference this week that the central and provincial government would "encourage the development of various types of commercial insurance to increase people's ability to deal with risks posed by major diseases." He said private cover was needed to help fund demand for health services, with the number of people over 60 already exceeding 200 million. However Mr Ma didn't explain how people will be enticed to take out private health insurance given that there are currently virtually no private doctors or hospitals and very few services or benefits from having insurance.

Underpaid, overworked and under fire: that's the life of an emergency medicine specialist in Guizhou province, according to a Sina article this week. In China, emergency doctors accompany ambulances and are often first on the scene of trouble, even before police. One doctor said he often had to jump in and stop bleeding in stabbing victims while people were still fighting around him. Another said emergcny doctors were often faced with physical challenges such as getting critically ill patients down stairs of apartment blocks with no lifts. Emergency doctors said they worked 24 hour shifts then had a day off during which they mostly slept, and there was no time for leisure, holidays or study. The stress of daily life as an emergency doctor meant there were high rates of burnout - and doctors were considered grizzled veterans if they lasted three years, they said.

In clinical news, new research shows that older Chinese are consuming more calories - and eating more unhealthy food - than their counterparts of the previous generation. A study from nine provinces found that the average daily energy intake had increased among older Chinese adults from 1379 total kilocalories in 1991 to 1463 kilocalories in 2009. The increases had come from greater consumption of high fat and high carbohydrate foods such as plant oil, wheat buns, and wheat noodles.

Chinese are also consuming more polluted air and it is killing them as much as smoking. A study carried out by the School of Public Health in Peking University found that there were
257,000 premature deaths related to PM2.5 pollution in 31 major Chinese cities. This made air pollution a major killer equivalent to smoking. Conditions such as lung cancer and stroke triggered by air pollution killed about 18,000 people in Beijing alone in 2013, the researchers said.

And finally, a study from Shanghai as shown that the number of cervical cancer diagnoses in the city has increased six fold in the last decade. Data from 13,518 women with gynaecological cancers  from 2003 to 2013 showed that the number of women with diagnosed gynaecological cancers increased by almost sixfold with the increase largely due to the increase of women with newly diagnosed cervical cancer. The study also showed that the age of diagnosis of cervical cancer had increased.

Sunday, 1 February 2015

My weekly news blog for 1 Feb

The medical news in China has been dominated this week by the death of a doctor at a Luoyang hospital after a brawl with a drunken patient. Both fell down a lift shaft and were killed. It's just the latest in a long line of violent incidents against medical staff. Each time one occurs there are protest by staff, stern editorials in the media and vows to crack down on such incidents. There have even been gimmicks, including plans to have 'volunteers' or police patrols in hospitals to defend doctors from violence and defuse violent situations And yet still they continue. I can't understand why Chinese hospital don't have 'crash' alarms like they do in western countries, that trigger lockdowns and mutual protection protocols.

On a more positive note, Chinese drug makers have registered the world's first Sabin-inactivated poliovirus vaccine (S-IPV). The vaccine, developed by the Chinese Academy of Medical Sciences is being produced by the Institute of Medical Biology within the Kunming Hi-Tech Zone. It is said to be more effective than the current oral polio vaccine and also inexpensive.

Such a vaccine may have a role in remote parts of China such as Xinjiang, which recently reported an outbreak of polio. After more than a decade being polio free, in 2011 there were 23 polio cases reported, 55% of which were in young adults.  The polio was presumably brought in from the neighbouring Muslim state of Pakistan, where polio has not been eradicated due to the Taliban.

Another first for China this week was the first patient to be treated - and survived - a new H5N6 strain of avian influenza. The patient treated by well-known specialist Dr Zhong Nanshan at Guangzhou hospital after contracting the infection from - guess where - a live poultry market (why don't they just shut them down for good?). Dr Zhong said this was the second patient to contract the dangerous infection - the first one died. he said the second patient had been treated with high doses of antivirals and was in a stable condition. China is also struggling with a winter outbreak of H7N9 avian flu, with 30 cases so far around Guangdong.

In the healthcare reforms, some healthcare managers have said that hospital reforms should focus on the model of funding, and switch to an 'activity based funding' system to reward outcomes. At a meeting of the Beijing Chinese Peoples Consultative Committee they said that the funding system based on "diagnosis-related groups" (DRG)  would "break the link between doctors' incomes and prescriptions, thereby preventing excessive medical treatments and over-prescription of drugs." Hospital managers complained that they were underfunded because fees had been fixed at low prices set in 1999 whereas costs (and incomes) had risen considerably since then.

Well, fees may be too low according to hospital managers, but some patients still can't afford them. A woman has made news in Kunming by dressing up in a wedding gown and offering herself for marriage to any man who will pay her brother's medical fees. Her brother has leukaemia and she says he needs 300,000 yuan for treatment. China is supposed to have a public health fund for people with catastrophic illness, but it obviously hasn't trickled don to this young man.