Press releases Monday 5 July to Friday 9 July 2010
Please remember to credit the BMJas source when publicising an article and to tell your readers that they can
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(1) No evidence that four hour A&E target benefits clinical care, say doctors (2) Many mephedrone alternatives just as risky, warn experts (3) Suicide barriers may fail to cut suicide rates as people go elsewhere (4) Rudeness at work causes mistakes (5) Should specialist medical training be more flexible? (6) HPV infection linked to increased risk of skin cancer (7) Wrist fractures have an important public health impact
(1) No evidence that four hour A&E target benefits clinical care, say doctors
(Letter: Impact of target led care in UK emergency departments)
http://www.bmj.com/cgi/content/extract/341/jul06_1/c3579
In this week’s BMJ, a group of senior doctors say they have no evidence that the four hour A&E target benefits clinical care. They also argue that it has encouraged target led rather than needs led care.
The UK four hour standard for processing patients attending emergency departments was introduced at 90% in 2004 and has sat at 98% since 2005, write Suzanne Mason and colleagues in a letter to the journal.
Last week, this target was relaxed to 95% by the new coalition government.
In 2005, the authors showed that patients admitted to hospital from the emergency department were affected most by a “spike” in activity during the last 20 minutes of the four hours, which affected 12.3% of admitted patients and 3.6% of discharged patients in 2004.
Now they set out to find out whether this spike was still occurring nationally.
They analysed 12.2 million new patient episodes at English emergency departments in 2008-2009. The data show that the spike is still present and larger than in 2004, affecting 30.7% of admitted patients and 10.5% of discharged patients.
“Although many in the specialty of emergency medicine support the benefits that the four hour target has brought, these results suggest that they are not being experienced by all patients, and that processes throughout the hospital and wider healthcare system may not have improved to accommodate it,” they say.
“Good evidence based indicators of quality in emergency medicine need development,” they add. “We have no evidence that the 98% four hour target benefits clinical care, and our findings suggest that it has encouraged target led rather than needs led care.”
Contact:
Suzanne Mason, Professor of emergency medicine, Director of Health Services Research, Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, UK
Email: s.mason@sheffield.ac.uk
(2) Many mephedrone alternatives just as risky, warn experts
(Letter: The confusing case of NRG-1)
http://www.bmj.com/cgi/content/extract/341/jul06_1/c3564
Since the recent ban on mephedrone, many so-called “legal substitutes” available on the internet are in fact banned cathinones (chemically related to amphetamines) and just as risky, warn experts in a letter to this week’s BMJ.
One such product is Energy 1 (NRG-1), also advertised as naphyrone (naphthylpyrovalerone, O-2482), write Simon Brandt and colleagues. These products are offered as legal substitutes for the recently criminalised “legal highs,” the mephedrone derivatives.
Previous studies exploring the motivation for using these drugs suggested that consumers think that they are more likely to be of higher purity than street drugs, carry a lower risk of physical harm, and not be liable for the criminal sanctions associated with drugs controlled under the Misuse of Drugs Act.
To obtain an initial snapshot of the post-ban situation, they purchased 17 products online from 12 UK based websites over the six weeks after the ban on mephedrone in mid-April 2010. Chemical analysis was carried out by established procedures.
They found that most of the NRG-type products were recently banned cathinones that just carried a new label. This suggests that both consumers and online sellers are, most likely without knowledge, at risk of criminalisation and potential harm, they say.
They conclude: “This has important health and criminal justice consequences that will require carefully thought out responses and further investigation.”
Contact:
Simon Brandt, Senior Lecturer in Analytical Chemistry, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
Email: s.brandt@ljmu.ac.uk
(3) Suicide barriers may fail to cut suicide rates as people go elsewhere
(Research: Effect of a barrier at Bloor Street Viaduct on suicide rates in Toronto: natural experiment)
http://www.bmj.com/cgi/content/abstract/341/jul06_1/c2884
(Editorial: Strategies to prevent suicide)
http://www.bmj.com/cgi/doi/10.1136/bmj.c3054
Suicide barriers on bridges might not reduce overall suicide rates by jumping from heights, as people may change location for their suicide attempt, according to a new study published on bmj.com today.
