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Press releases Saturday 5 April 2008
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(1) New test could cut unnecessary treatment for blood disorder in pregnancy (2) Are there too many female medical graduates? (3) Removing barriers to the distribution of life saving vaccines (4) Hospital follow-up services not necessary for all child cancer survivors
(1) New test could cut unnecessary treatment for blood disorder in pregnancy (Effect of high throughput RhD typing of fetal DNA in maternal plasma on use of anti-RhD immunoglobulin in RhD negative pregnant women: a prospective feasibility study) http://www.bmj.com/cgi/content/short/bmj.39518.463206.25 (Editorial: Universal RhD genotyping in fetuses) http://www.bmj.com/cgi/content/short/bmj.39533.358252.BE
A new test for identifying a mismatch between the blood of a pregnant woman and her baby is accurate, feasible, and could substantially reduce unnecessary treatment, finds a study published on bmj.com today.
Problems can occur if a woman's blood is Rhesus (Rh) negative but she is carrying a baby whose blood is Rh positive. This is because Rh positive blood contains a substance called RhD antigen, which passes into the mother's blood at birth. The mother then makes antibodies against the RhD positive blood.
There are usually no problems during a woman's first pregnancy, but if she goes on to have another RhD positive baby, these antibodies cross the placenta and destroy the baby's red blood cells, causing a blood disorder known as haemolytic disease that can be serious and even fatal.
To prevent this, all pregnant women have their blood tested at their first antenatal visit. RhD negative women are given one or two antiserum injections (anti-RhD immunoglobulin, derived from blood products) during the pregnancy.
However, about 38% of RhD negative women are carrying an RhD negative baby, so they receive this treatment unnecessarily.
So researchers at the NHS Blood and Transplant Centre in Bristol assessed a new test for predicting a baby's blood group by "typing" its DNA in the plasma of RhD negative pregnant women.
They analysed blood samples from 1,997 women taken at or before the 28 week antenatal visit. In 96% of cases, the correct RhD phenotype of the baby was predicted by the genotyping tests. This was confirmed by comparing the results obtained from cord blood samples taken at delivery.
A false positive result was obtained in 0.8% (14 samples), and in only three samples (0.2%) were false negative results obtained.
In 3.4% of cases results were either unobtainable or inconclusive.
If these results had been applied as a guide to treatment, only 2% of the women would have received anti-RhD unnecessarily, compared with 36% without genotyping.
The results show that fetuses of RhD negative women can be genotyped with an acceptable level of accuracy and a low rate of false positive results, say the authors. Testing would avoid unnecessary treatment in about 38% of RhD negative women and avert the associated discomfort, inconvenience, and risk of exposure to donor blood products that such injections entail, they conclude.
These findings are important because they demonstrate the reliability of the automated technique and the feasibility of large scale antenatal testing, writes Sailesh Kumar from Queen Charlotte's and Chelsea Hospital in an accompanying editorial.
He concludes: "If these techniques are shown to be as reliable earlier in pregnancy the arguments for recommending universal testing will be compelling."
Contacts: Geoff Daniels, Head of Molecular Diagnostics, International Blood Group Reference Laboratory, NHS Blood and Transplant, Bristol, UK Email: geoff.daniels@nbs.nhs.uk Editorial: Sailesh Kumar, Consultant in Fetal and Maternal Medicine, Queen Charlotte's and Chelsea Hospital, London, UK Email: sailesh.kumar@imperial.ac.uk
(2) Are there too many female medical graduates? (Head to Head: Are there too many female medical graduates) Yes: www.bmj.com/cgi/content/short/336/7647/748 No: www.bmj.com/cgi/content/short/336/7647/749 (Editorial: Effects of gender on performance in medicine) www.bmj.com/cgi/content/short/336/7647/731
More women now graduate from medical school than men, and soon male doctors will be in the minority. But are we risking future staffing problems, or is there still some way to go before we reach true equality?
Two experts debate the issue in this week's BMJ.
Increasing numbers of female graduates will create a major shortfall in primary care provision and may also affect education, research, and development, argues Brian McKinstry, senior research fellow at the University of Edinburgh.
Evidence is growing, he says, to demonstrate the negative consequences of the feminism of primary care in the UK and elsewhere. For example, fewer women than men choose to work out of hours, and the increase in women doctors may have partly influenced the recent abandonment of out of hours work by general practitioners in the UK, he claims.
But according to McKinstry we are yet to feel the full effects of this feminisation. For instance, above the age of 45 years men, mostly working full time, are in the majority, whereas general practitioners younger than 45 years are mostly female and working part time. As older, mainly fully time doctors retire, unless employment behaviour changes, there will be a major shortfall in primary care provision, he argues.
This demographic change may also affect education, research, and development, he adds. An American study of women in internal medicine found that women with children had fewer publications than men with children, while Scottish data indicates that women contribute about 60% of the activity of men in development aspects of general practice such as training, teaching, research, and committee work.
He concludes that in the absence of any profound change in societal views on responsibility for child care, a balanced approach to recruitment in the interests of equity and the future delivery of services is vital.
But Jane Dacre from University College London, argues that rather than worrying about having too many women in medicine we should be focusing on ensuring equality of opportunity.
Although women outnumber men in most medical schools by about 3:2, they are under-represented in some areas, especially in clinical academia and in specialties requiring more acute and on call responsibilities and more technical skills.
