Press releases Monday 4 October to Friday 8 October 2010

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) Investigation reveals shocking lack of surgical training posts that could cost the NHS millions
• (2) Inconsistencies of care account for different caesarean rates across England
• (3) Strict cannabis laws are not working, warns new report
• (4) Time to end the silence surrounding stillbirth, says doctor whose son died
• (5) Low Apgar score at birth linked to cerebral palsy

(1) Investigation reveals "shocking" lack of surgical training posts that could cost the NHS millions
See BMJ Careers
careers.bmj.com

Hundreds of aspiring surgeons have been unable to obtain specialist training posts this year and are being left adrift in the medical training system, finds an investigation by BMJ Careers, published online today.

The sums of wasted education this represents runs well into the millions.

According to deanery statistics (the bodies responsible for doctors training), only a handful of this year's core trainees in general surgery were even interviewed for a specialist training (ST3) post and none were appointed at all across the Northern, and Yorkshire and Humber areas.

Research by Dr Alison Carr, dean advisor for MMC England to the Medical Programme Board in June, also shows that in 2010 fewer than a quarter of doctors qualifying in 2005-6 were recruited to ST3 posts. Competition ratios ranged from 4.4 applicants per post to 14.9 applicants per post in some specialties.

Dr Carr also showed there was a bottleneck of surgical trainees, some of whom have been waiting as long as 13 years for an ST3 post.

Shreelata Datta, chair of the BMA Junior Doctors Committee, said the mismatch between core training and surgical training posts was absolutely shocking and could be costing the NHS several million pounds a year. Some may be forced to look elsewhere and take their skills abroad, while others may leave medicine altogether, she warned.

Richard Marks, Remedy UKs head of policy, said too many trainees were being deliberately put through the medical training system. Trainees are caught up in a system that is fundamentally deceptive. They might as well chuck their CVs up in the air.

Yet this large disparity is known to government. A spokesperson for the Department of Health said surgical training had always been highly competitive. The profession knows this and is supportive of it - competition helps to ensure that the best candidates progress in the field.

The Royal College of Surgeons is now urging the Department to extend the surgical core training period from two to three years. The BMA will also be liaising with the College and the Department to make sure the importance of career progression is prioritised in surgery.

In an accompanying commentary, Edward Davies, Editor of BMJ Careers says this investigation is merely the latest in a litany of mediocrity to afflict doctors at every single stage of their careers.

He acknowledges that healthy competition is good for standards and surgery is extremely popular but argues that this much competition is not good for anybody. He also warns that, as each year this goes on, the number of backlogged doctors who have reached ST2 level simply increases, meaning future ratios could well get worse.

At best it is poor planning, and at worst dishonest, he writes. Were effectively throwing money at crippling the morale of junior doctors in our health service.

He believes there is no magic bullet to fix this, but that certain core issues need urgent addressing. Firstly, the Department of Health must decide whether junior doctors are supposed to be the consultants of tomorrow or cheap labour for now. There needs to be more joined up thinking about professional numbers, based around service needs, and there needs to be much more honesty around what is achievable in a medical career, he concludes.

Contacts:

Edward Davies, Editor, BMJ Careers, London, UK

Email: edavies@bmj.com

(2) Inconsistencies of care account for different caesarean rates across England
(Research: Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5065
(Editorial: Variation in caesarean delivery rates)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5255

Inconsistencies of care are responsible for the large variation in rates of emergency caesarean section across England, according to a study published on bmj.com today.

The results do not support the view that low-risk women are requesting elective caesareans for non-medical reasons.

Since the 1970s, many developed countries have experienced a substantial growth in caesarean section rates. In England, the rate has increased from 9% in 1980 to almost 25% in 2008-09. Recent figures also show that caesarean rates vary substantially between English NHS trusts, with higher rates in the south of England compared to the north. But these figures did not take account of differences in patient populations.

So researchers based at the Royal College of Obstetricians and Gynaecologists examined whether the variation could be explained by maternal characteristics or clinical risk factors.

Using routinely collected hospital data, they analysed singleton births among women aged between 15 and 44 years at 146 English NHS trusts during 2008.

A mathematical model was then used to estimate the likelihood of women having a caesarean section based on patient characteristics (age, ethnicity, number of previous pregnancies, social and economic deprivation) and clinical risk factors (previous caesarean, breech presentation, fetal distress).

Among 620,604 births, almost one in four (24%) were delivered by caesarean section. A high proportion of women underwent a caesarean section if they had previously had a caesarean (71%), a breech baby (90%), or serious medical complications (85%). The likelihood of a caesarean was also higher in older women.

Unadjusted caesarean rates among NHS trusts varied substantially, from 13.6% to 31.9%.

After adjusting for maternal characteristics and clinical risk factors, caesarean rates still varied considerably, from 14.9% to 32.1%. However, adjustment removed the north-south divide.

