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Press releases Saturday 2 September 2006
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(1) MEMORY CLINICS ARE DIVERTING NHS RESOURCES FROM HIGH QUALITY CARE
(2) ARE THE DANGERS OF CHILDHOOD FOOD ALLERGY EXAGGERATED?
(3) MANY MEDICAL
STUDENTS UNPREPARED FOR SKILLED PRESCRIBING
(4) “AID SNOBBERY” HAMPERING PROJECTS IN DEVELOPING COUNTRIES
(1) MEMORY CLINICS ARE DIVERTING NHS RESOURCES FROM
HIGH QUALITY CARE
(Role of cholinesterase inhibitors
in dementia care needs rethinking)
http://bmj.com/cgi/content/full/333/7566/491
Specialist memory clinics for patients with dementia are taking NHS resources away from long term integrated care, warn senior doctors in this week’s BMJ.
Since 2001, the National Institute for Health and Clinical Excellence (NICE) has recommended that cholinesterase inhibitors should be available to people with mild to moderate Alzheimer’s disease, writes consultant psychiatrist, Anthony Pelosi and colleagues.
This was based on evidence that these drugs slowed cognitive (mental) decline, but NICE stressed that further research was required and it planned to revisit its recommendations after several years.
The guidelines were welcomed by patient and carer organisations, and a large number of specialist memory clinics were set up for the prescription and monitoring of these medicines, sometimes with funding from the drug manufacturers.
But widespread clinics have distorted clinical priorities, argue the authors. They have recruited full multidisciplinary teams while there is a shortage of mental health professionals throughout the United Kingdom, and they do not offer care in the community to their patients as they decline. Patients then have to be referred to ordinary old age psychiatry teams, which have to arrange proper long-term management plans.
Further research is now available and shows quite consistently that these medicines have modest beneficial effects compared with placebo. As a result, NICE recommended that the NHS should no longer prescribe cholinesterase inhibitors because they do not provide value for money.
But after hostile reactions from clinicians, patients and carers, with support from the lay media, NICE now proposes restricting use to moderate Alzheimer’s disease. But doctors are concerned that it will be extremely difficult (perhaps impossible) to wait for a diagnosed patient to deteriorate before starting treatment.
NICE has been unfairly accused of ageism and stigmatisation of people with dementia, and it has been claimed that adoption of the revised guidelines would be devastating for patients and carers. But the tragedy is not the proposed restrictions, but the fact that the only currently licensed medicines for a cruel illness have turned out to be of marginal benefit, write the authors.
Whatever the final outcome of NICE’s deliberations, the human and financial resources that have become tied up in clinics organised around prescription of cholinesterase inhibitors must be diverted to old age psychiatry teams and their social care counterparts, they say.
These medicines should no longer be allowed to have such influence on services for patients with Alzheimer’s disease and their families.
Contact:
Anthony Pelosi, Consultant Psychiatrist,
Department of Psychiatry, Hairmyres Hospital, East Kilbride, Scotland, UK
Email: a.pelosi@clinmed.gla.ac.uk
(2) ARE THE DANGERS OF CHILDHOOD FOOD ALLERGY EXAGGERATED?
(For and against: the dangers
of childhood food allergy are probably exaggerated)
http://bmj.com/cgi/content/full/333/7566/494
Two child health experts go head to head in this week’s BMJ over whether the dangers of childhood food allergy are exaggerated.
Professor Allan Colver from the University of Newcastle upon Tyne believes that the dangers are overstated, and that the increasing prescription of adrenaline injector kits fuels anxiety rather than saving lives.
Food allergy is often thought to be more dangerous and frightening than pneumonia, asthma, or diabetes, he writes. In reality, the risk of death is very small. Eight children under 16 years died from food allergy between 1990 and 2000 in the UK. That is one death per 16 million children each year. Yet childhood food allergy is being diagnosed more often and the number of prescribed adrenaline kits has greatly increased.
A diagnosis of food allergy creates much anxiety for all who care for the child, so it is important to get the diagnosis right, take sensible measures to reduce risk, and reassess regularly to check whether the child has grown out of their allergy, he says.
It is unclear what proportion of children with food allergy should be prescribed an adrenaline kit. The main argument in its favour is that reactions are best treated within a few minutes rather than waiting for medical assistance. But Colver suggests that they cause unnecessary anxiety, may not prevent death, and should be prescribed only when a diagnosis of food allergy has been confidently established.
The dangers of food allergies are not exaggerated, argues Professor Jonathan Hourihane from University College Cork, Ireland. Food allergy is common – 2% of adults and up to 6% of preschool children are affected and, although deaths are rare, other reactions are almost inevitable over time.
No tests are available to predict who will or will not have a severe allergic reaction, so management consists of empowering patients and providing rescue drugs. Delay in use of these drugs is associated with a worse outcome in severe reactions.
Proper management in allergy clinics means that most patients never have to use these drugs, but it is wrong to say that they are not needed, he says. Nobody is advocating “more general use” of adrenaline. What is advocated is increased availability of adrenaline kits for people who might need to use them. They should not be withheld because of the medical uncertainty surrounding allergy.
