“Signs of autism can be detected in six-month-old babies by measuring brain activity,” the Daily Mail has reported. While the Mail was correct, the research has not yet proved to be a perfect diagnostic test.

This and other related headlines are based on a study that assessed the brain activity of 104 infants aged 6-10 months as they watched an image of an adult’s face whose eyes moved from looking away from them, to directly at the infant, then away again. Researchers called these eye movements ‘dynamic eye-gaze shifts’. They then assessed whether differences in brain activity in response to the eye-gaze shifts were related to autism developing in the same children at three years.

Children who did not develop autism showed large spikes in brain activity when they saw the ‘gaze shifts’. Much smaller spikes in brain activity were detected in the infants who went on to develop autism, raising the prospect that autism could be identified earlier than is currently clinically possible.

However, this test was not 100% accurate. Some babies showing low brain activity spikes did not go on to develop autism and vice versa. As the groups overlap, there cannot be a simple and useful cut-off value to predict autism.

Developing and refining this type of test into something that can be routinely used to detect autism in infants is likely to take some time and will certainly require more research on larger groups of infants with autism and unselected healthy infants too.

Where did the story come from?

The study was carried out by a collaboration of researchers from English, Canadian and Australian universities and was funded by the UK Medical Research Council. It was published in the peer-reviewed science journal Current Biology.

The media reporting of this story was generally well balanced. Many stories included quotes from the study authors that a definitive test would take time to develop and that the current assessment is not 100% effective.

What kind of research was this?

This study was a prospective longitudinal study investigating whether the brain function of infants aged 6-10 months differed in response to viewing faces that changed the direction of their gaze. The researchers then looked at whether these brain function differences could predict a diagnosis of autism at three years of age.

The authors report that there are currently no reliable methods of predicting autism in infants younger than about two years of age. Current diagnosis relies on the detection of behavioural symptoms of autism that typically develop in a child’s second or third year. Behaviours associated with autism include impairments in social skills and communication, and the presence of rigid, stereotyped and repetitive behaviours.

The authors say previous research shows typical infants’ sensitivity to eye gaze in the first year of life predicts a range of social and communication skills that emerge later. Detecting autism at an early age could potentially lead to ways of better supporting the child during early development, improving their wellbeing and life chances.

What did the research involve?

The researcher recruited a group of 104 infants - 54 at risk of autism because of a family history of the condition and 50 controls, with no family history of autism. The infants were followed from 6-10 months through to three years of age.

The researchers measured the 6 to 10-month-old infants’ response to changing images of faces. They did this by recording event-related potentials (ERPs), which are a measure of brain electrical activity in response to a thought or perception. In this study, ERPs were used to measure the perception of a face changing between looking directly at the infant and then away from them. The researchers called this ‘dynamic gaze-shift stimuli’.

The researchers also tracked the eyes of the infants to examine the amount of time they spent looking at the eye region of the faces they were shown. This allowed the researchers to assess whether different responses to the eye gaze were due to differences in attention to the eye region or whether brain functions were more important.

The researchers reported that dynamic gaze-shift stimuli are more likely to engage wider social brain mechanisms than static images as they mimic a real social interaction more closely. However, researchers compared their dynamic gaze results with that from ‘static gaze’, (images of a face whose eyes were looking at, or away from, the infant) to see how they compared to each other.

The brain activity levels of infants at risk of autism were contrasted with the controls. The researchers then looked at how the brain function differences at 6-10 months related to a later diagnosis of autism. An independent team assessed whether the infants had autism at two and three years old.

What were the basic results?

The brain activity of the control group showed large spikes of activity in response to eye gaze changes when the face image held a gaze toward, compared to away from, the infant. The brain activity spikes of infants at risk of autism were significantly smaller in response to the same stimulus.

The differences in brain activity of the control group verse at risk group were not restricted to the dynamic gaze results. Similar results were seen when static images were used.

The researchers found that those who did not go on to develop autism at three years of age showed large spikes in brain activity relating to the changes in eye gaze at 6-10 months. Crucially, those that did develop autism showed significantly smaller spikes in brain activity. The static image test did not predict a later diagnosis of autism.

