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(2) RADICAL
SOLUTIONS FOUND TO MEET
LIMITS ON JUNIOR
DOCTORS' HOURS
(3) WHY
DO PATIENTS CHOOSE NOT TO DONATE
TISSUE?
(4) EXPERT REVIEWS CANNOT BE TRUSTED
(1) BANNING SMOKING
AT HOME PROTECTS
INFANTS
(Effect of strategies to reduce exposure
of infants to
environmental tobacco smoke in the
home: cross
sectional survey)
http://bmj.com/cgi/content/full/327/7409/257
Banning smoking in the home leads to a
small but
meaningful fall in infant exposure to
environmental
tobacco smoke, whereas less strict measures
have no
effect, finds a study in this week's BMJ.
Parents from 314 households with young
infants took
part in the study. Parents were interviewed
at home
about their knowledge and use of harm
reduction
strategies, tobacco consumption, and details
of the home
environment. A sample of the infant's
urine was taken to
measure levels of cotinine (a by-product
of nicotine) and
creatinine.
Over 80% of parents believed that environmental
tobacco smoke is harmful and 90% believed
that infants
can be protected from it in the home.
Only one in 10
parents was unaware of any measures to
reduce
exposure. More than half the parents reported
using
more than one measure. Just under a fifth
reported
banning smoking in the home.
Banning smoking in the home was associated
with a
small but significant reduction in cotinine
levels, whereas
less strict or no measures had no effect
on exposure of
infants.
Despite some limitations, these results
suggest that
banning smoking at home significantly
reduces infant
exposure to environmental tobacco smoke,
say the
authors. Less strict measures, such as
opening windows
when smoking and using fans, are likely
to have little
effect on the exposure of infants, but
this requires
verification.
Contacts:
Nick Spencer, Professor of Child Health
or Alan Dolan,
Lecturer, School of Health and Social
Studies,
University of Warwick, UK
Email: n.j.spencer@warwick.ac.uk;
a.dolan@warwick.ac.uk
(2) RADICAL SOLUTIONS
FOUND TO MEET
LIMITS ON JUNIOR DOCTORS' HOURS
(Improving compliance with requirements
on junior
doctors' hours)
http://bmj.com/cgi/content/full/327/7409/270
This Friday (1 August 2003) UK regulations
on junior
doctors' working hours become a contractual
right, but
meeting these regulations will need radical
solutions,
argue researchers in this week's BMJ.
The team, based at Great Ormond Street
Hospital for
Children, set out to redesign the night
rota to improve
compliance with regulations on working
hours, without
compromising patient care, medical training,
or quality of
life of the junior doctors.
They created a new type of senior nurse
labelled 'clinical
site practitioners' (CSP) with a unique
role. Under the
new structure CSPs provide leadership,
expert clinical
advice and management support through
a rapid
response service to all areas of the hospital,
24 hours a
day, seven days a week. The CSP's found
that they
could manage 70% of calls that traditionally
would have
been answered by a doctor.
Before the study, night cover was provided
through
partial shift rotas involving 11 doctors
and one senior
nurse. Instead, they introduced a full
night shift team
comprising three middle grade doctors,
two senior
nurses (CSPs), and a fourth sleeping doctor
as back-up
for emergencies.
The new rota increased compliance with
regulations on
working hours from 33% to 77%. Workload
changed
little and was well within the capacity
of the new night
team. Most staff were happy with the new
rota and the
safety of patients was not compromised.
Meeting requirements on junior doctors'
hours cannot be
achieved by manipulating rotas that maintain
existing tiers
of cover and work practices, say the authors.
They
require changes to roles, processes, work
practices and
attitudes throughout the organisation.
Whilst the authors are committed to achieving
safe hours
for junior doctors, they also warn that
the current
inflexible systems for monitoring compliance
with targets
are putting professionalism at risk.
Contact:
Hilary Cass, Director of Postgraduate Medical
Education, Great Ormond Street Hospital
for Children
NHS Trust, London, UK
Email: cassh@gosh.nhs.uk
(3) WHY DO PATIENTS
CHOOSE NOT TO DONATE
TISSUE?
(Why surgical patients do not donate
tissue for
commercial research: review of records)
http://bmj.com/cgi/content/full/327/7409/262
When patients have adequate information,
donating
surgically removed human tissue to commercial
research
is not a contentious issue, finds a study
in this week's
BMJ.
At Peterborough District Hospital, a trained
nurse
interviews patients before their operation
and, with
consent, surplus tissue is collected and
supplied for
commercial research.
Researchers reviewed 3,140 interviews and
recorded
reasons why patients refused to donate
tissue, and
whether involvement of commercial companies
was an
influencing factor.
Overall, 38 patients refused to allow their
tissue to be
used for commercial research. Only two
patients cited
commercial involvement as the main reason
for refusal.
Other reasons included incidents at Alder
Hey and
Bristol, extreme anxiety, and perceived
lack of time to
make a decision.
Patients awaiting surgery are often pleased
and even
grateful to have been given an opportunity
to play a part
in research, which could in the future
possibly benefit
other people including their family, say
the authors. A
minority of patients will always be hostile,
difficult to
communicate with, or apprehensive about
forthcoming
surgery and will choose not to donate
tissue.
Contact:
Ann McHugh, Communications Manager, Peterborough
Hospital NHS Trust, UK
Email: ann.mchugh@
pbh-tr.nhs.uk
(4) EXPERT REVIEWS CANNOT BE TRUSTED
(What happened to the valid POEMS?
A survey of
review articles on the treatment
of type 2 diabetes)
http://bmj.com/cgi/content/full/327/7409/266
The results of the most important research
in diabetes in
the past 25 years have not been conveyed
accurately to
doctors, claim researchers in this week's
BMJ.
These findings have far reaching implications
for how the
current medical information system transmits
new
research results from academia to practitioners.
Thirty five reviews on treatment of type
2 diabetes were
analysed to evaluate how experts represented
the results
of the United Kingdom prospective diabetes
study
(UKPDS).
Only six of the reviews included the finding
that tight
blood sugar control had no effect on overall
or
diabetes-related mortality. Just seven
mentioned that
giving the drug metformin was associated
with decreased
mortality.
Almost half (17) of the reviews did not
mention the need
for blood pressure control, while only
five pointed out
that diabetic patients with high blood
pressure benefit
more from blood pressure control than
blood sugar
control.
The current system of transmitting new
research to
clinicians by means of reviews is less
than optimal, at
least for new important research in type
2 diabetes, say
the authors. Clinicians relying on these
information
sources for accurate clinical information
may be misled,
they conclude.
The faults of expert reviews are already
well known,
argues David Fitzmaurice in an accompanying
commentary.
He agrees that review articles, particularly
those written
by specialists, tend to be of dubious
value, but say that
most UK primary care physicians are aware
of the key
messages in the UKPDS study. "We should
perhaps
question why these expert reviews continue
to be
published, given both their lack of rigour
and their
apparent lack of influence," he concludes.
Contacts:
Paper: Allen Shaughnessy, Director of Medical
Education, PinnacleHealth System, Professor
of Family
Medicine, Penn State University School
of Medicine,
Pennsylvania, USA
Email: ashaughnessy@PinnacleHealth.org
or
David Slawson, Professor of Family Medicine,
University of Virginia, Charlottesville,
Virginia, USA
Email: dslawson@virginia.edu
Commentary: David Fitzmaurice, Department
of Primary
Care and General Practice, Medical School,
University
of Birmingham, UK
Email: d.a.fitzmaurice@bham.ac.uk
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