Researchers from Canada found that the overall suicide rate (by any means) in Toronto reduced after a barrier was erected at one particular bridge known for a high suicide rate, but suicides from jumping remained the same.
Restricting peoples’ access to a means of suicide can delay and prevent suicide such as in the UK where switching to carbon monoxide-free sources of gas was successful in reducing suicide numbers.
Suicide barriers erected to prevent jumping have been established at the Empire State Building in the USA, the Eiffel Tower in France, and bridges worldwide. No study so far, however, has shown that a suicide barrier has led to a statistically significant drop in overall suicide rates in an area.
Researchers from Toronto studied the impact of the erection of a suicide barrier at the Bloor Street Viaduct, the bridge with the world’s second highest annual rate of suicide by jumping after Golden Gate Bridge in San Francisco.
The barrier was constructed between April 2002 and June 2003. Prior to that, there was an average of 10 suicides a year by jumping from the bridge between 1992 and 2002.
The researchers studied data covering all suicides in Ontario during the period 1 January 1993 to 30 June 2007. They classified the nine years from 1993 to 2001 as being before the barrier and the four years from July 1 2003 to June 30 2007 as being after the barrier.
Results showed that suicide deaths at the Bloor Street Viaduct fell from 9.3 per year before the barrier to zero after it was constructed.
However, there was no impact on suicide by jumping in the region as a whole. Toronto’s overall yearly suicide rate by jumping was almost unchanged when comparing the pre and post barrier periods at 56.4 per year compared to 56.6 per year.
It was also noted that, post-barrier in Toronto, there was a statistically significant increase in suicides by jumping from bridges other than the Bloor Street Viaduct (8.7 suicide rate per year rising to 14.2 per year).
There was, however, a decrease in both the overall rate of suicides in Toronto and the rate of suicides by means other than jumping in the post-barrier period.
The researchers conclude: “This research shows that constructing a barrier on a bridge with a high rate of suicide by jumping is likely to reduce or eliminate suicides at that bridge but it may not alter absolute suicide rates by jumping when there are comparable bridges nearby.”
“This study reminds us that means restriction may not work everywhere, and that we have much to learn about the determinants of the choice of method in suicidal acts,” writes David Gunnell from the University of Bristol and Matthew Miller from Harvard School of Public Health, in an accompanying editorial.
“Yet, where and when means restriction works, it may save more lives than other suicide prevention strategies, especially in children and young adults, who tend to act impulsively in fleeting suicidal crisis,” they conclude.
Contacts:
Research: Mark Sinyor, Resident Physician, Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Canada
Email: nadia.radovini@sunnybrook.ca
Editorial: David Gunnell, Professor of Epidemiology, Department of Social Medicine, University of Bristol, UK
Email: d.j.gunnell@bristol.ac.uk
(4) Rudeness at work causes mistakes
(Editorial: Rudeness at work)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2480
If someone is rude to you at work or if you witness rudeness you are more likely to make mistakes, says Rhona Flin, Professor of Applied Psychology at the University of Aberdeen, in an editorial published in this week’s BMJ.
Professor Flin believes that the link between rudeness and mistakes is particularly concerning in healthcare settings, where it can pose a threat to patient safety and quality of care.
Research suggests that in confined areas, such as operating theatres, even watching rudeness that occurs between colleagues might impair team members’ thinking skills.
She warns: “In surgical environments, all staff require high levels of attention and memory for task execution …. If incivility does occur in operating theatres and affects workers’ ability to perform tasks, the risks for surgical patients - whose treatment depends on particularly high levels of mental concentration and flawless task execution – could increase.”
Rudeness at work is not uncommon, says Professor Flin. In a survey of 391 NHS operating theatre staff, 66% of respondents said they had “received aggressive behaviour” from nurses and 53% from surgeons during the previous six months.