Food allergy is here to stay, he writes. The disease is a killer (though rarely); it can erode or inhibit normal formative experiences in childhood, and it impairs a child’s quality of life. Let’s get allergy services out of the academic centres and into the community, which is where food allergy is really “dangerous,” he concludes.
Contacts:
Allan Colver, Professor of Community
Child Health,, School of Clinical Medical Sciences, University of Newcastle
upon Tyne, UK
Email: allan.colver@ncl.ac.uk
Jonathan Hourihane, Professor of
Paediatrics and Child Health, University College Cork, Ireland
Email: j.hourihane@ucc.ie
(3) MANY MEDICAL STUDENTS UNPREPARED FOR SKILLED PRESCRIBING
(Editorial: A prescription
for better prescribing)
http://bmj.com/cgi/content/full/333/7566/459
Many medical students are unprepared for skilled prescribing, warn doctors in this week’s BMJ.
Evidence of poor prescribing in the UK is abundant, write Jeffrey Aronson and colleagues. Effective treatments are often underprescribed and prescription errors are common, especially when new doctors start work in hospitals.
The reasons for these errors are manifold, say the authors. Some relate to system failures, while another fundamental problem is that medical students are not adequately trained.
For example, in 1994, UK medical students received an average 61 hours of teaching related to pharmacology, clinical pharmacology, and therapeutics. Since then the numbers of pharmacologists and clinical pharmacologists in the UK (and thus the amount of teaching) have fallen.
In contrast, nurses seeking to obtain the Postgraduate Certificate in Prescribing must complete a training course of 162 hours of theory and 90 hours of practice.
Prescribing is becoming increasingly difficult, and the inherent risks of adverse reactions and interactions have increased, they add. Tomorrow’s doctors need a firm grounding in the principles of pharmacology and clinical pharmacology, linked to practical therapeutics, so that they can weigh up the potential benefits and harms of treatment; understand the sources of variability in drug response; base prescribing decisions on sound evidence; and monitor drug effects appropriately.
Their prescription to improve prescribing includes regular education and assessment (linked to a licence to prescribe), a national prescription form for hospitals, guidelines and computerised prescribing systems.
There are too few pharmacologists and clinical pharmacologists to provide all the necessary teaching and assessments, so partnerships with other prescribers should be encouraged, they write. Medical students too can play their part by encouraging their medical schools to provide more tuition in practical drug therapy and prescribing.
“We challenge medical students, and all those involved in teaching students and training doctors to implement these proposals. After all, we shall all benefit from better prescribing,” they conclude.
Contact:
Jeffrey Aronson, University of Oxford,
Radcliffe Infirmary, Oxford, UK
Email: jeffrey.aronson@clinpharm.ox.ac.uk
(4) “AID SNOBBERY” HAMPERING PROJECTS IN DEVELOPING COUNTRIES
(Personal View: The sour
taste of aid snobbery)
http://bmj.com/cgi/content/full/333/7566/505
Snobbery over aid projects is preventing charitable groups from working together in developing countries, warns a doctor in this week’s BMJ.
Daniel Magnus, a senior house officer at Southmead Hospital in Bristol describes the Kenyan Orphan Project – a small group started by him and two friends that sends doctors, nurses and medical students to Kenya to help with health, education, and social welfare programmes. Their most recent trip was in July to run a series of free medical camps in one of the most impoverished areas in the country.
“We have observed in that time a persistent and insidious phenomenon which is essentially aid snobbery,” he writes.
The problem is that aid and development work is big business, and in the arguments and snobbery and wrangling over who is more sensitive to the local culture or having the least negative effects on the local economy, all cooperation and collaboration is lost, he says.
“As we have seen worldwide, organisations end up repeating and overlapping their aid and development initiatives to the tune of millions of dollars.”
“I appreciate that there is enormous potential for organisations to have damaging and destructive effects in developing countries, despite the best of intentions,” he adds. “But in five years, I have seen very few to whom this applies, and yet the snobbery is ubiquitous.”
This trip did not provide a sustainable or lasting solution to the disease and social and economic deprivation that have a stranglehold on thousands of people living in the province. But it is a step, and it is action, he writes. “In partnership with local organisations and by supporting health initiatives in the area, we can move forward, repeat the medical camps, and look at ways to build long term, viable health and community programmes.”
Surely, charitable groups can best maximise their contribution to the causes in which they believe so fervently by working together to streamline their activities, increase their efficiency, ad minimise administration costs. This can only be done by accepting and respecting others’ activities and approaches.
“The key is to stay focused on working for, and in the interests of, the people we are trying to help. And whether or not a world without poverty and suffering can ever truly exist, it is our continuing duty to try to build one,” he concludes.
Contact:
Daniel Magnus, Senior House Officer
in Paediatrics, Southmead Hospital, Bristol, UK
Email: dan_magnus@hotmail.com
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