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(2) SURVIVAL
AFTER MELANOMA NOT AFFECTED BY
SURGICAL BACKGROUND
(3) LOWER
RISK THRESHOLDS FOR HEART DISEASE
NEEDED
(4) CONCERNS
OVER PUBLIC REPORTING ON
QUALITY OF
CARE IN THE NHS
(1) POOR DIABETES
CONTROL LINKED TO
PREGNANCY COMPLICATIONS
(Association between outcome of pregnancy
and glycaemic
control in early pregnancy in type
1 diabetes: population based
study)
http://bmj.com/cgi/content/full/325/7375/1275
Women with poorly controlled diabetes during
early
pregnancy run an increased risk of their
baby being
malformed, finds a study in this week's
BMJ.
Researchers in Norwich identified 158 first
pregnancies in
women with type 1 diabetes. They defined
adverse pregnancy
outcome as spontaneous abortion, major
congenital
malformation (potentially life threatening
or associated with
serious long term disability), stillbirth,
or infant death.
The women were divided into two groups
according to their
level of blood glucose control - a group
with fair control and a
group with poor control.
Adverse outcome was over fourfold higher
in the poor control
group than the fair control group. Compared
with the fair
control group, the poor control group
had a fourfold increase
in spontaneous abortion, and a ninefold
increase in major
congenital malformation. Stillbirth or
infant death was also
higher in the poor control group, but
the difference was not
significant.
This study confirms earlier reports of
increased risk of
spontaneous abortion and malformation
with poor glycaemic
control in early pregnancy in women with
type 1 diabetes, say
the authors.
"Our findings suggest that good glycaemic
control around the
time of conception is necessary to optimise
outcome of
pregnancy in diabetic women. Diabetic
women and their
carers need to be advised of the risks
and encouraged to
optimise glycaemic control before and
during pregnancy," they
conclude.
Contact:
Rosemary Temple, Consultant Physician Elsie
Bertram
Diabetes Centre, Norfolk and Norwich University
Hospital
NHS Trust, Norwich, UK
Email: rosemary.temple@Norfolk-norwich.thenhs.com
(2) SURVIVAL AFTER
MELANOMA NOT AFFECTED BY
SURGICAL BACKGROUND
(Observational study of type of surgical
training and outcome
of definitive surgery for primary
malignant melanoma)
http://bmj.com/cgi/content/full/325/7375/1276
Survival of melanoma patients does not
depend on the surgical
background of the person removing the
primary tumour,
concludes a study in this week's BMJ.
Such a specialist treatment effect has
been observed for breast
cancers, with better outcomes for surgeons
who carry out
breast cancer surgery regularly.
Researchers at the University of Glasgow
identified 4,159
melanoma patients. All patients had had
their primary
melanoma removed between 1979 and 1998.
They divided
the surgeons performing the procedure
into dermatological,
plastic surgery, or general surgery training.
They also looked at the effect within the
three surgical groups
of treating up to six or more than six
primary melanomas
annually.
They found no evidence that any type of
surgeon performing
excisions of primary melanomas regularly
had a better
outcome than those who carried out fewer
excisions, possibly
because it is a relatively simple procedure.
The authors therefore recommend referral
of suspected
primary melanomas to the dermatological,
plastic surgery, or
general surgical service with the shortest
surgical waiting time.
Contact:
Rona MacKie, Leverhulme Professional Research
Fellow,
Department of Public Health, University
of Glasgow, UK
Email: R.M.Mackie@clinmed.gla.ac.uk
(3) LOWER RISK
THRESHOLDS FOR HEART DISEASE
NEEDED
(Application of Framingham risk estimates
to ethnic minorities
in United Kingdom and implications
for primary prevention of
heart disease in general practice:
cross sectional population
based study)
http://bmj.com/cgi/content/full/325/7375/1271
General practitioners should use lower
risk thresholds for
heart disease when they are treating high
blood pressure in
people from ethnic minorities, finds a
study in this week's
BMJ.
The current recommended threshold predicts
the risk of heart
disease with reasonable accuracy in white
people, but
underestimates the risk in people of south
Asian and African
origin.
Researchers identified 1,069 men and women
from nine
general practices in south London. All
participants were aged
40-59 years, 404 were white, 342 were
south Asian, and 323
were of African origin.
They used a standard risk threshold of
15% to compare the
ten year risk of coronary heart disease
(CHD), stroke, and
combined cardiovascular disease (CVD).
This threshold
identifies 91% of white people, but only
81% of south Asians
and people of African origin for blood
pressure treatment.
After adjusting for age and sex, the estimated
10 year risk of
CHD varied significantly by ethnic group.
South Asians had
the greatest risk of CHD and combined
CVD, whereas
people of African origin had the lowest.
However, people of
African origin had the highest risk of
stroke.
These results imply that we should be using
lower thresholds
of CHD risk when treating raised blood
pressure in people of
African or south Asian origin, say the
authors. Using
thresholds of 12% in south Asians and
10% in people of
African origin would increase the probability
of identifying
those at risk to 100% and 97% respectively.
Risk of CVD
would be an even better measurement, they
conclude.
Contact:
Francesco Cappuccio, Professor of Primary
Care Research
and Development, Department of General
Practice and
Primary Care, St George's Hospital Medical
School, London,
UK
Email: f.cappuccio@sghms.ac.uk
(4) CONCERNS OVER
PUBLIC REPORTING ON
QUALITY OF CARE IN THE NHS
(Attitudes to the public release
of comparative information on
the quality of general practice
care: qualitative study)
http://bmj.com/cgi/content/full/325/7375/1278
The public disclosure of information about
quality of care is a
central component of UK government plans
for the reform of
the NHS.
A study in this week's BMJ finds that the
public and health
professionals support the principle of
publishing information
about general practice performance, but
are concerned about
the practical implications.
Researchers conducted 12 focus groups with
35 patients, 24
general practitioners, and 18 quality
improvement clinical
managers in an urban area in north west
England and a
semirural area in the south of England.
Patients regarded public disclosure as
a political initiative and
were uneasy about practices being encouraged
to compete
against each other. They were also more
inclined to trust their
own experience or that of friends and
family than to trust
comparative data. One person said: "If
I saw my own doctor
being slagged off in the Good Doc Guide,
I'd still go to him
because personally he suits me and I've
got faith in him."
General practitioners focused on the unfairness
of drawing
comparisons from current data and the
risks of "gaming" the
results, while managers were concerned
that public release of
the information would encourage a "name
and shame" culture
in general practice, damaging their developmental
approach to
improving quality. One commented: "We'll
get cover-ups, we'll
get further entrenched in our blame culture."
These findings should not derail an initiative
that has the
potential to improve accountability and
stimulate
improvements in quality. However, the
technical barriers, the
antipathy of the general public, the impact
on professional
morale, and the opportunity costs of focusing
on public
reporting at the expense of other health
service reforms,
should not be discounted, say the authors.
A greater understanding of the practical
implications of public
reporting is required before the potential
benefits can be
realised, they conclude.
Contact:
Martin Marshall, Professor of General Practice,
National
Primary Care Research and Development
Centre, University
of Manchester, Manchester, UK
Email: martin.marshall@man.ac.uk
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