Disagreements between surgeons and theatre nurses were reported by 63% of respondents, and disagreements between theatre nurses and ward nurses were reported by 58%. The main source of this problem was the management of the operating list.
Interviews with scrub nurses also indicated that they sometimes had to tolerate surgeons’ bad temper and tantrums.
Flin concludes: “People concerned with patient safety should note that civility between workers may have more benefits than just a harmonious atmosphere.”
Contact:
Rhona Flin, Professor of Applied Psychology, King’s College, University of Aberdeen, Scotland, UK
Email: r.flin@abdn.ac.uk
(5) Should specialist medical training be more flexible?
(Research: Medical graduates’ early career choices of specialty and their eventual specialty destinations: UK prospective cohort studies)
http://www.bmj.com/cgi/content/abstract/341/jul06_1/c3199
(Editorial: The durability of early career choices)
http://www.bmj.com/cgi/content/extract/341/jul06_1/c3500
Specialist medical training programmes should retain some flexibility to help trainee doctors make the right career choices, according to a study published on bmj.com today.
Some UK medical graduates choose a specialty as soon as they qualify and others after a few years of postgraduate work. But changes to postgraduate medical training mean that junior doctors will generally have to make choices sooner than in the past.
This concern was first highlighted by the Tooke report in 2008, which suggested that medical education and Modernising Medical Careers policy in the UK encourages foundation trainees to make career choices when many are not ready to make such commitments.
Researchers at the University of Oxford, set out to compare doctors’ early career choices with their eventual career destinations.
Using questionnaire data from five cohorts of doctors from UK medical schools, who graduated between 1974 and 1996, they compared the extent to which choices of specialties at one, three, and five years after graduation corresponded to career destinations 10 years after graduation.
They found that, 10 years after graduating, almost half of doctors were working in a specialty different from the one chosen in their first year after graduation and about a quarter were working in a specialty different from their year three choice.
This trend stayed reasonably constant across graduation cohorts despite the changes in training programmes over time.
Differences between specialties were considerable - for example, 90% of practising surgeons but only 50% of general practitioners had chosen their specialty in year one.
The research shows that many doctors who want to be general practitioners from the outset achieve their ambition, but also that many doctors who initially aspire to other careers eventually work in general practice, explain the authors. It also suggests that eventual success in surgery is only likely if surgery was always the intended specialty, but also that many with that early aspiration do not achieve it.
Some respondents commented about an increasing lack of flexibility, as they saw it, in applying for specialty training, while some expressed concerns about having only one lifetime opportunity to succeed in getting on to a training programme for their chosen specialty.
The authors conclude that a two point entry to specialty training programmes would alleviate this problem by allowing those who have made early, definite choices to progress quickly into their chosen specialty, while recognising the need for flexibility for those who choose later.
In an accompanying editorial, Jeremy Brown, a senior lecturer at Edge Hill University in Lancashire acknowledges that the career advice service provided by medical schools and deaneries has improved greatly, but warns that “specialty programmes need to identify ways of supporting those trainees who need time and experience in the postgraduate setting to make a firm commitment that will match their eventual career destination.”
He concludes: “These findings may strengthen the argument that the existing two year foundation programme followed by two or three years of core specialist training may provide the necessary flexibility to match and underpin the natural variation in career aspirations for many postgraduate doctors.”
Contacts:
Research: Michael Goldacre, Professor of Public Health, UK Medical Careers Research Group, Department of Public Health, University of Oxford, UK
Email: michael.goldacre@dphpc.ox.ac.uk
Editorial: Jeremy Brown, Senior Lecturer, Evidence-based Practice Research Centre, Faculty of Health, Edge Hill University, Ormskirk, Lancashire, UK
Email: brownjm@edgehill.ac.uk
(6) HPV infection linked to increased risk of skin cancer
(Research: Genus ß human papillomaviruses and incidence of basal cell and squamous cell carcinomas of the skin: population-based case-control study)
http://www.bmj.com/cgi/doi/10.1136/bmj.c2986
HPV infection heightens the risk of developing certain skin cancers and is worsened if people are taking immunosuppression drugs, according to a new study published on bmj.com today.