Eye tracking information was available for 93 of the 104 infants. There was no difference in the time at-risk infants and control infants spent looking at the faces’ eyes relative to other areas of the face.

How did the researchers interpret the results?

The authors conclude that ‘brain function measures can successfully differentiate groups of infants at risk [of autism] from low-risk control within the first year of life'. They go on to say that ‘response to dynamic gaze shifts during the first year of life distinguished the group of infants who later develop autism’.

Conclusion

This small study highlights a potential method of identifying children who are likely to develop autism at 6-11 months, much earlier than the current method of diagnosis. The authors suggest this could potentially pave the way for more selective targeting of early intervention efforts and procedures to these children, increasing their life chances.

While this study provides intriguing results it is important to bear in mind some practical limitations. For instance, while the average differences between the brain function of the infants that went on to develop autism compared to those that did not were significantly different, individual values from the two groups did overlap. This means that there is probably no useful clinical cut-off value to predict autism. Similarly, the researchers do not describe how the controls were selected or report how good the test was at diagnosing autism, known as the ‘test sensitivity’. Reporting these key results would have helped us better assess the accuracy and importance of these findings.

Much larger studies would be needed to establish a suitable brain activity level to use to identify as child as 'likely to develop autism'. These studies could better assess the natural variation in brain activity from a large group of infants. Similarly, it is unlikely a future autism assessment would rely on a single test, such as dynamic eye gaze, but would instead use a combination of tests.

The uncertainty about what cut-off values to use, and the drawbacks of using a single predictive test, makes the development of an early identification test more complex. It may be some time before a predictive test is routinely available to identify infants likely to develop autism earlier than is currently possible.

Links To The Headlines

Autism: Brainwaves 'show risk from age of six months'. BBC News, January 27 2012

Signs of autism 'can be detected in six-month-old babies' by measuring brain activity. Daily Mail, January 27 2012

Signs of autism at six months. The Daily Telegraph, January 27 2012

Early test to detect autism. The Independent, January 27 2012

Links To Science

Elsabbagh M, Mercure E, Hudry K, et al. Infant neural sensitivity to dynamic eye gaze is associated with later emerging autism. Current Biology. 2012;22:1-5

‘More than a million cancer carers may be missing out on vital support,’ the Daily Mirror and other newspapers have reported today. The news reports are based on a survey carried out for Macmillan Cancer Support, which identified that among 386 people who provided five or more hours of care a week to someone with cancer, around half had no support of any kind.
 
There are more than 1 million carers of people with cancer in the UK, and more than 6 million carers of all kinds. The report detailed the impact of the apparent lack of support on carers’ mental health, relationships and finances, finding that just 5% say they have received a local authority carer’s assessment, which enables them to access practical, emotional and financial support.

What is the caring role for people supporting others who have cancer? 

The ‘More than a Million’ report published by Macmillan is based on the results of a survey carried out by Ipsos MORI. The charity said that around one in seven people had given some unpaid informal support to a person with cancer in the past 12 months and that around one in 50 could currently be described as carers of people with cancer. The survey was carried out between May and August 2011 and it asked questions to identify carers among 18,449 people interviewed face-to-face. They then polled 386 of these people who were identified as carers of people with cancer.

The survey found that, as with all carers, most carers of people with cancer were women (62%) mostly aged between 45 and 54. The carers most often supported a member of their family such as a parent (23%) or a spouse or partner (17%), but surprisingly 31% said they cared for a friend or neighbour. In this research, being a carer was defined as giving at least five hours of support a week, or giving one to four hours with it affecting their lives in some way. Despite meeting this definition, only 43% of the people surveyed actually considered themselves to be carers (51% said that they would not consider themselves carers). You can find out more who is considered a carer at Carers Direct: what is a carer? 

The type of care given is varied, and includes emotional support for someone with cancer and helping with errands such as shopping and collecting prescriptions and helping with transportation. On average, the carers surveyed gave almost 15 hours of support per week and 81% said that being a carer impacted on other aspects of their life. The impacts included effects on:

• emotional wellbeing and mental health
• social life
• relationships
• working life
• finances

Do carers receive adequate support?

