Press releases Monday 9 March to Friday 13 March 2009

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) Migraines increase stroke risk during pregnancy
(2) Should breast tissue be screened for cancer after cosmetic surgery?
(3) College best option for young people during times of high unemployment
(4) Call for doctors to lead the way on ‘greener’ healthcare
(5) Injected medication errors "a serious safety problem" in intensive care units
(6) Concerns over "persistent weaknesses" of practice based commissioning

(1) Migraines increase stroke risk during pregnancy
(Research:Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b664

Women who suffer migraines are at an increased risk of stroke during pregnancy as well as other vascular conditions such as heart disease, high blood pressure and blood clots, concludes a study published on bmj.com today.

Migraine headache occurs in up to 26% of women of childbearing age and around one third of women aged between 35 and 39. Although it is very common in this age group, little is known about the prevalence of migraine during pregnancy.

So in the largest study of its kind, researchers in the United States set out to test the association between migraine and vascular diseases during pregnancy.

Using a national database of over 18 million hospital discharge records, they identified 33,956 pregnancy related discharges with a diagnosis of migraine from 2000 to 2003.

Older women (40 years of age or more) were 2.4 times more likely to have a diagnosis of migraines than women under 20 years of age, and white women were more likely to have a diagnosis of migraines than any other race or ethnicity.

Migraines during pregnancy were linked to a 15-fold increased risk of stroke. Migraines also tripled the risk of blood clots in the veins and doubled the risk of heart disease. Vascular risk factors were also strongly associated with migraines. These included diabetes, high blood pressure and cigarette smoking.

Even when pre-eclampsia (the most influential factor in relation to migraine) was removed from the analysis, there was little change in the results, suggesting that these are independent associations.

The relation between migraine and stroke was the strongest, and this is consistent with a previous analysis in the same sample of women from 2000-1 which found that migraine was associated with a 17-fold increased risk of pregnancy related stroke. However, stroke in pregnancy is very rare (around four cases per 100,000 births), so this relative increase is not as alarming as it might seem, and these results will not apply to every woman with migraine during pregnancy. Nevertheless, for pregnant women admitted to hospital with active migraines, doctors should recognise and help to reduce cardiovascular risk factors and should treat complications of pregnancy such as pre-eclampsia.

The authors suggest that the most logical explanation for these findings lies in the interaction between migraines and the normal physiological changes during pregnancy (such as increased blood volume and heart rate) which put extra stress on the vascular system.

But regardless of the mechanism, active migraine during pregnancy could be viewed as a potential marker of vascular diseases, especially stroke, they say.

Although cause and effect still need to be established, the results of this study lay the groundwork for future studies related to migraine and pregnancy, they conclude.

Contacts:
Research: Cheryl Bushnell, Associate Professor, Department of Neurology, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC, USA
Email: rbush@wfubmc.edu
Or
Andra James, Assistant Professor, Division of Maternal Fetal-Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
Email: Andra.james@duke.edu


(2) Should breast tissue be screened for cancer after cosmetic surgery?
(Analysis: Tissue screening after breast reduction)
http://www.bmj.com/cgi/doi/10.1136/bmj.b630

(Commentary: The big question remains unanswered)
http://www.bmj.com/cgi/doi/10.1136/bmj.b759

(Commentary: A call for preventive ethics)
http://www.bmj.com/cgi/doi/10.1136/bmj.b753

(Commentary: The lay view)
http://www.bmj.com/cgi/doi/10.1136/bmj.b776

Young women undergoing cosmetic breast reduction surgery are being screened for cancer without their informed consent, according to a paper published on bmj.com today.

Breast reduction surgery (mammoplasty) is one of the most common procedures performed by plastic surgeons all around the world. For decades it has been common practice to test the removed tissue for cancer.

The incidence of cancer found after surgery is small and often clinically insignificant. But, if found, it can lead to further surgery of unproven benefit. So should the current practice of routinely testing tissue after surgery be abandoned, or should doctors discuss this issue in advance with the patient and ensure that they are aware of the possible consequences?

A team of breast surgeons based at the Royal Free Hampstead NHS Trust and Royal Free and University College Medical School in London describe finding cancer after a routine cosmetic operation on a 37 year old woman. The discovery led to a succession of further operations, but the team question the ethics of acting on test results when there is no evidence for benefit.

They also point out that it is often not possible to identify exactly where in the breast the tissue came from because tissue specimens are not orientated during surgery.

In an accompanying commentary, Tom Treasure, a Professor of Cardiothoracic Surgery at University College London suggests that the question of what is the best management of a patient with these findings in the future remains unanswered. "Not putting the tissue under the microscope may seem unacceptable," he writes, "but so is continuing surgical practices that may result in harm, without having evidence of benefit."

In a second commentary, ethicist Jeremy Sugarman suggests that even though the likelihood of the specimens being malignant is small, discussing this issue in advance should help to prepare patients to receive the news and to face the complex decisions that follow. He believes that this matter warrants careful, expert review. In the meantime, he suggests that obtaining informed consent for screening and orientating these specimens should help to mitigate some of the difficult ethical issues that are encountered in practice.