Most of this variation was associated with rates of emergency caesarean section, which probably reflects the lack of a precise definition for fetal distress or dystocia (an abnormal or difficult labour) - both common reasons for an emergency caesarean - as well as differences in practices among professionals, say the authors. These findings also challenge the view that low-risk women are requesting elective caesareans.

They suggest that comparing unadjusted caesarean section rates should be avoided and call on NHS trusts to examine the reasons for this variation in their regions, and how the consistency of care for pregnant women can be improved.

This research indicates, at a minimum, the need for more informed surveillance of caesarean sections at a hospital, regional, and national level, say Marian Knight from the University of Oxford and Elizabeth Sullivan from the University of New South Wales, in an accompanying editorial. They call for a more detailed examination of variations in caesarean delivery practice and the generation of the high quality evidence needed to inform practice guidelines.

Contacts:

Research: Dr David Cromwell, Senior Lecturer, Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, UK
Email: david.cromwell@lshtm.ac.uk
Marian Knight, Senior Clinical Research Fellow, National Perinatal Epidemiology Unit, University of Oxford, UK
Email: marian.knight@npeu.ox.ac.uk

(3) Strict cannabis laws are not working, warns new report
(Editorial: Prohibition of cannabis)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5492

Prohibition of cannabis in the United States is not achieving its aims, and may even worsen outcomes, warns a new report.

The implications are discussed in an editorial by expert Professor Robin Room published on bmj.com today.

The report, Tools for Debate: US Federal Government Data on Cannabis Prohibition, focuses on the effects of the enforcement of drug prohibition in recent decades in the United States.

It shows that efforts to suppress the selling and use of cannabis increased substantially. Adjusting for inflation, the US federal antidrug budget increased from about $1.5bn (0.95bn; 1.1bn) in 1981 to more than $18bn in 2002. Between 1990 and 2006, cannabis related arrests increased from fewer than 350,000 to more than 800,000 annually and seizures of cannabis from less than 500,000 lb (226,798 kg) to more than 2,500,000 lb.

In the same period, the retail price of cannabis decreased by more than half, the potency increased, and the proportion of users who were young adults went up from about 25% to more than 30%. Intensified enforcement of cannabis prohibition thus did not have the intended effects.

The report also argues that drug prohibition has contributed to increased rates of violence, and concludes that experience with regulation of alcohol and tobacco offers many lessons on how a regulated market in cannabis might best be organised.

Tools for Debate joins a bookshelf of reports from the past half century describing perverse effects of drug prohibition and charting ways out of the maze, writes Professor Room. So far, no government has dared to follow the thread all the way, but he believes the drug prohibition wave may finally be ebbing. So there are lessons to be learned from the last time this happened, with the end of national alcohol prohibitions in the 1930s.

He points to the strong alcohol regulatory systems of the 1930s which limited the harms from drinking in the period before about 1960, but the lessons have not been applied to regulating cannabis or other drugs.

He suggests that state control instruments - such as licensing regimes, inspectors, and sales outlets run by the government which are still in place for alcohol in some areas could be extended to cover cannabis and would provide workable and well-controlled retail outlets for cannabis.

While treaties and other barriers stand in the way of regulating cannabis, Room suggests that countries who choose to adopt a new approach to cannabis control could allow a regulated legal domestic market, while keeping in place international market controls as a matter of comity (whereby jurisdictions recognise and support each others internal laws).

He concludes: The evidence from Tools for Debate is not only that the prohibition system is not achieving its aims, but that more efforts in the same direction only worsen the results. The challenge for researchers and policy analysts now is to flesh out the details of effective regulatory regimes, as was done at the brink of repeal of US alcohol prohibition.

Contact:

Robin Room, School of Population Health, University of Melbourne; Centre for Social Research on Alcohol and Drugs, Stockholm University; and AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Australia
Email: robinr@turningpoint.org.au

(4) Time to end the silence surrounding stillbirth, says doctor whose son died
(Personal View: Towards an end to stillbirths)
http://www.bmj.com/cgi/doi/10.1136/bmj.c5070

The time has come to end the silence surrounding stillbirth, says Dr Alexander Heazell in a personal account of his experience published on bmj.com today.

I now realise that our son is one of many such deaths, and the impact of stillbirth is greater than anyone seems to recognise, he writes, and he calls for stillbirth to be prioritised by government, support groups, and those in maternity care.

On average there are around 10 stillbirths everyday in the United Kingdom and more than 4000 a year, the equivalent of a years births in many hospitals. The worldwide burden is estimated at 3 million stillbirths a year, 99% of which are in the developing world.

In the UK, the rate of stillbirths has not fallen significantly for more than a decade, remaining at 5.1 per 1000 live births. In the same period, advances in neonatal care have seen neonatal deaths fall from 4.1 to 3.2 per 1000. So why is stillbirth, which affects one in 200 parents, so under-researched and under-prioritised, he asks?

