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Press releases Saturday 25 June 2005
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(1) EVACUATION NOT AUTOMATICALLY BEST FOR HEALTH DURING CHEMICAL INCIDENTS
(2) MORE TRAINING
AND SUPERVISION NEEDED TO CUT MENINGITIS DEATHS
(3) UNEASE OVER GUIDELINES THAT LABEL 9
OUT OF 10 PEOPLE AS SICK
(4) DO SINGLEHANDED
GENERAL PRACTICES HAVE A FUTURE?
(1) EVACUATION NOT AUTOMATICALLY BEST FOR HEALTH DURING CHEMICAL INCIDENTS
(Evacuation decisions in a
chemical air pollution incident: cross sectional survey)
http://bmj.com/cgi/content/full/330/7506/1471
(Commentary: Evacuation decisions
in chemical incidents benefit from expert health advice)
http://bmj.com/cgi/content/full/330/7506/1474
Sheltering at home may be more appropriate than evacuation for protecting the health of local residents close to chemical air pollution incidents, says a paper in this week's BMJ.
In the first study of its kind, researchers compared the effects of both sheltering and evacuation on the local population during a fire at a Devon plastics factory which resulted in hazardous chemicals released into the surrounding environment.
During the first six hours, many of the local residents were evacuated. But it was then decided that remaining residents should stay in their homes. Researchers looked at the number of 'cases' in both groups - i.e. those experiencing symptoms related to the incident.
They found that soon after the fire, the evacuated group had almost twice as many cases as compared with those in the sheltered group (19.7% compared to 9.5%), though the difference did not seem to persist after two weeks (3.3% compared to 1.9%).
The study was based on a health survey involving 1096 residents in the town, 797 of whom were sheltered and 299 evacuated. Both evacuated and sheltered sets of residents lived similar average distances from the factory (565m and 572m respectively).
The effects of severe chemical air pollution are similar to those of respiratory illness, say the authors - cough, for instance, or runny eyes. To distinguish cases - those whose symptoms were incident-related - they compared how many of these symptoms were typically suffered by a neighbouring community unaffected by the fire, with those in the affected town. With an average of 0.48 symptoms per person in the nearby town, the researchers defined a case in the affected town as someone with at least 4 symptoms.
The authors stress that there were several limitations with this study, including a lack of data on whether the level and nature of the smoke exposure could have been different between the groups.
Sheltering may have been a better protective action than evacuation in this chemical incident, they conclude, which confirms existing expert advice recommending sheltering in serious chemical air pollution incidents.
An accompanying commentary agrees that existing emergency planning advice also advocates sheltering during chemical air pollution incidents for those living nearby hazardous sites, at least for the time of peak exposure to dangerous chemicals.
But the stay indoors strategy may not always be appropriate. Other factors – such as weather conditions, how the fire is being managed by emergency services, or the type of fire itself – may make evacuation more appropriate.
Contacts:
Paper: Dr Sanjay Kinra, Lecturer
in Epidemiology and Public Health Medicine, University of Bristol, Bristol,
UK
Email: sanjay.kinra@bristol.ac.uk
or through the Press Office - Renny Jones
Commentary: Peter Baxter, Consultant
Occupational Physician, Department of Public Health and Primary Care, University
of Cambridge, Cambridge, UK
Email: pjb21@medschl.cam.ac.uk
(2) MORE TRAINING AND SUPERVISION NEEDED TO CUT MENINGITIS
DEATHS
(The role of healthcare delivery
in the outcome of meningococcal disease in children: case-control study of
fatal and non-fatal cases)
http://bmj.com/cgi/content/full/330/7506/1475
Improved training and supervision of emergency medical staff is needed to reduce the number of child deaths from meningococcal disease, finds a study in this week's BMJ.
Meningococcal disease remains the most common infectious cause of death in children in many developed countries. Most patients present to their nearest emergency department but, because the disease can progress very rapidly, many die before they can be transferred to specialist units.
Researchers identified all deaths from meningococcal disease in UK children aged 0-16 years between December 1997 and February 1999. For each death (case) they identified three survivors (controls) matched by age from the same region of the country.
A panel of paediatricians reviewed each case to assess the promptness and quality of emergency medical care provided in the first 24 hours after admission, according to published protocols.
A total of 143 cases and 355 controls were included in the study. Failures in management were significantly more common in children who died than in survivors.
Independent risk factors for death included failure to be looked after by a paediatrician, insufficient supervision of junior staff, and failure to administer adequate drugs to treat shock and organ damage. Failure to recognise complications of meningococcal disease was also a risk factor, although this was linked with absence of paediatric care.