Like any potential patient, I welcome any procedures made to safeguard my health and would appreciate being informed of every aspect (and associated risk) of an operation. I would not appreciate being left in the dark, writes Tessa Boase, in a final commentary. She believes that the current practice of screening of breast tissue after reduction mammoplasty should be maintained and perhaps refined, but the patient should, from start to finish, be kept in the loop. "Who else, after all, is this screening supposed to benefit?" she says.

Contacts:
Mohammed Keshtgar, Consultant Breast Surgeon, University Department of Surgery, Royal Free Hampstead NHS Trust and Royal Free and University College Medical School, London, UK
Email: m.keshtgar@ucl.ac.uk
Or
Tom Treasure, Professor of Cardiothoracis Surgery, Clinical Operational Research Unit, University College London, UK
Email: tom.treasure@gmail.com
Or
Jeremy Sugarman, Harvey M Meyerhoff Professor of Bioethics and Medicine, Berman Institute of Bioethics and Department of Medicine, Baltimore, USA
Email: jsugarm1@jhmi.edu

(3) College best option for young people during times of high unemployment
(Editorial: Unemployment and health)
http://www.bmj.com/cgi/doi/10.1136/bmj.b829

From a health perspective, going to college is the best option for young people during times of mass unemployment, says a senior researcher in an editorial published on bmj.com today.

Unemployment is bad for health, writes Danny Dorling, Professor of Human Geography at the University of Sheffield.

In the UK, we know much about the detrimental health effects of unemployment. For example, studies show that deaths doubled among men aged 40-59 in the five years after redundancy in 1980, while research during the early 1990s found that unemployment increased rates of depression, particularly in the young who are usually most badly hit when jobs are few.

The direct effect of reducing unemployment has been estimated to prevent up to 2,500 premature deaths a year, says Dorling, but health benefits vary according to the method used.

For example, youth opportunity-type schemes are almost as detrimental to psychological health as is unemployment itself. Temporary employment is slightly better but not as good as a properly rewarded and organised apprenticeship. Secure work is better than all these options, but the best option for men and women aged 16-24 in the 1980s and 1990s was going to college, which was associated with lower suicide risks.

The most highly valued education is university education, writes Dorling. If three extra young people per 100 this summer go to university and are out of the job market, another three people could fill those jobs that the first three might have taken, another three percentage points come off the dole queue and fewer youngsters compete with older workers who have recently been made redundant.

More importantly, says Dorling, this approach recognises that unemployment is bad for health, and that the best way of alleviating it is to show faith in and respect for the young, because they are always worst hit by unemployment.

More university students does not need to mean more debt for young people, he adds. It is just a case of priorities and recognising when the time is right for someone to be there to help.

Contact:
Danny Dorling, Professor of Human Geography, Department of Geography, University of Sheffield, Sheffield, UK

Please note, the author is currently on sabatical at the University of Canterbury, New Zealand
Email: Daniel.dorling@sheffield.ac.uk

(4) Call for doctors to lead the way on ‘greener’ healthcare
(Analysis: Coming round to recycling)
http://www.bmj.com/cgi/doi/10.1136/bmj.b609

Clinicians have an important role to play in reducing hospital waste and should not be discouraged by lack of knowledge or the threat of legal liability, according to a paper published on bmj.com today.

In 2005-6, the NHS produced 408,218 tonnes of waste, 29% of which was clinical waste, and spent nearly £73m (€80m; $103m) on its disposal. Concerns about the risk of prion transmission and sterility have also led to large increases in both the amount of anaesthetic packaging and the use of disposable devices over the past 5-10 years.

Concerned by these figures, David Hutchins and Stuart White carried out a two-week audit of the waste produced by six operating theatres at their hospital, the Royal Sussex County Hospital in Brighton.

The results were striking: a total of 540kg of anaesthetic waste was produced (about 2,300 kg/theatre/year), 40% of which was potentially recyclable paper, card, plastic and glass.

Sharps waste (needles and broken glass) accounted for 54kg, but analysis of the contents of five sharps bins found that only 4% by weight was true sharp waste. The rest was made up of glass, packaging, plastic, metal, and fluid.

With around seven million operations performed each year in England and Wales, the authors suggest that clinical anaesthesia accounts for between 10 and 20,000 tonnes of NHS solid waste annually.

They also estimate that recycling anaesthetic waste across the hospital trust would save £21,000 per year (about 30% of the hospital’s annual budget for disposing of clinical waste), although with waste disposal and landfill costs expected to rise, this sum could increase.

They discuss the social, logistical and legal barriers to improving waste management within the NHS, and suggest that clinicians are central to countering these.

Hospitals need government support to change current waste management strategies, while new NHS hospitals must incorporate recycling facilities, they write. Professional bodies and medical publishers also have an important role to play in the spread of ideas and solutions.

Medicine has a considerable environmental impact, they say. Increases in landfill and incineration costs, together with financial recycling incentives and our social and moral responsibilities, should encourage clinicians to improve clinical waste management, as long as the quality of patient care remains unaffected.

