Releases Saturday 16 December 2000
No 7275 Volume 321
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(1) WITNESSING TESTS FOR BRAIN STEM DEATH MAY
HELP RELATIVES COPE WITH THEIR LOSS
(2) EPIDURAL
OR SPINAL ANAESTHESIA REDUCES
MAJOR POSTOPERATIVE
COMPLICATIONS
(3) A
NEW APPROACH FOR DETECTING HIGH
CHOLESTEROL
IN FAMILIES
(4) EMERGENCY
DEPARTMENTS CAN HELP TACKLE
COMMUNITY VIOLENCE
(5) HIGH
RATES OF CAESAREAN SECTION IN CHILE DO
NOT REFLECT
PATIENT CHOICE
(6) SHOULD
DOCTORS BE ADVISING YOUNG PEOPLE
TO ABSTAIN
FROM SEX?
(1) WITNESSING
TESTS FOR BRAIN STEM DEATH MAY
HELP RELATIVES COPE WITH THEIR LOSS
(Presence of relatives during testing
for brain stem death:
questionnaire study)
http://bmj.com/cgi/content/full/321/7275/1505
The majority of health care professionals
involved in testing for
brain stem death believe that allowing
relatives to be present
during testing may help them to understand
that death has
occurred and may assist the grieving process,
finds a study in
this week's BMJ.
Bonner and colleagues surveyed 147 consultants
and 167
senior nurses in neurotrauma intensive
care units. Although
only 37 consultants and 54 senior nurses
had experience of
relatives being present during testing
for brain stem death, two
thirds (69%) felt that this was helpful
for relatives and 48%
thought that relatives may also gain comfort
from being
present. However, major potential problems
such as spinal
reflexes (85%) and dealing with relatives'
distress (70%) must
be anticipated. Forty-five per cent of
respondents said they
would be more willing to allow the presence
of relatives if
adequate support was available.
At present, a minority of doctors and nurses
invite relatives to
observe testing for brain stem death.
More may consider doing
so in the future. However, it remains
to be seen whether
allowing relatives to observe testing
is beneficial, and the
associated problems should not be underestimated,
conclude
the authors.
Contact:
Stephen Bonner, Consultant, Intensive Care
Unit, South
Cleveland Hospital, Middlesbrough, UK
Email: Steve.Bonner{at}btinternet.com
(2) EPIDURAL OR
SPINAL ANAESTHESIA REDUCES
MAJOR POSTOPERATIVE COMPLICATIONS
(Reduction in postoperative mortality
and morbidity with
epidural or spinal anaesthesia:
results from overview of
randomised trials)
http://bmj.com/cgi/content/full/321/7275/1493
Giving patients epidural or spinal anaesthesia
(known as
neuraxial blockade) during major surgery
reduces mortality by
about a third and also reduces the risk
of serious postoperative
complications in a wide range of patient
groups, finds a study in
this week's BMJ.
Rodgers and colleagues analysed 141 trials,
involving over
9,500 patients, to provide more reliable
estimates of the effects
of neuraxial blockade. In patients receiving
neuraxial blockade,
overall mortality was reduced by about
a third. Neuraxial
blockade also approximately reduced the
odds of deep vein
thrombosis by 44%, pulmonary embolism
by 55%, transfusion
requirements by 50%, pneumonia by 39%,
and respiratory
depression by 59%. There were also reductions
in heart attack
and kidney failure. Furthermore, the benefits
did not differ by
the type of surgical group, the type of
neuraxial blockade
(epidural or spinal), or in trials where
neuraxial blockade was
combined with general anaesthesia, add
the authors.
The size of some of these benefits remains
uncertain, and
further research is required to determine
whether these effects
are due solely to benefits of neuraxial
blockade or partly to
avoidance of general anaesthesia, say
the authors. However,
given that the risks of fatal or life
threatening events are
increased several fold after major surgery,
these findings
support more widespread use of neuraxial
blockade, they
conclude.