He points out that it isnt just health professionals who see stillbirth as rare and insignificant. A survey of the general public showed that most people think that Downs syndrome is more common than stillbirth (the risk is in fact one in 700). And cot death, which is at the forefront of every expectant parents mind, is 10 times less common than stillbirth.

He believes that the invisibility of stillbirth is compounded by the reluctance of professionals and parents to deal with stillbirth openly. But for parents this is a devastating and confusing time, that nothing and no one has equipped them to deal with, he says.

And because most stillbirths remain unexplained, health professionals have little to offer parents in subsequent pregnancies, save for increased surveillance, to minimise their risk of another stillbirth, which is twofold to 10-fold greater than in women with a live born child, he adds.

In many cases, stillbirth also represents a perceived failure of maternity care. A recent study found suboptimal care in 45% of stillbirths.

Finally, he points out that many of the factors associated with stillbirth are outside the realms of medical care. Poverty, educational attainment, smoking, alcohol and drug misuse, and lack of appropriate birthing facilities all affect the risk of stillbirth.

Dr Heazell thinks the time has come to end the silence surrounding stillbirth. For improvements to be made policy makers must recognise the impact of stillbirth and the need for research to develop strategies to prevent it and its consequences for parents, he writes.

He concludes: Thirty years ago no one talked about cancer. Today the diagnosis and treatment of cancers is improving all the time. If parents are brave enough to speak, and doctors, midwives, and policy makers courageous enough to listen to them, then the barriers to reducing the number of these deaths can be overcome. In time stillbirth, like cancer, will no longer be taboo but a condition thats openly debated, researched, treated and prevented.

Contact:

Alexander Heazell, Clinical Lecturer in Obstetrics, University of Manchester, UK
Email: alexander.heazell@manchester.ac.uk

(5) Low Apgar score at birth linked to cerebral palsy
(Research: Association of cerebral palsy with Apgar score in low and normal birth weight infants: population based cohort study)

http://www.bmj.com/cgi/doi/10.1136/bmj.c4990
(Editorial: Apgar score and risk of cerebral palsy) http://www.bmj.com/cgi/doi/10.1136/bmj.c5175

A low Apgar score at birth is strongly associated with cerebral palsy in childhood, concludes a study from researchers in Norway published on bmj.com today.

The Apgar score is a quick and simple way to assess a baby's condition at birth. The baby is assessed on five simple criteria (complexion, pulse rate, reaction when stimulated, muscle tone, and breathing) on a scale from zero to two. The five values are then summed up to obtain a score from zero to 10.

Scores of 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal.

Cerebral palsy is a rare disease, affecting two to three infants in every 1000 live born children in Western countries. Recent studies have found a strong link between low Apgar score and cerebral palsy in children born to term or with normal birth weight, whereas studies in children with a low birth weight or born preterm have shown conflicting results.

Using linked data from the Medical Birth Registry of Norway and the Norwegian Registry of Cerebral Palsy in Children, the researchers assessed the association of Apgar score five minutes after birth with cerebral palsy in 543,064 children born between 1986 and 1995.

A total of 988 children included in the study (1.8 in 1000) were diagnosed with cerebral palsy before the age of five years.

Low Apgar score was strongly associated with later diagnosis of cerebral palsy. The prevalence of cerebral palsy in children with Apgar score of less than 3 was more than 100-fold higher than in children with a score of 10.

This association was high in children with normal birth weight and modest in children with low birth weight.

Low Apgar score was also associated with all subgroups of spastic cerebral palsy, but the association was strongest for quadriplegia.

Despite the strong association of low Apgar score with cerebral palsy, it is encouraging that almost 90% of children with an Apgar score of less than 4 at birth did not develop cerebral palsy, say the authors.

Given that Apgar score is a measure of vitality shortly after birth, our findings suggest that the causes of cerebral palsy are closely linked to factors that reduce infant vitality, they conclude. In fact, low Apgar score might be interpreted as an indicator of brain impairment that has occurred during pregnancy or delivery.

In an accompanying editorial, Professor Nigel Paneth from Michigan State University in the US says that a low Apgar score in a baby of normal weight is an important clue that the baby has an increased risk of death and disability, even though most infants with such scores recover quickly and do well.

He advises that such babies should be watched closely for the persistence or development of signs of brain damage, especially in the light of robust evidence that babies with brain injury may benefit from head or body cooling.

Contacts:

Research: Kari Kveim Lie, Senior Researcher, Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
Email: kari.kveim.lie@fhi.no
Editorial: Nigel Paneth, Departments of Epidemiology and Pediatrics and Human Development, College of Human Medicine, Michigan State University, USA
Email: paneth@msu.edu

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Email: edickinson@bma.org.uk

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http://intranet.bmj.com/departments/dept-bmj/bmj-team-resources/web-team-resources/General_blogging_principles.doc