Over the past 60 years, the NHS has set a worldwide example in free high quality healthcare at the point of contact. It should continue to set an example by developing and integrating a national medical waste management policy to reduce its environmental impact, they conclude.

Contact:
Dr Stuart White, Consultant in Anaesthesia, Brighton Anaesthesia Research Forum, Royal Sussex County Hospital, Brighton, East Sussex, UK
Email: stuart.white@bsuh.nhs.uk

(5) Injected medication errors "a serious safety problem" in intensive care units
(Research: Errors in administration of parenteral drugs in intensive care units: multinational prospective study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b814

Errors in the administration of injected (parenteral) medication occur with alarming frequency, and are a serious safety problem in intensive care units, concludes a large study published on bmj.com today.

A previous study found that medication errors were frequent at the administration stage, so Dr Andreas Valentin and colleagues set out to examine this further on a multinational level. They monitored errors occurring at 113 intensive care units (ICUs) in 27 countries - 17 in the United Kingdom - over the same 24-hour period (January 17 or January 24 2007). All nurses and physicians on duty during the study period were asked to record errors using a questionnaire available at the bedside of each patient.

Errors were classified by type of error, type of drug administration and class of drug, and a detailed description of the error was recorded to allow assessment of contributing factors.

Further data were recorded to calculate occupancy rate, relative turnover, patient-nurse ratio, and patient-to physician ratio for each shift in ICU. The severity of illness in each patient and nursing workload were also assessed on the day of the study.

In a total of 1328 patients, 861 errors affecting 441 patients were reported over the 24-hour period. Just over two-thirds (67%) of patients experienced no error, 250 patients (19%) experienced only one error, and 191 patients (14%) experienced more than one error.

Although 71% of errors resulted in no change in the status of the patient, 12 patients (0.9% of the total study population) suffered permanent harm or death related to a total of 15 medication errors at the administration stage. Trainees were reported as being involved in eight of these errors.

The most frequent errors were related to wrong time of administration (386) and missed medication (259), followed by wrong dose (118), wrong drug (61), and wrong route (37).

Workload/stress/fatigue was reported by ICU staff as a contributing factor in 32% of all errors. Other contributing factors included a recently changed drug name (18%), communication - written (14%), communication-oral (10%), and violation of standard protocol (9%).

Odds for the occurrence of at least one medication error increased significantly with a higher severity of illness, a higher level of care, and a higher rate of parenteral drug administrations. This finding directly reflects the complexity of care of these patients and thus the increased opportunity for error, suggest the authors.

In contrast, odds decreased when a critical incident reporting system was in place and when there was an established routine of checks at nurses’ shift change.

This study demonstrates that the administration of parenteral medication is a weak point in patient safety in ICUs, say the authors. And since the results are based on data from 113 participating ICUs worldwide, this problem represents a common pattern. With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks at shift changes can reduce the risk of such errors in ICUs, they conclude.

Contacts:
Andreas Valentin, General and Medical Intensive Care Unit, Rudolfstiftung Hospital, Vienna, Austria
Email: andreas.valentin@meduniwien.ac.at

(6) Concerns over "persistent weaknesses" of practice based commissioning
(Editorial: Practice based commissioning in the UK)
http://www.bmj.com/cgi/doi/10.1136/bmj.b832

The government’s commitment to "reinvigorate" practice based commissioning will need more than just extra funding if it's to tackle its persistent weaknesses, warns an editorial published on bmj.com today.

Practice based commissioning - the system in which family doctors decide which health services to buy for local people - has been a central part of the government’s health policy since April 2005, when interested practices were first entitled to indicative budgets.

Yet nearly two decades of experimentation in the English NHS have provided little evidence that any form of commissioning has greatly affected hospital services, argue general practitioner Stephen Gillam and Richard Lewis, Director at Ernst and Young.

Even the government acknowledges that practice based commissioning is stalling, they add.

Of course, practice based commissioning is a work in progress, say the authors. However, all manifestations of primary care commissioning have been beset by common weaknesses. These include a lack of clinical engagement, organisational immaturity, insufficient support from management, limited public involvement or accountability, and lack of information on which to base commissioning decisions.

The right formula with which to tackle these weaknesses remains, as yet, stubbornly out of reach, they write, and this raises the question of whether these deficits are simply intrinsic.

So where do we go from here, they ask? Several "solutions" abound, including a "matrix" model that places different responsibilities at different levels, and the Royal College of General Practitioners’ proposal for practice federations (associations of practices and community primary care teams) to develop expertise.

New "integrated care organisations" are also about to be piloted. These will offer real budgets to practices in return for the responsibility to manage health and population care, and offer the prospect of much stronger incentives for general practitioners and other professionals to shape local services.

Practice based commissioning is clearly not about to be dismantled, even with a change of government, conclude the authors, but if tangible results remain elusive, evidence based policy makers will wonder whether this patient needs palliative care not reinvigoration.

Contacts:
Stephen Gillam, General Practitioner, Luton, UK
Email: sjg67@medschl.cam.ac.uk

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(contact: pressoffice@bma.org.uk)

and from:

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