Are medical students turning to prostitution to pay bills?

The answer is "No" but you wouldn’t know it if you read the headlines.

Here are a few:

Are med students turning to prostitution to pay tuition?-MSNBC
Sex Work Among Medical Students On the Rise?-ABCNews
Worrying rise in number of medical students in prostitution over last 10 years-Yahoo

And of course, not to be outdone, a London paper, the Metro, gets it all wrong.

Photo courtesy of Noorulann Shahid ‏(@NoorulannShahid)

Goggle “Medical Student Prostitution” and you will find many more, none of which give the reader any hint that US medical students are involved in the alleged practice..

The problem is that the article that these scandalous headlines are referring to says nothing of the kind. It was published in Student BMJ, a division of the formerly prestigious BMJ Group. Its flagship publication, the British Medical Journal, is one of the leading medical journals in the world.

The article is an opinion piece written by Jodi Dixon, a final year medical student at the University of Birmingham. She cites a previously published paper, which surveyed undergraduate students at a London university and stated that 10% of those students “knew of someone” who had worked as a prostitute or an escort. This is what is termed “hearsay” in legal circles. And isn’t it possible that many of the students knew the same person? Please note again that this study did not include medical students.

Ms. Dixon goes on to speculate that some medical students might have to consider prostitution as tuition in UK medical schools rises. She discusses the ethical and legal implications of medical students possibly becoming prostitutes.

The BMJ group apparently sent out a press release that conflates medical students and undergraduate students. This was reprinted as the Yahoo Groups “Research in Psychiatry” story.

Oh there is one bit of additional information, which does not exactly support the headlines. Student BMJ simultaneous published “Confessions of a student prostitute.” The author is anonymous and is a man.

The BMJ Group ought to be ashamed of this.

Strokes, Sex, Headlines, Reportage

Today’s hot medical press release is about a paper describing factors which may trigger the rupturing of a cerebral aneurysm.

The study was performed using a questionnaire and included 250 subjects who had experienced a stroke related to a cerebral aneurysm. According to the article, published ahead of print in the journal Stroke, there are eight factors which can trigger the rupturing of a cerebral aneurysm.

In decreasing order of importance they are coffee drinking, vigorous exercise, nose blowing, sexual intercourse, straining to defecate, cola drinking, being startled and being angry.

There was some good news. Alcohol consumption mostly lowered the risk of stroke. Masturbation and using marijuana had no effect.

The study had some limitations such as those whose strokes left them with serious disabilities or death were unable to complete the questionnaire.

I have two comments.

Why is it that sexual intercourse, only the fourth most important factor in causing aneurysm rupture, was featured in the headlines of all of the organizations that printed the story—BBC News, Huffington Post, MSNBC, Eurekalert, Reuters to name but a few?

What the paper did not address was whether the risks were cumulative. For example, what if you had sexual intercourse while angry? Or even worse, what if you drank some coffee, then went to the bathroom to defecate [a common occurrence], while sitting on the toilet blew your nose and then were startled? Perfect storm?

DNR Patients and Outcomes of Surgery: Two Papers, Same Data, Different Results

Just the other day, a paper from Archives of Surgery reported that patients who have existing DNR orders have a higher postoperative mortality rate than patients who do not. This, of course was not surprising since people with DNR status are usually old and sick. The paper did receive some media attention with routine “churnalistic”* coverage. [HealthDay News, Medscape, MSN Health]

Having read the paper with mild interest, I didn’t think too much about it until yesterday when the May issue of the journal Critical Care Medicine [CCM] arrived. In it was a paper which is very similar to the Archives article. Let’s compare the two papers. The Archives paper was entitled “High mortality in surgical patients with do-not-resuscitate orders: analysis of 8256 patients,” and the CCM paper “Pre-existing do-not-resuscitate orders are not associated with increased postoperative morbidity at 30 days in surgical patients.”

Both papers used data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database for the years 200-2008. The Archives paper found some 4128 DNR patients while the CCM paper found only 2199. Both studies matched the DNR patients with non-DNR patients who had similar operations and demographics.

Both papers found that DNR patients were a little more than twice as likely to die within 30 days than non-DNR patients, but the mortality rates were markedly different. The Archives mortality rates were 23.1% for the DNR and 8.4% for the non-DNR versus the CCM cohorts which were 12.5% and 5.2% respectively.

The Archives paper noted a significantly higher rate of major complications for the DNR patients with no difference in minor complications whereas the CCM paper reported that the DNR patients actually had significantly fewer wound infections and no difference in the major complication rate.

I could go on but I think you get the idea. Both sets of authors did mention that their studies could be confounded by the limitations of retrospective studies and the use of an administrative database, such as the NSQIP.