Owing to the different ways being a carer can affect outside life, the survey considered many different types of support a carer of someone with cancer may need. The survey found that most of the support that carers receive is informal, coming from their family (44%) or friends (28%). Some carers (20%) received support from their GP or another person working within the NHS. However, half of carers polled said they received no support. The survey revealed that the type of support carers wanted was training on how to give care, and someone to provide emotional support. The carers also wanted more information on the general support available to them.

It is important to note that entitlement to a carer’s assessment is based on them being considered as giving ‘regular and substantial care’ to the person they look after. The report defined carers as those caring for more than five hours a week. While there is no legal definition for what this entails, it could explain why some carers have never had an assessment.

What is a local authority carer’s assessment?

A local authority carer’s assessment allows carers of all types to discuss with social services the help they need to maintain health and a balance between caring and other life commitments. The Macmillan Cancer Support report said that out of the people they surveyed, only 11% said they had received support from social services or local authorities and only five per cent have had a carer's assessment. If you are looking after someone, social services are obliged to consider the different issues that can affect your caring role to assess your needs. 

What other sources of help are available for carers?

The Carers Direct helpline (0808 802 0202) is a free and confidential helpline for carers (living in England) needing help or advice on their caring role or on the needs of the person they are caring for. Carers Direct can also be contacted by mail, email and live, online webchat. You can also use Carers Direct to find addresses, phone numbers and websites for carers’ services near you.
 
Macmillan Cancer Support recognises the needs of people living with cancer and their carers. In the survey, 72% of carers named at least one service or activity that they thought Macmillan offers to carers and over a third said they had used at least one of these services. These included contact with Macmillan nurses and gaining information and advice through the Macmillan website.

Links To The Headlines

Millions of cancer carers missing out on benefits. The Daily Telegraph, January 27 2012

More than a million cancer carers may be missing out on vital support, charity reveals. Daily Mirror, January 27 2012

Carers 'missing out on support', says charity. BBC News, January 27 2012

Women concerned about French-made PIP breast implants can find all the latest NHS information about the issue on this page.

Worries about the implants have emerged since news of a major investigation into them in France was widely covered in the media in December 2011.

It is thought that around 40,000 women in the UK have the implants, with about 95% of them having been provided privately for purely cosmetic reasons.

What’s the problem?

The French implants caused global concern after it was revealed they contained industrial silicone rather than medical-grade fillers and that they may be more prone to rupture and leakage. Initially reports also linked the implants to a rare form of cancer known as ALCL. This cancer link has been now been firmly discounted by medical experts here and in Europe.

What type of implants are involved?

The implants involved are called Poly Implant Prosthèse (PIP) and were made, starting in 2001, by a French company of the same name.

The marketing, distribution and use of the PIP implants was suspended in March 2010 after regulators found that the manufacturers were using silicone intended for industrial use, and not medical-grade silicone fillers. It is reported that the company used a cheap type of silicone gel intended for making mattresses.

Do the implants have to be removed early?

Most breast implants need to be removed or replaced after 10-15 years.

An expert committee was set up recently to examine the specific risks associated with PIP implants. It concluded that as yet there was not enough evidence to recommend their early removal.

However, the committee said the NHS would remove and replace the implants without charge if patients that the NHS had operated on remained concerned. The government expects the private sector to follow suit.

NHS medical director Professor Sir Bruce Keogh, who led the expert review group, said: “On the basis of the information we have, we do not think it is necessary to recommend the routine removal of these implants.

“But we understand that some women will be very concerned so we support the government’s position that the NHS will support removal of PIP implants if the patient has concerns and, with her doctor, she decides that it is right to do so.”

How many people are affected?

More than 300,000 PIP implants have been sold globally in 65 countries over the past 12 years. Europe was a major market but more than half of the implants went to South America.

In the UK, 40,000 women are thought to have the implants. Private clinics fitted 95% of these for women seeking cosmetic breast augmentation. The remaining 5% were fitted on the NHS.

The NHS provides breast implants only where there is clinical need. For example, women who have a mastectomy (breast removal surgery) as part of treatment for breast cancer are often offered implants as part of reconstructive surgery.
 