Contacts:
Anthony Rodgers, Clinical Trials Research
Unit, Division of
Medicine, The University of Auckland,
New Zealand
Email: a.rodgers{at}ctru.aukland.ac.nz
or
Stephen Schug, Division of Anaesthesiology
, The University
of Auckland, New Zealand
Email: s.schug{at}auckland.ac.nz
(3) A NEW APPROACH
FOR DETECTING HIGH
CHOLESTEROL IN FAMILIES
(Outcome of case finding among relatives
of patients with
known heterozygous familial hypercholesterolaemia)
http://bmj.com/cgi/content/full/321/7275/1497
(Editorial: Screening for familial
hypercholesterolaemia)
http://bmj.com/cgi/content/full/321/7275/1483
A nurse-led genetic register, linking lipid
clinics nationally, may
be a more effective way of detecting new
patients with a
family history of high cholesterol than
general population
screening, suggests a study in this week's
BMJ.
Two-hundred first degree relatives of known
patients with a
family history of high cholesterol were
given cholesterol tests
by nurses in two lipid clinics in Manchester.
The screening
yielded 121 newly detected patients with
a family history of
high cholesterol and most were diagnosed
before evidence of
coronary heart disease was apparent. Because
1 in 500 people
in Europe and North America are affected
by this condition, to
detect a similar number by population
screening over 60,000
tests would have been required. Furthermore,
general
screening would have failed to identify
most of these patients
because testing is restricted to those
with other risk factors for
coronary heart disease - such as high
blood pressure and
diabetes - which were uncommon in the
newly diagnosed
patients, explain the authors.
Given the high death rate associated with
a first heart attack
(around 30%) detecting new cases before
evidence of
coronary heart disease is apparent is
one important benefit of
this method, say the authors. Indeed,
there are many potential
advantages of detecting new patients with
a family history of
high cholesterol through established lipid
clinics using the
genetic register approach reported in
this study, they conclude.
Contact:
Professor Paul Durrington, University of
Manchester,
Department of Medicine, Manchester Royal
Infirmary, UK
Email: pdurrington{at}hq.cmht.nwest.nhs.uk
(4) EMERGENCY
DEPARTMENTS CAN HELP TACKLE
COMMUNITY VIOLENCE
(Using injury data for violence prevention)
http://bmj.com/cgi/content/full/321/7275/1481
Injury data derived from hospital emergency
departments will
be shared with the police as part of new
government proposals
to help tackle community violence. In
this week's BMJ
Jonathan Shepherd and colleagues look
at how a medical
perspective of violence, combined with
the traditional police
perspective, has already begun to reap
rich rewards.
In the UK only about 25% to 50% of offences
which lead to
treatment in emergency departments appear
in police records.
Yet recording injuries treated in emergency
departments has
the potential for largely complete coverage
of serious
community violence and provides local
information of
importance to the police that will help
them respond.
A recent pilot scheme in Cardiff, South
Wales - giving
emergency departments opportunities to
share non-confidential
data with the police and local authority
- has focused policing
on local violence hotspots, such as bars,
nightclubs and public
streets. As well as helping locally, this
approach has identified
and led to modifications of one of the
most commonly used
weapons in assaults in the UK - bar glasses.
Recent high profile cases of serious community
violence
emphasise that health care is often the
only public service
which knows about many violent offences,
say the authors. If
based on a sound ethical framework to
protect the interests of
patients, this approach should help to
reduce the burden on
emergency departments and is a rational
step towards safer
and more just communities, they conclude.
Contact:
Jonathan Shepherd, Professor of Oral and
Maxillofacial
Surgery, University of Wales College of
Medicine, Cardiff, UK
Email: shepherdjp{at}cardiff.ac.uk
(5) HIGH RATES
OF CAESAREAN SECTION IN CHILE DO
NOT REFLECT PATIENT CHOICE
(Relation between private health
insurance and high rates of
caesarean section in Chile: qualitative
and quantitative study)
http://bmj.com/cgi/content/full/321/7275/1501
In Chile, the rate of caesarean sections
in women with private
health insurance is double that of those
in the public sector, yet
this does not reflect patients' choice,
according to a study in
this week's BMJ.