What is not clear and certainly beyond my ability to explain, are the marked discrepancies in the number of patients found with DNR orders when the time period of both studies was identical and the substantial differences in mortality and complication rates.

Bottom line. Although they are at a higher risk of death, DNR patients may undergo necessary surgical procedures with a reasonable expectation of success.

*Churnalism is a news article that is published as journalism, but is essentially a press release without much added

Clever New Diagnostic Test for Pancreatitis Fails to Measure Up

Today Eurekalert!, a science news service, featured a story about a new diagnostic test that at first glance seems interesting and possibly of value. Researchers at the University of Texas have developed a simple, inexpensive test for diagnosing acute pancreatitis using an LED sensor, aluminum foil, gelatin, milk and lye. Using about $1.00 worth of materials, the test identifies the presence of high levels of a pancreatic enzyme, trypsin, in the blood and takes only a few minutes to do.

According to the press release on the Texas Science website, “The sensor could help prevent damage from acute pancreatitis, which is a sudden inflammation of the pancreas that can lead to severe stomach pain, nausea, fever, shock and in some cases, death.”

Unfortunately, the breakthrough is not really all that dramatic.

Acute pancreatitis usually resolves in a few days. It is treated conservatively using bowel rest, intravenous fluids to maintain hydration and pain medication.

Pancreatitis is commonly diagnosed by history and physical examination and confirmed by elevated levels of one or two blood tests, serum amylase and lipase. Lipase, which rises more slowly but remains elevated in the blood longer than amylase, is the preferred test. Checking on line reveals that a serum lipase test can be obtained for as little as $39.00 retail. The actual cost of performing the test is under $6.00. In a hospital emergency department, the result is available within an hour of obtaining a blood sample, which negates the small speed advantage of the gelatin-based test. And let’s not forget that according to Joint Commission and other regulatory organizations, any point-of-care test must undergo frequent calibration to assure consistent quality. Technically, even a simple test for occult fecal blood cannot be performed at the bedside in the 21^st century.

It is not clear exactly how a diagnostic test that might save a few dollars and produces a result a little quicker than a standard blood test can prevent damage to the pancreas. Since the test is qualitative [elevated trypsin levels are present or not] rather than quantitative like the lipase test [a numerical value is reported], the gelatin test cannot be used to determine whether the level of pancreatic inflammation is increasing or not.

In fairness, the press release does point out that the gelatin test could be used in developing countries where automated blood analyzers might not exist or in situations where electrical power has failed. This of course is based on the assumption that aluminum foil, LED sensors gelatin etc are handy.

Bottom line. The test is ingenious but seems unlikely to replace standard blood tests for pancreatitis. Don’t believe everything you read in a press release.

[Note: Only 32 (7%) of the 451 words in this post were taken directly from the press release.] 

Swimming in Chlorinated Water Causes Bladder Cancer (Not)

Here is a great example of what can happen when a press release is published as news.

Referring to a recent paper, several outlets came out with headlines such as “Swimming too often in chlorinated water 'could increase risk of developing bladder cancer', claim scientists” and “Swimming too often in chlorinated water 'ups bladder cancer risk.'” The paper, entitled “Socioeconomic status and exposure to disinfection by-products in drinking water in Spain,” is available in full text on line.

The researchers looked at data from a study of people in various regions of Spain. The 1271 subjects in the study had served as controls in a different study that was done 10 years ago. They concluded that those in higher socioeconomic groups drank less tap water but took longer showers and used swimming pools more often. It seems that by-products of chlorination, trihalomethanes (THM), have been linked to an increased incidence of bladder cancer. And THM can be absorbed through the skin, making a link of bladder cancer with swimming plausible.

Here is the catch and it can only be discovered by reading the full text of the paper. Participation in swimming was characterized as follows:

“swimming pool attendance, [was recorded] as a dichotomous variable: attending a swimming pool once or more than once per year contrasted with never (or less than once per year)”

In other words, a subject was asked whether he swam in a pool during a year. If he said “Yes,” he was listed as a swimmer, whether he swam once a year or once a day.

You need not be a scientist or a statistician to see the fallacy of this purported association of swimming and bladder cancer.

By the way, as far as I can tell, none of the 1271 subjects actually developed bladder cancer. The research wasn’t designed to look at that. It was taking a post hoc look at water usage by a group of people who were the subjects of a different research hypothesis.

Also, an author of the paper conceded in the press release that the risk of contracting bladder cancer from swimming was “small.”

Bottom line. Swimmers, please relax and ignore this overblown drivel.

And if you are worried about getting bladder cancer from drinking chlorinated water, here are two interesting points. One, a study from the New England Journal of Medicine a few years ago reported that drinking a lot of fluid decreases the risk of bladder cancer. Two, the incidence of bladder cancer has been remarkably stable over the last 30 years.