What happens if I got a PIP implant through the NHS?

Women who received a PIP implant from the NHS will be contacted to let them know they have one.

If you are worried, you should book a consultation with your specialist or GP. They will offer clinical advice on the best way forward. This could include an examination using scans, such as MRI, to look for any signs that the implant may have ruptured.

The NHS will support removal and replacement of PIP implants if a woman and her doctor decide that it is the right thing to do. The secretary of state has made clear that patients' concerns must be put first.

What if I got a PIP implant privately?

The following private clinics have said they will replace PIP implants free if clinically necessary: Holly House, Highgate Hospitals, Make Yourself Amazing (MYA Cosmetic Surgery), Ramsay Health Care, Spire Healthcare, BMI Healthcare, Nuffield Healthcare and HCA International. The Transform medical group has said it will remove the implants free for its patients who had them fitted since 2001 and The Hospital Group said it would offer free removal to patients it operated on from 2001-2009; both will charge for replacements.

If a private clinic that provided PIP implants no longer exists or refuses to help, then, so long as you are entitled to NHS services, the NHS will cover the cost of the removal of PIP implants if your doctor agrees there is a clinical need. This would not include the replacement of private cosmetic implants.

What’s the evidence around the safety of PIP implants?

During December 2011 UK media had originally focused on a possible link between PIP implants and a rare type of cancer called anaplastic large cell lymphoma (ALCL). This arose after a French woman with PIP implants developed the cancer and died. However, after reviewing the evidence, the expert group conducting the review agreed that there was no link with cancer.

More recently, attention has focused on the rupture rate of the implants, and whether the unapproved gel filling of PIP implants could have a toxic effect.

The review has specifically looked at these issues, and found:

• From the “patchy” data available, the review panel was not able to tell whether the rupture rate for PIPs is higher than for other types of implant.
• From the implants that have been tested there appears to be no risk of dangerous toxic effects in the event of a rupture.
• The review group said it could not be certain that the manufacturer did not change the content of the implants, so could not completely rule out the possibility that some might contain toxic substances. 

What is a rupture and what are the signs?

A rupture is a split that occurs in the implant’s casing. A rupture can be caused if:

• the implant’s shell gets weaker over time
• the implant is damaged during the operation
• there is a flaw in the implant
• the breast is injured

If you have any of the following signs or symptoms, you should discuss them with your GP, who will refer you to a specialist:

• lumpiness of the breast
• lumpiness or swelling in the area around the breast
• change in shape of the breast
• deflation of the breast
• redness
• tenderness of the breast
• swelling of the breast
• pain or sensitivity

Is the situation being investigated further?

Yes, the Department of Health has set up two reviews to look at how the PiP situation occurred and the issue of regulating the cosmetic surgery industry as a whole.

The first review will be led by Lord Howe and will address a number of specific issues, including:

• what information about PiP implants was available from routine systems for reporting adverse events
• what external concerns about PiP implants were brought to the attention of regulators, and when
• how these concerns and any related information were handled
• what information was shared between MHRA and counterpart agencies abroad 
• what action was taken to safeguard and advise patients
• whether action was sufficiently prompt and appropriate

The report is due to be submitted to the Health Secretary by the end of March 2012.

The second review will look at whether the cosmetic surgery industry needs to be regulated, and if so how this should happen. It be led by Professor Sir Bruce Keogh, the NHS Medical Director, who said:

“I am working with experts from the plastic surgery field to look at what we can do to make sure people who choose to have cosmetic surgery and other cosmetic procedures are safe.

“I will be looking at all aspects of regulation – at the regulation of implants and fillers, at whether the people who carry out cosmetic interventions have the right skills, at whether the clinics look after the care and welfare of their patients."

The extensive report is due to be submitted by March 2013.

In France, Jean-Claude Mas, head of Poly Implant Prosthese, has been charged with causing involuntary injury. He was released on bail after being arrested on January 26.

