No 7148 Volume 316

Press Releases Saturday 20 June 1998

(1) CONCERN ABOUT THE CARE OF PATIENTS BEFORE THEY ARE  ADMITTED
      TO INTENSIVE CARE

(2) HRT AND ITS ROLE IN PREVENTING HIP FRACTURES

(3) DOCTORS NAGGING PATIENTS TO GIVE UP SMOKING IS NOT EFFECTIVE


 

(1) CONCERN ABOUT THE CARE OF PATIENTS BEFORE THEY ARE
      ADMITTED TO INTENSIVE CARE

(Confidential inquiry into quality of care before admission to intensive
care)
http://www.bmj.com/cgi/content/full/316/7148/1853

Emergency admissions have risen by 50 per cent since 1984, but this
increase in quantity should  not be at the expense of quality, say Dr Peter
McQuillan et al from intensive care units in the UK in this week's BMJ.
They present the results of their confidential inquiry into the quality of
care received by 100 patients admitted to intensive care.  They found that
54 of the 100 patients received suboptimal care and nearly half of these
(48 per cent) patients died (almost twice the rate of those whose care was
managed well).  In addition, two thirds of the 54 patients who were not
treated adequately were admitted late into intensive care.

The authors discovered that the problems lay in suboptimal management of
oxygen therapy, airway, breathing, circulation and monitoring before
admission to intensive care which led to increased morbidity, mortality and
avoidable admissions.  They believe that these problems were caused by poor
organisation, lack of knowledge, failure to appreciate clinical urgency,
lack of  supervision and failure to seek advice.

McQuillan et al conclude that the structure and process of acute care and
their importance require major re-evaluation and debate and suggest that
one solution may be to create medical emergency teams who respond
pre-emptively to airway, breathing or circulation problems.

Contact:
Dr Peter McQuillan, Consultant in Intensive Care and Anaesthesia,
Department of Intensive Care Medicine, Queen Alexandra Hospital, Cosham,
Portsmouth
 

(Suboptimal care of patients before admission to intensive care)
http://www.bmj.com/cgi/content/full/316/7148/1841

In an accompanying editorial, Christopher Garrard and Duncan Young from the
Intensive Care Unit at the John Radcliffe Hospital in Oxford, note that
little will be gained from apportioning blame or resorting to
recrimination for the failings that McQuillan et al have identified.  They
say that the findings need to be investigated on a national scale to
ascertain the full extent of the problem, and advocate a national
confidential inquiry.

They suggest that one way of dealing with the problem may be to increase
the seniority of the doctors assessing and treating this type of patient.
(For example in Oxford, the trauma surgeons now have 24 hour, resident
consultant cover, which ensures that all victims of major trauma are
assessed and have their treatment planned by a consultant.)  Alternatively,
they suggest that medical emergency teams should be formed and that their
role should be educational as well as troubleshooting.

Contact:
Christopher Garrard, Consultant Physician or Duncan Young, Consultant
Anaesthetist, Intensive Care Unit, John Radcliffe Hospital, Oxford.
 

(2) HRT AND ITS ROLE IN PREVENTING HIP FRACTURES

(Hormone replacement therapy and risk of hip facture:  population based
case-control study)
http://www.bmj.com/cgi/content/full/316/7148/1858

Menopause is accompanied by accelerated bone loss and by an increase in
fractures, such as those of the hip.  In the past many studies have shown
that hormone replacement therapy (HRT) can reduce bone loss and diminish
the risk of hip fracture.  However, questions surrounding the dose and
duration of the therapy have, until now, remained unanswered.

In this week's BMJ Dr Karl Michaelsson et al from Sweden present their
findings.  They suggest that substantial hip fracture protection only
exists if women are taking HRT or have done so recently (within five
years), and that the greatest gain is found in those women who have been
taking it for a long period of time.  They found that even those women who
had started taking HRT several years after their menopause had reaped the
benefit.

Michaelsson et al also found that lower doses of oestrogen were permitted
by the inclusion of progestins within the treatment and that the
protectiveness of HRT was unrelated to how it was taken (through skin
patches or orally).

