This week in the BMJ
Volume 324, Number 7332, Issue of 2 Feb 2002Excess mortality at Bristol is not explained by low volume of operations
Excess mortality at Bristol is not explained by low volume of operations
Mortality in paediatric cardiac surgery in English hospitals is
inversely related to the volume of surgery, but only a small part of
the excess mortality found by the Bristol Royal Infirmary Inquiry was
due to the centre's lower volume of cases. Using routine administrative data, Speigelhalter (p 261) showed that the mortality of
centres with a higher volume was approximately two thirds of that found
in smaller centres when data from Bristol were not included in the
analysis. He cautions that this finding does not necessarily mean that
concentrating resources in fewer centres would reduce
mortality.
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Developing rheumatoid arthritis is not due to genes
In a study of twins in Denmark concordance for rheumatoid arthritis was
no more common in monozygotic twins than in dizygotic twins, suggesting
that genes are not an important factor in the development of the
disease. In a population based nationwide twin study Svendsen and
colleagues (p 264) identified 13 monozygotic and
36 dizygotic pairs of twins in which at least one twin had rheumatoid
arthritis. No monozygotic pairs and two dizygotic pairs were concordant
for rheumatoid arthritis.
Ileoprost may alleviate cholesterol emboli syndrome
Patients with cholesterol emboli syndrome
a progressive
disease unresponsive to treatmentmay benefit from intravenous
ileoprost. In a research pointer on p 268, Elinav and colleagues report
on how four patients improved after treatment with ileoprost. Most cyanotic lesions disappeared, renal function improved, and pain was
dramatically reduced. The authors say that ileoprost should be started
early to stabilise and reverse the clinical syndrome.
Management of profound hypokalaemia should be revised
Current guidelines for potassium replacement may not deal
adequately with rare but life threatening profound hypokalaemia associated with metabolic acidosis. Welfare and colleagues (p 269)
identified 13 children admitted to a Kenyan hospital with potassium
concentrations <1.5mmol/l and found a significant correlation between
late phase change in potassium and the average rate of potassium
replacement over 24 hours. In developing countries, many children with
gastroenteritis receive intravenous fluids that have little or no
potassium, such as 0.9% saline, Ringer's lactate, or Hartmann's. The
authors say that this may worsen the situation, causing a further
lowering in serum potassium.
Concerns over direct consumer advertising are justified
Doctors often prescribe medicines requested by patients, despite
personal reservations, leading to an increase in sales at the expense
of the appropriateness of prescribing. In their study in California and
British Columbia, Mintzes and colleagues (p 278) found that patients
requested prescriptions in 12% of surveyed visits, 42% of which were
for products advertised to consumers. The prescribing rate was similar
for advertised and non-advertised drugs. The authors conclude that
concerns about direct consumer advertising are justified.
Booked inpatient admissions systems require reserve capacity
Considerable reserve capacity (20-40%) is required if the cancellation
rates for operations is to be kept below 5%. Gallivan and colleagues
(p 280) used a simple mathematical model to estimate the day to
day variations in intensive care beds required for a hypothetical
booked admissions system. The authors warn that as limited reserve
capacity and a high degree of variability are common in the NHS,
difficulties with operations schedules will continue.
Genetic abnormalities are responsible for childhood leukaemia
The common chromosome translocations in childhood leukaemia seem to
initiate disease and often arise prenatally, but one or more postnatal
genetic alterations are also needed for leukaemia to develop. In
childhood lymphoblastic leukaemia these may be caused by an abnormal
immune response to infection. Greaves (p 283) also writes that
different chromosomal and gene abnormalities define biological subsets of disease, which is
important for prognosis and proteins coded by fusion genes are
potential targets for new treatments as they block cell differentiation
in leukaemic cells.
Fear of partner is linked to domestic violence
General practitioners may be able to identify women who experience
domestic violence by asking them whether they are afraid of their
partner. Bradley and colleagues (p 271) found that nearly 40% of
women had experienced domestic violence, but only 5% recalled being
asked about it by their doctor. Most women said they would not mind
being asked about domestic violence by their general practitioner.
Should GPs screen for domestic violence?
The high prevalence of domestic violence and its underidentification
might support a case for screening all women in general practice, and
specifically in antenatal clinics. Richardson et al (p 274) found that
425 of 1035 women had ever experienced physical violence from a
partner, yet medical records recorded domestic violence for fewer than
one in five women who reported it in a survey. Women pregnant within
the previous 12 months were twice as likely to experience current
physical violence from a partner.
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