Links To The Headlines

No Routine Removal For PIP Breast Implants. Sky News, January 6 2012

NHS will remove implants free of charge for their patients but private clinics must pay for operations themselves, Government says. Daily Mail, January 6 2012

Government will pay for women who had breast implants on NHS to have them removed. The Daily Telegraph, January 6 2012

Clinics 'should remove implants'. BBC News, January 6 2012

“Working eleven hours a day can lead to severe depression,” Metro has today reported. According to the newspaper, staff who put in 11 or more hours a day at the office are twice as likely to suffer a severe bout of depression than those working just eight.

This news is based on a study that examined the working habits of over 2,000 UK civil servants and how their working related to major depressive symptoms in the six years that followed. After accounting for other factors linked to depression, the researchers found that working 11 or more hours a week was associated with a 2.5 times increase the odds of experiencing a major depressive episode compared with their colleagues working the Civil Service’s standard seven to eight hours a day.

This research has found a link between working overtime and the risk of subsequent major depressive episodes. However, the relationship is complicated and this research cannot concretely tell whether or not overtime actually causes depression. Verifying this potential link would probably require controlled studies looking at whether or not cutting back work hours proves effective at reducing people’s risk of depression.

Also, this study found strong links between financial status, seniority and a reduced risk of major depression, making the influence of working hours harder to judge. Overall, it is likely that several factors work together to cause depression and the role working hours play in this is unclear.

Where did the story come from?

The study was carried out by researchers from Queen Mary’s of the University of London, University College of London, the University of Bristol, McGill University in Canada, and the Finnish Institute of Occupational Health. The research was funded by the Medical Research Council, the British Heart Foundation, the Stroke Association and the US National Institutes of Health.

The study was published in the peer-reviewed scientific journal PLoS ONE.

The study was covered appropriately in the media, although headlines that suggested working overtime definitely causes depression are not supported by the research. The Daily Mail, The Daily Telegraph and The Independent all reported, in both their headlines and main story, that the research found an association or link between overtime and the risk of depression.

What kind of research was this?

This was a prospective cohort study that examined the association between people’s number of hours worked a day and their risk of going on to experience a major depressive episode (MDE).

This research analysed data from a large well-known cohort study, called the Whitehall II study, which examined how work related to health in over 10,000 London based civil servants. This particular analysis on depression included full-time workers who were free from any psychiatric disorders and still employed at the time of the study’s follow-up period.

Prospective cohort studies have the advantage of ensuring that the exposure of interest (in this case, working hours) precedes the outcome of interest (experiencing MDE). This is one of several criteria needed to show causality. It is not, however, sufficient on its own to prove that the number of hours worked leads to or causes depression.

What did the research involve?

At the start of the study (known as the baseline) participants completed a survey that included questions on:

• job characteristics: including hours worked, degree of work stress, strain and social support
• socio-demographic factors: including sex, age, marital states and socio-economic status
• health-related behaviours: including alcohol consumption and smoking status
• physical health: including the presence of a longstanding illness or coronary heart disease

Participants were divided into four groups based on their working hours:

• those who worked seven to eight hours a day (the standard civil service day)
• those who worked nine hours a day (classed as one hour of overtime a day)
• those who worked 10 hours a day (classed as two hours of overtime a day)
• those who worked 11 to 12 hours a day (classed as three to four hours of overtime a day)

Approximately six years later they completed another interview that included a clinical health examination. At this interview, researchers determined whether or not participants had experienced a MDE during the previous year.

Researchers then analysed the data to assess how the odds of experiencing MDE in the two groups working the fewest and most hours. This analysis adjusted for possible confounding factors, including the baseline job characteristics, socio-demographic, health-related and physical health factors outlined above, in several separate analyses.

What were the basic results?

In all, 2,123 participants were included in the study. Those included in this study tended to be younger than those participating in the general Whitehall II cohort, and more likely to be male, married and from higher occupational grades. Participants were also more likely to experience low work strain than the Whitehall II cohort, and less likely to have a chronic disease or be a smoker.

Of the included participants:

• 52% worked a standard seven to eight-hour day
• 21% worked a nine-hour day
• 16% worked a 10-hour day
• 11% worked an 11- to 12-hour day

Employees with the longest working days were more likely to be male, married, from higher occupational grades, have more active jobs and high social support at work compared to those who worked the standard seven to eight-hour day. In addition, they tended to drink more alcohol than the recommended daily limits and to be ex-smokers.