Between 1995 and 1997, Susan Murray of
University College
London studied the day to day organisation,
norms and
relationships in private sector maternity
care in Santiago, Chile,
to examine the link between private health
insurance ? which
has been promoted in Chile since the 1980s
? and high rates of
caesarean section.
Women with private obstetricians showed
consistently higher
rates of caesarean section than those
cared for by midwives or
doctors on duty in public or university
hospitals. However, only
a minority of women receiving private
care reported that they
had wanted this method of delivery.
Private health insurers require an obstetrician,
rather than a
midwife, to be the primary care provider.
The need to provide
such a high level of personalised care
often conflicts with the
demanding work schedules of obstetricians
who take on
private work to increase their incomes.
As a result, the
"programming" (or scheduling) of births
by induction of labour
or elective caesarean is a common time
management strategy,
says the author. Indeed, the study found
that elective
caesarean section is more common in women
with private
obstetricians (30-68%) than women not
attended by a private
obstetrician (12-14%).
Policies on healthcare financing can influence
maternity care
management and outcomes in unforseen ways,
says the
author. The prevailing business ethos
in health care encourages
such pragmatism among those doctors who
do not have a
moral objection to non-medical caesarean
section.
Contact:
Susan Murray, Lecturer, Centre for International
Child Health,
Institute of Child Health, University
College London, UK
Email: s.murray{at}ich.ucl.ac.uk
(6) SHOULD DOCTORS
BE ADVISING YOUNG PEOPLE
TO ABSTAIN FROM SEX?
(For and against: Doctors should
advise adolescents to abstain
from sex)
http://bmj.com/cgi/content/full/321/7275/1520
Against a background of high rates of teenage
conceptions and
an increasing level of sexually transmitted
infections, a debate
in this week's BMJ considers whether advising
abstinence is
an effective response to declining teenage
sexual health.
Abstinence makes sense and is effective,
argues Trevor
Stammers, a tutor in general practice
and an author and
broadcaster on sexual health. Research
shows that early
intercourse carries greater risks and
often leads to subsequent
regret. Sexually active teenagers are
also more likely to be
emotionally hurt and have an increased
risk of depression and
suicide. Abstinence programmes from the
US also show "a
sharp reduction in the number of pregnancies."
Easier availability of contraception and
more explicit sex
education at an earlier age are tired
and inadequate responses
to declining teenage sexual health, says
the author. Doctors
should encourage adolescents to avoid
early sexual intercourse
so that they can enjoy better long term
sexual health, he
concludes.
Roger Ingham, a researcher on sexual conduct
and sex
education, believes that the answer lies
in promoting greater
openness about young people's sexuality.
A policy of advising
young people not to have sex will not
encourage them to deal
with issues such as peer group pressure.
It also runs the risk
that they will become even more alienated
from adults and that
they will be less likely to use the services
available, argues the
author. Indeed, countries such as Norway,
Sweden and the
Netherlands - where teenage conception
rates are
considerably lower than in the UK - have
an earlier and more
open approach to sexual issues in schools
and families.
Although poor sexual health among young
people is a complex
issue, many people in the UK are making
efforts to improve
the sexual health of young people by teaching
about
responsibility and good personal relationships,
he concludes.
Contacts:
Trevor Stammers, Church Lane Practice,
London, UK
Email: stammtg{at}globalnet.co.uk
Roger Ingham, Centre for Sexual Health
Research, University
of Southampton, UK
Email: ri{at}soton.ac.uk
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London WC1H 9JR
(contact: pressoffice{at}bma.org.uk)
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(http://www.eurekalert.org)
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