Suboptimal healthcare delivery significantly reduces the likelihood of survival in children with meningococcal disease, say the authors.
Improved training of medical and nursing staff, adherence to published protocols, and increased supervision by consultants may improve the outcome for these children and also those with other life threatening illnesses, they conclude.
Contact:
Julia Warren, Meningitis Research
Foundation, Bristol, UK
Email: ninisn@gosh.nhs.uk
(3) UNEASE OVER GUIDELINES THAT LABEL 9 OUT OF 10 PEOPLE
AS SICK
(Editorial: Thresholds for
normal blood pressure and serum cholesterol)
http://bmj.com/cgi/content/full/330/7506/1461
Guidelines that set ever lower thresholds for “normal” blood pressure and cholesterol mean that 90% of people over 50 could be labelled as sick, warn doctors in this week’s BMJ.
The latest European guidelines on prevention of cardiovascular disease suggest blood pressure above 140/90 mm Hg, with no age correction, and serum cholesterol of 5 mmol/l as the appropriate thresholds for being labelled at risk.
Although the guidelines recommend a range of lifestyle changes alongside drug treatment, the bottom line is that a disease label is to be attached to the patient, write Drs Steinar Westin and Iona Heath.
When researchers applied these guidelines to adults in Norway, they found that half the population would be considered at risk by the early age of 24 years, rising to 90% by the age of 49. As much as 76% of the total adult population would be considered at “increased risk.”
These proportions are disturbingly high, and are likely to be even higher in other populations, such as the United Kingdom, say the authors.
They suggest that several issues need to be considered if such a large part of the population is to become a target for individual and lifelong risk interventions. For instance, the potential benefits for treated patients become less at lower risk levels, whereas the rates of side effects remain similar. Evidence for the long term effectiveness of treatment is also lacking.
Finally, the huge cost of drug treatment for an ever greater proportion of the population has the potential to destabilise publicly funded healthcare systems in even the richest nations, they warn.
“Such considerations are urgent as the guidelines from the European Society of Cardiology are in the process of being implemented and the quality and outcomes framework of the new general practitioner contract in the UK can be seen as part of this implementation,” they conclude.
Contact:
Iona Heath, General Practitioner,
Caversham Group Practice, London, UK
Email: iona.heath@dsl.pipex.com
(4) DO SINGLEHANDED GENERAL PRACTICES HAVE A FUTURE?
(Editorial: The future of
singlehanded general practices)
http://bmj.com/cgi/content/full/330/7506/1460
Do singlehanded general practices have a future in the United Kingdom’s NHS, asks a senior doctor in this week’s BMJ?
Between 1994 and 2004, the number of singlehanded general practitioners in England fell from 2,959 to 1,918 (from 11% to 6% of all general practitioners). This contrasts sharply with the United States, where 46% of family practitioners and 34% of general internists were practising alone in 1998.
Ever since the foundation of the NHS, singlehanded general practitioners have made an important contribution in the UK, particularly in inner city and rural areas. Why then is the future of singlehanded general practitioners now in doubt?
Some of the decline represents a desire for doctors to work in larger practices because they reduce the likelihood of clinical isolation, allow scope for specialisation, and offer a wider range of services than small practices, writes the author.
However, a more important reason could be that small practices do not feature in the UK government’s long term vision for primary care. Small practices are seen as less efficient and more difficult to manage by many policy makers and managers. The case of serial killer Harold Shipman, who was a singlehanded general practitioner, may also have contributed to this desire to reshape general practice.
But will the government’s new vision of large group practices and walk-in centres lead to a more efficient and higher quality service? Studies have found little relation between practice size and quality of care. Smaller practices are also considered by patients to be more accessible and achieve higher levels of satisfaction than larger practices.
Creating a primary care service based on larger practices also reduces patients’ choice. This is anomalous at a time when the government is proposing to increase patients’ choice in the NHS.
A better approach might be to use the quality data from the new general practice contract to compare the performance of singlehanded practices with that of larger practices, he suggests. This could be combined with making more information about practices available to the public so that patients could make informed choices.
“If doctors continued to want to work in them, if they provided health services of comparable quality and cost effectiveness to larger practices, and if sufficient patients wished to register with them, then they would continue to exist, and possibly even flourish in the NHS,” says the author.
“If, however, they failed on these criteria, they could then die a natural death in which their fate would have been decided by market forces and patients’ choice, rather than through a policy based on making general practice an entirely collective endeavour."
Contact:
Azeem Majeed, Professor of Primary
Care, Department of Primary Care and Social Medicine, Imperial College Faculty
of Medicine, London, UK
Email: a.majeed@imperial.ac.uk
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