An international team of researchers found that people with several types of human papillomaviruses (HPVs) were more than one and a half times as likely to develop certain skin cancers compared to people with no HPVs.
The most common skin cancers (basal cell carcinoma and squamous cell carcinoma) are increasing globally and ultraviolet radiation is the main established risk factor.
In addition, HPV infection - of which there are more than 100 types - may play a role in their development. Other types of HPVs are known to cause cancers of the cervix, vulva, vagina, anus, and penis.
Research so far has identified increased risks for people with skin HPV types called beta HPVs, particularly among organ transplant recipients and people with epidermodysplasia verruciformis (EV) – a rare genetic disorder, which leads to warts and malignant skin lesions.
Now researchers, led by Professor Margaret Karagas of the Dartmouth Medical School in the USA, wanted to find more conclusive evidence of a link between beta HPVs and the common skin cancers among the general population.
They studied 2,366 people living in New Hampshire, USA, made up of 663 people with squamous cell carcinoma, 898 people with basal cell carcinoma and 805 healthy controls.
As well as interviewing the study participants, the researchers measured HPV antibodies in blood samples of newly diagnosed and confirmed basal cell and squamous cell carcinoma patients from two periods - July 1993 to June 1995 and July 1997 to March 2000 and matched population controls.
Results showed that people with squamous cell carcinoma, but not basal cell carcinoma, were far more likely to have each of the beta HPV types compared to people in the control group. The likelihood of having squamous cell carcinoma increased as people were found to have more of the HPV types.
For example, people with squamous cell carcinoma were 1.4 times more likely to have two to three types of HPV, and 1.7 times more likely to have greater than eight types of HPV compared with the control group.
The researchers also found that people who were long term users of immunosuppressant drugs had more than a three-fold risk of squamous cell carcinoma in relation to HPV, but with limited statistical precision.
“Given the widespread and growing occurrence of these malignancies, our results raise the possibility of reducing the health and economic burden of these cancers through prevention or treatment of human papillomavirus infection,” conclude the authors.
Contact:
Research: Margaret Karagas, Section of Biostatistics and Epidemiology, Department of Community and Family Medicine and Norris Cotton Cancer Center, Dartmouth Medical School, Hanover, NH, USA
Email: margaret.karagas@dartmouth.edu
(7) Wrist fractures have an important public health impact
(Research: Functional decline after incident wrist fractures - study of Osteoporotic Fractures: prospective cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.c3324
Wrist fractures have an important personal and public health impact and may play a role in the development of disability in older people, according to a new study published on bmj.com today.
Wrist fractures are the most common upper extremity fractures in older adults and can affect everyday tasks like carrying heavy objects, opening doors, cutting food, pouring liquid, turning the key, and getting out of a chair. But their precise impact on functional decline (ability to carry out usual daily activities) has not been well studied.
So a team of US researchers set out to quantify the clinical impact of wrist fractures in a group of older women.
They identified 6,107 healthy women, aged 65 years and older, without prior wrist or hip fracture. Five activities of daily living were used as a measure of functional decline (meal preparation, heavy housekeeping, ability to climb 10 stairs, shopping, and getting out of a car). Participants were examined approximately every two years for an average of 7.6 years.
During the study period, 268 women had a wrist fracture. These women were approximately 50% more likely to experience clinically important functional decline compared to women without a wrist fracture, even after accounting for demographic, health and lifestyle factors.
In fact, the effect of a wrist fracture on functional decline was clinically as significant as other established risk factors such as falls, diabetes and arthritis.
“Our findings highlight the personal, public health, and policy implications of wrist fractures,” say the authors.
They call for greater public health awareness of the impact of wrist fractures, including measures to prevent wrist fractures and prompt rehabilitation after a wrist fracture to help improve recovery.
Contact:
Beatrice Edwards, Bone Health and Osteoporosis Center, Feinberg School of Medicine, Northwestern University Chicago, USA
Email: bje168@northwestern.edu
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