This week in the BMJ
Volume 324, Number 7349, Issue of 1 Jun 2002Cell salvage during surgery reduces need for blood
Cell salvage during surgery reduces need for blood
Intraoperative cell salvage reduces the number of patients
needing allogenic blood or blood products during coronary artery bypass
surgery. In McGill and colleagues' randomised controlled trial of 252 patients having elective coronary bypass surgery (p 1299), 31% of
patients in whom intraoperative cell salvage was used required a blood
transfusion, compared with 51% of patients in whom no form of
mechanical blood conservation was used. Reducing the amount of blood
transfused during surgery benefits patients by lowering their risk of
contracting bloodborne or other infections or having a perioperative
myocardial infarction.
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Nurses improve door to needle time
Thrombolysis started by nurses improves door to needle time and may be
a way in which the national service framework targets can be achieved.
Qasim and colleagues (p 1328) conducted an audit of a three phase study
of nurse involvement in thrombolysis of patients admitted with acute
myocardial infarction. In phase 1 patients were seen and treated by
doctors; in phase 2 they were assessed by nurses and treated by
doctors; and in phase 3 they were assessed and could be treated by a
coronary care thrombolysis nurse. In phase 3 patients had a median door
to needle time of 15 minutes, and 80% were treated within 30 minutes.
There were no cases in which a nurse initiated thrombolysis
inappropriately.
Rich and poor respond differently to chest pain
People living in a socioeconomically deprived area feel more
vulnerable to heart disease than people living in a more affluent area
but are no more likely to report chest pain symptoms to their doctor.
These findings are from a community based interview study of 30 people
from a deprived area of Glasgow and 30 people from an affluent area of
Glasgow conducted by Richards and colleagues (p 1308). Barriers to
presentation included normalisation of their chest pain, self blame,
and fear of chastisement. The authors conclude that these socioeconomic
variations in responses to chest pain may contribute to the
inequalities in uptake of cardiology services.
Prescribing in children must improve
Three papers in this issue highlight the problem of unlicensed and off-label prescribing in children. Bücheler and colleagues (p 1311) found that 13.2% of prescriptions for a representative group of children in primary care in Germany were off label. Schirm and colleagues (p 1312) found that labelling of drugs prescribed for children was poor: in 21.3% the use in children was not mentioned in the summary, and 19.7% mentioned use in children but without any indication of age. The authors of both papers argue that efforts to improve the quality of pharmacotherapy in children should not exclude widely marketed and firmly established drugs. Although unlicensed and off-label prescribed drugs do not necessarily carry an actual threat to the health of a child, the risk of adverse drug reactions is high as adequate dosing schemes have often not been assessed, report Jong and colleagues (p 1313). This situation is highly unsatisfactory, and efforts should be made to improve it.
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| (Credit: AARON HAUPT/SPL) |
Europe is complacent over HIV
Trend data by Nicoll and Hamers (p 1324) show that new diagnoses of
sexually acquired HIV infections increased by 20% in western Europe
between 1995 and 2000, principally among heterosexuals. Outbreaks of
syphilis have recently been reported in several countries and reports
of gonorrhoea have increased in France, the Netherlands, Sweden,
Switzerland, and the United Kingdom. These preliminary data, the
authors say, imply that people may increasingly take sexual risks and
that complacency over HIV transmission may have set in among
individuals, populations, and some governments in western Europe.
Efforts to prevent the transmission of HIV need to be strengthened, and
consistent surveillance needs to be established at a European level.
The future is vaccinology
In the next five to 15 years new vaccines and new technology for
delivering them will fundamentally change how clinicians prevent and
treat disease, with substantial impact on public health. Poland and
colleagues (p 1315) describe how advances in current vaccines, such as
conjugated pneumococcal and nasal spray vaccines, will provide an
efficient way to produce longlasting protective immunity. The future
holds the development of new vaccines against non-infectious diseases
such as cancer, diabetes, and even nicotine dependence. However,
concerns about vaccine safety and a rise in anti-vaccine sentiment are
currently adversely affecting the use and development of new vaccines.
Who to screen for hypercholesterolaemia
A modelling analysis by Marks and colleagues (p 1303) found that screening relatives of people with familial hypercholesterolaemia is a cost effective way of detecting cases, whereas blanket population screening is not. Hypercholesterolaemia is currently not diagnosed in 75% of people with the condition, and in many it is discovered only after the first coronary event. The estimated cost of family tracing was £3097 per life year gained (or £4914 with genetic confirmation). This represents good value for money compared with common medical interventions, and the authors say that pilot evaluation programmes should be conducted.
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| (Credit: BSIP VEM/SPL) |
Kaiser versus the NHS
The BMJ received 75 letters in response to a paper we
published comparing the NHS with California's Kaiser Permanente, a not for profit health maintenance organisation. The paper concluded that
Kaiser delivered substantially better care to its patients while
spending no more per head than the NHS. In the letters section (p 1332)
we print seven of these letters and a summary of the rest. Forty six
letters comprehensively dismantled the authors' analysis; the message
implicit in many of these letters is that the authors and commentators
had let their ideology cloud their judgment. Twenty seven supported the
paper, offering the explanation that Kaiser's superiority was due to
having more of everything: more beds, more doctors, more nurses, and
better information technology.
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