Dacre believes that medicine needs and wants to attract the best and brightest people whatever their sex. But in order to welcome more women into senior positions, she says, institutional barriers that prevent their progression such as a lack of rota flexibility, low acceptance of career breaks and part-time working, and the need for greater availability of child care and easily accessible and funded part time training options needs to be addressed.
The feminisation of medicine should be welcomed as an opportunity to be creative with workforce planning and to recognise that a more flexible way of working is essential to delivering good quality patient care at all times of the day and night, she says.
In an accompanying editorial, Jenny Firth-Cozens from The London Deanery, acknowledges that the implications of the proportional rise in female doctors must be taken into account. But she warns that any financial estimation that compares the cost of employing male or female doctors must take into account sex differences in the costs of poor performance, litigation, re-education, and rehabilitation that are consistently higher for male doctors.
Contacts: Brian McKinstry, Senior Research Fellow, Community Health Sciences: General Practice Section, University of Edinburgh, UK Email: brian.mckinstry@ed.ac.uk Jane Dacre, Vice Dean, Faculty of Biomedical Sciences, University College London, UK Email: j.dacre@medsch.ucl.ac.uk Editorial: Professor Jenny Firth-Cozens, London Deanery, London, UK Email: jfirth-cozens@londondeanery.ac.uk
(3) Removing barriers to the distribution of life saving vaccines (Removing barriers to the distribution of life saving vaccines) www.bmj.com/cgi/content/short/336/7647/750
Barriers to the distribution of life saving vaccines in low income countries can and should be overcome, say experts in this week's issue of the BMJ.
They suggest that building local clinical research and vaccine production capacity in developing countries will increase the global availability of affordable vaccines.
Delay in delivering vaccines in low and middle income countries results in more than two million deaths a year.
Many of the reasons offered for the unequal access to vaccines in poorer countries can be challenged with new evidence and a better understanding of the underlying problems, write Dave Chokshi, from the University of Pennsylvania School of Medicine and Aaron Kesselheim, from the Division of Pharmacoepidemiology anfd Pharacoeconomics at Brigham and Women's Hospital.
They point out that an exclusive focus on the primacy of public health infrastructure can result in a missed opportunity to build infrastructure through vaccination. Studies of polio eradication in the Americas have shown how immunisation programmes can strengthen the infrastructure of health systems.
Vaccines are one of the few interventions that can save lives even when healthcare infrastructure is inadequate or non-existent, they argue.
However, there are worries about insufficient funding, say the authors. For instance, the Global Alliance for Vaccines and Immunization (GAVI) has collected almost $7bn since its inception in 2000, but it estimates that it will cost $35bn to carry out its existing programmes in the 72 poorest countries up to 2015.
In addition, there are concerns about intellectual property rights slowing the distribution of vaccine technology from rich to poor countries, prices offered by pharmaceutical manufacturers being too high, and the implementation of donation programmes being too slow.
So what needs to be done to increase the availability of these life saving vaccines, ask the authors?
Constructing clinical research of vaccine efficiency in low and middle income countries would expand scientific capacity, encourage more ethical clinical trials, and better inform government's risk-benefit calculations for investing in vaccines, claim the authors.
In addition, lowering the barriers to vaccine production in developing countries by, for example, improving local manufacturers' access to specialised technology, would build innovative capacity as well as production capacity, they say.
But the authors believe that the ultimate aim of any effort to improve global access to vaccines is to show the benefits of vaccination to local leaders in health care and government.
Local political leadership when combined with increased investment can prioritise disease prevention, raise awareness of the benefits of vaccination, and encourage country-level leadership, they conclude.
Contact: Dave Chokshi, University of Pennsylvania School of Medicine, Philadelphia, USA Email: daveash@med.upenn.edu
(4) Hospital follow-up services not necessary for all child cancer survivors (Editorial: Follow-up of children who survive cancer) www.bmj.com/cgi/content/short/336/7647/732
Many child cancer patients will benefit from ongoing follow-up, but others should be allowed to move on and put the experience of cancer behind them, say experts in this week's issue of the BMJ.
Most adults who survive cancer are discharged from active follow-up after five years, but historically children have been followed up for life, however this is becoming unsustainable, write Meriel Jenney from the Children's Hospital for Wales and Gill Levitt from Great Ormond Street Hospital.
Follow-up of children who survive cancer should be individually tailored and may not be necessary for all, they argue.
Previous studies have shown that at least 62% of child survivors have some late side effects as a result of their curative treatment. But this data is based on different treatments than those used today. For example, many of the late side effects seen in older studies were caused by radiotherapy, a treatment that is now used less frequently.
More than three quarters of children with cancer now survive into adulthood, but how can a follow-up service be developed for this growing and diverse group of patients, ask the authors.
Patients who are at high risk of late side effects - such as those who have received a bone marrow transplant - will require ongoing observation by skilled clinicians in a hospital setting.
But for an increasing number of patients who are at low risk of late side effects, an accessible summary of the patient's previous treatment with a plan for any necessary investigations and likely late side effects, managed by primary care doctors, could be the solution, suggest the authors.
As long as there is a mechanism in place to recall any patient for a more detailed follow up if new late side effects are identified, only those with the highest risk of late effects should be brought back regularly to the clinic, say the authors.
The other patients must be allowed to move on, to leave the clinical setting and put the experience of cancer behind them, or they may never believe they have been cured, they conclude.
Contact: Meriel Jenney, Consultant paediatric oncologist, Children's Hospital for Wales, Cardiff, UK Email: meriel.jenney@cardiffandvale.wales.nhs.uk
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