Of the 2,123 participants, 66 experienced a major depressive episode; this is equivalent to a 3.1% rate of depression. When assessing MDE risk, and adjusting for multiple potential confounding variables, the researchers found that employees who worked 11 to 12 hours a day had 2.52 time the odds of experiencing MDE compared to those who worked the standard seven to eight hours a day (Odds ratio [OR] 2.5, 95% confidence interval [CI] 1.12 to 5.65).

Other factors that were associated with increased odds of MDE were:

• sex: females were just over twice as likely to experience MDE compared to males (OR 2.08, 95% CI 1.25 to 3.46)
• presence of a chronic physical disease (OR 2.30, 95% CI 1.41 to 3.78)
• moderate alcohol consumption, compared to teetotallers (OR 2.68, 95% CI 1.05 to 6.82)
• lower occupational grades (grades 4-5), compared to the highest grade, which is grade 1 (grade 5: OR 4.53, 95% CI 1.47 to 13.90; grade 4: OR 3.19, 95% CI 1.02 to 9.99)

Factors that were not associated with increased odds of MDE included:

• marital status
• smoking status
• high alcohol use
• job strain
• social support at work

How did the researchers interpret the results?

The researchers conclude that, ‘working overtime predicted the onset of a major depressive episode in a middle-aged cohort of British civil servants’. They add that this association held after adjusting for ‘a range of socio-demographic, lifestyle and work-related factors at baseline.’

Conclusion

This was a large cohort study that examined the association between the number of hours worked a day and the risk of subsequent major depressive disorder. It found that, after an adjusted analysis, those who worked three to four hours of overtime a day at the start of the study had a 2.5 fold increase in the chance they would go on to experience MDE.

The size and prospective nature of this cohort study mean that we can be quite confident in the results. There are, however, several limitations to the study that should be considered before insisting that our work hours are cut back. These include:

• The participants in this study were a specific subgroup of an already specific cohort group. Generalising these results to non-urban, non-civil service workers may not be appropriate. The researchers call for further research to determine whether this association can be found in non-civil service contexts.
• This study only included workers with no history of psychological disorders. It is unclear how work hours influence mental health in people with a history of psychological disorders.
• Working hours were assessed only at the start of the study. It is possible that these conditions changed in the six years between the first and second interviews. This could have distorted the results.
• There were a limited number of MDE cases in the cohort. This makes it impossible to determine the role specific factors play in this association.
• Despite news reports to the contrary, the researchers say that this study cannot offer plausible explanations of why long working hours are associated with the development of depression. The say that ‘intervention studies are needed to examine whether interventions designed to reduce working hours would alter depression risk in working populations’.
• The rate of depression found in this study being 3.1%. While those with longer workdays were found to have 2.5 times greater odds of MDE, this is still a low rate overall. Additionally, this rate is lower than the general population rate of depression, which the authors estimate to be approximately 5%.
• This study confirmed a strong link between occupational grade and depression, with higher socioeconomic status associated with a reduced risk of major depression. This had to be carefully adjusted for in the analysis.
• Major depressive episodes involve a specific range of depressive symptoms, but people can also experience milder forms of depression that will not meet the criteria for this diagnosis.

Overall, this research indicates that a very specific subset of civil servants were at increased risk of experiencing a major depressive episode. It is likely that several factors work together as ‘causes’ of depression and so the researchers were correct to avoid saying that they had found a cause.

Links To The Headlines

Working 11 hours a day can lead to severe depression, says study. Metro, January 26 2012

Three hours' extra work a day doubles risk of depression. The Independent, January 26 2012

People who work 11 hours are twice as likely to suffer depression. The Daily Telegraph, January 26 2012

Long work day a shortcut to depression as those spending over 11 hours in the office 'face higher risk'. Daily Mail, January 26 2012

Links To Science

Virtanen M, Stansfeld SA, Fuhrer R, Ferrie JE, Kivima M. Overtime Work as a Predictor of Major Depressive Episode: A 5-Year Follow-Up of the Whitehall II Study. PLoS One 2012; 7(1):e30719.