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Press releases Saturday 24 February 2007

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(1) Children should not be left unsupervised with dogs, say experts
(2) Should the NHS curb spending on translation services?
(3) Doubts over studies raise serious implications for patients
(4) New act could give rise to more complaints against doctors

(1) Children should not be left unsupervised with dogs, say experts
(Clinical Review: Dog bites)
http://www.bmj.com/cgi/content/full/334/7590/413
(Personal View: Dog attacks: it±s time for doctors to bite back)
http://www.bmj.com/cgi/content/full/334/7590/425

Children should not be left unsupervised to play with a dog, say experts in this week±s BMJ. Their advice is part of a review aimed at doctors who deal with dog bites.

Dog bites and maulings are a worldwide problem, particularly in children, write Marina Morgan and John Palmer. Every year 250,000 people who have been bitten by dogs attend minor injuries and emergency units in the United Kingdom, and half of all children are reportedly bitten by dogs at some time, boys more than girls.

Accurate death figures are difficult to obtain, but in the past five years, two to three cases a year have made news headlines.

Based on the latest medical evidence, they advise doctors how to examine and treat a patient presenting with a dog bite. They discuss the risk of infection and when to refer to specialist care. For travellers bitten abroad, they suggest assessing the risk of rabies.

In terms of prevention, they suggest that children should be taught to treat dogs with respect, avoid direct eye contact, and not tease them. They should be taught not to approach an unfamiliar dog; play with any dog unless under close supervision; run or scream in the presence of a dog; pet a dog without first letting it sniff you; or disturb a dog that is eating, sleeping, or caring for puppies.

Dog owners also need to change their behaviour, writes Rachel Besser, a children±s doctor and lifetime dog owner, in an accompanying article.

It is clear that not all dog owners appreciate that children should not be left unsupervised with a dog, she says. Just as some parents are obliged to take parenting classes, she would like to see equivalent mandatory classes for expectant dog owners to teach them about the responsibilities of dog ownership. Educational programmes for children are also needed to instil precautionary behaviour around dogs.

Finally, she would like to see vets advising dog owners about bite prevention, and doctors promoting bite prevention when treating patients who have been bitten by dogs.

Contacts:
Clinical review:
Marina Morgan, Consultant Medical Microbiologist, Royal Devon and Exeter Foundation Trust, Exeter, UK
Email: marina.morgan@rdeft.nhs.uk

Personal view:
Rachel Besser, Specialist Registrar Paediatrics, London Deanery Trainee, London, UK
Email: rachelbesser@hotmail.com

(2) Should the NHS curb spending on translation services?
(Head to head: Should the NHS curb spending on translation services?)
http://www.bmj.com/cgi/content/full/334/7590/398
http://www.bmj.com/cgi/content/full/334/7590/399

In December it was reported that the NHS was spending ±55 million (±82m; $107m) each year on translation services. In this week±s BMJ, two doctors practising in inner London go head to head over whether language services in the NHS should be curbed.

Kate Adams, a general practitioner in Hackney, believes that doctors should encourage patients to learn English to avoid future public health problems.

Many people who have lived in the UK for more than 20 years speak little English, she writes. These patients are vulnerable to depression and related psychological responses to alienation. Can we really say that this is in either their interests or the interests of the wider community?

In the UK, the legal right to translation services is unclear. Citizenship must balance rights against duties, and may include a right to a reasonable standard of health care that will, in certain circumstances, entail the use of a translator. But should there not also be a corresponding duty to learn the language of the adopted community which has granted the rights, she asks?

However we decide to respond to this, health professionals need to encourage their patients to learn English, thereby helping them in the process of integration, otherwise we will be storing up public health problems for the future, she warns.

Translation services will always need to be available for elderly people whose English is poor, and for new arrivals, but at a time when the NHS is facing a huge financial crisis, is it in anyone±s interests to see the costs of translation services increasing?

She believes that high profile campaigns are needed to encourage people to learn English. If doctors can prescribe gym classes for depression, is it really so far fetched to suggest that we should also be prescribing English classes?

But David Jones, a general practitioner in Tottenham, argues that more, not less, spending is needed on language services.

It is clearly a disadvantage not to speak the majority language of the country in which you live. But he believes it is inappropriate for doctors to encourage patients to acquire English language skills.

The GMC±s 2006 publication, Good Medical Practice, clearly states: ±To communicate effectively you must: make sure, wherever practical, that arrangements are made to meet patients± language and communication needs.± But all too often no such arrangements are in place.

This is not because such arrangements are impractical but because provision for translation and interpreting in the NHS is patchy and often not adequate or not used, he writes.

Current NHS interpreting services may also have negative health and social care consequences because they are so poor, he adds. For example, a new study from the United States has shown that adverse clinical events are more likely to result in physical harm in patients with limited English proficiency.

All doctors working in the NHS, certainly in the inner cities, understand quite clearly that care for non-English speakers regularly falls short of the GMC±s expectation of good communication with patients. ±We must not let the politicians persuade us that it is the patients± fault,± he says.

Contacts:
Kate Adams, General Practitioner, Hackney, London, UK
Email: kateadams@doctors.org.uk

David Jones, General Practitioner, Broadwater Farm Estate, London, UK
Email: david.jones9@nhs.net

(Editorial: Managing suspected research misconduct)
http://www.bmj.com/cgi/content/full/334/7589/378

Doubts over three influential head injury studies mean that patients are receiving treatment that may be unsound, warn doctors in this week±s BMJ.

Professor Ian Roberts and colleagues describe the worrying story of Dr Julio Cruz, a neurosurgeon who published three trials on the use of the drug mannitol for head injuries between 2001 and 2004.

The results showed that high dose mannitol greatly reduced death and disability six months after the head injury, but they have recently been called into question.

Dr Cruz committed suicide two years ago and his co-authors and the editors of the journals in which the three papers were published have failed to respond adequately to the concerns raised about the integrity of the data.

Despite considerable efforts, Professor Roberts and his colleagues say they are ±left with serious doubt about important studies but with no way of determining with confidence whether the results are fabricated or real.±

The implications for patients are serious,± they add. ±They are being treated on the basis of potentially unreliable evidence.± They believe that a strong case exists for an international body to respond to the problem of research misconduct.

These events have several important consequences, warn Charles Young and Fiona Godlee in an accompanying editorial. For instance, if some or all of Cruz±s data are false, then doctors will be providing their critically ill patients with uncertain and possibly harmful treatment.

The failure to retract unsound data also has long term consequences as the data become integrated into subsequent reviews and guidelines, they add.

Young and Godlee believe that editors should react promptly to alert readers in situations where inaccuracies or misleading statements may have been published. In the case of Cruz±s data, they also call on the editors and co-authors involved in the disputed papers to act quickly either to confirm the veracity of what they have published or to withdraw it, and they urge clinicians treating patients with head injuries to approach these data with caution.

Contacts:
Ian Roberts, Coordinating Editor of the Cochrane Injuries Group, London School of Hygiene and Tropical Medicine, London, UK
Email: ian.roberts@lshtm.ac.uk

Charles Young, Editor, BMJ Clinical Evidence, London, UK
Email: charles.young@bmjgroup.com

(4) New act could give rise to more complaints against doctors
(An alternative to the clinical negligence system)
http://www.bmj.com/cgi/content/full/334/7590/400

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