Contact:
Dr Karl Michaelsson, Senior Registrar, Department of Orthopaedics,
University Hospital,
S-751 85 Uppsala, Sweden
email: Karl.Michaelsson{at}ortopedi.uu.se
 

(Hormone replacement therapy again)
http://www.bmj.com/cgi/content/full/316/7148/1842

In a linked editorial in this week's BMJ, Professor Kay-Tee Khaw from the
Gerontology Unit at the University of Cambridge notes that HRT is
increasingly advocated not just for short term treatment of menopausal
symptoms but as long term prophylactic therapy against heart disease,
osteoporosis and even Alzheimer's Disease.

She tentatively warns that clinicians need to consider the long-term risk
versus benefit balance for each individual patient, as she believes that
the benefits of HRT may vary in different cases.  Khaw concludes that
clinicians and patients should instead concentrate on more major
determinants of women's health, such as diet, exercise and lifestyle.

Contact:
Professor Kay-Tee Khaw, Professor of Clinical Gerontology, Clinical
Gerontology Unit, University of Cambridge, Addenbrookes Hospital, Cambridge
email: kk101{at}medschl.cam.ac.uk
 

(3) DOCTORS NAGGING PATIENTS TO GIVE UP SMOKING
      IS NOT EFFECTIVE

(Qualitative study of patients' perceptions of doctors' advice to quite
smoking: implications for opportunistic health promotion)
http://www.bmj.com/cgi/content/full/316/7148/1878

Everyone knows the dangers of smoking now.  It's not like it's a top
secret...  If that smoker doesn't want to stop smoking, the doctor could be
there three hours talking to him and he'll walk out of the surgery... have
a fag and think thank God for that.   This was said by a 40 year old man
who participated in a study in this week's BMJ, conducted by Dr Christopher
Butler et al from the University of Wales, on how doctors can persuade
their patients to stop smoking.

The authors found that most people are already aware of the negative
effects of smoking and that they believe that it should be up to them
whether they give up or not.  In fact they discovered that the
doctor-patient relationship can be damaged if doctors routinely advise all
smokers to quit every time they visit the surgery.

Butler et al suggest that a better approach is for doctors to be
sympathetic and tailor their approach to the individual type of patient
rather than preaching messages of doom.

Contact:
Dr Christopher Butler, Lecturer, Department of General Practice, University
of Wales College of Medicine, Cardiff
email: butlercc{at}cf.ac.uk
 

(1998 European guidelines on resuscitation)
http://www.bmj.com/cgi/content/full/316/7148/1844

(The 1998 European Resuscitation Council guidelines for adult single
rescuer basic life supprt)
http://www.bmj.com/cgi/content/full/316/7148/1870

(The 1998 European Resuscitation Council guidelines for adult advanced life
support)
http://www.bmj.com/cgi/content/full/316/7148/1863

The new basic life support guidelines on resuscitation published in this
week's BMJ emphasise the importance of immediately alerting the emergency
medical services when you realise that the victim is  not breathing (phone
first), as the chances of successful defibrillation decline substantially
with each minute's delay.

Jerry Nolan from the Royal United Hospital in Bath summarises the revisions
which have been made to the guidelines on resuscitation by the European
Resuscitation Council and notes that they contain changes in response to
education needs and evolving technology of resuscitation, rather than any
important changes in the science.

Included in this issue of the BMJ are the new comprehensive guidelines on
basic life support for a single adult rescuer and also for adult advanced
life support.

Contact:
Dr Jerry Nolan, Consultant in Anaesthesia and Intensive Care Medicine,
Royal United Hospital Bath
email: jerrynolan{at}compuserve.com

Dr Colin Robertson, Consultant in Accident and Emergency, Edinburgh Royal
Infirmary and European Resuscitation Council (advanced life support
guidelines)
or
Dr Anthony Handley, Consultant Cardiologist, Colchester General Hospital
and Chairman of the Resuscitation Council (UK) (basic life support
guidelines)
 
 

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