The GMC documents Tomorrow’s Doctors and Good Medical Practice and the Foundation Programme Curriculum all outline the need for junior doctors to develop their teaching skills because doctors have a professional obligation to contribute to the training of other doctors, medical students and non-medical healthcare professionals.
According to an article in the BMJ Careers written by a F1 doctor together with a foundation school director, most foundation trainees have little formal training in teaching when they leave medical school. Many foundation trainees teach medical students at the bedside in their job and develop their own teaching style through trial and error. The authors said that these skills are not innate but can be learnt and developed.
The article discusses the teaching role of foundation trainees, the skills required to be bedside teachers including : practical and theoretical understanding of the topics to be taught, assessing each student's needs, develop good learning relationship, how to give feedback, planning the session and different styles of teaching. Ways foundation trainees can improve their teaching skills are also suggested.
It is advised that junior doctors who want to involve in teaching medical students should discuss their teaching activities with their firm lead and education supervisor to ensure support and workload planning can be arranged.
Source: Foundation doctors and bedside teaching. BMJ Careers ( free article)
See also : Teaching and Learning ‘At the Bedside’ . London Deanery. ( free article)
Friday, April 08, 2011
Friday, March 18, 2011
What distinguishes top-performing hospitals.....
In recent years, public reporting of hospitals' performance is becoming increasingly common in America to improve patient outcomes and accountability. Many hospitals have made substantial efforts in quality improvement including investing in high-tech equipments and systems, but disparities still persist between the highest and lowest performing hospitals in patient mortality rates.
According to a new study, conducted by Yale Global Health Leadership Institute at Yale University, published in the Annals of Internal Medicine, between 2005 and 2007, the 30-day mortality rates for Medicare heart attack patients ranged from 11.4%-14% among the high performers and 17.9%- 20% among the low.
Earlier studies suggested that the high mortality rates in low-performing hospitals could have been caused by factors such as hospital location, bed size, for-profit status, nurse staffing ratio and patient population, eg black, elderly. However, the Yale researchers found that these factors accounted for a small percentage of the variation between the high and low peforming hospitals.
They compared the characteristics of 11 hospitals ranking the top or bottom 5% measured by the 30-day mortality rates for acute myocardial infarction (AMI). They interviewed 158 key staff who were involved with AMI care at the hospitals and found few differences in protocols and processes used in treating heart attacks, but what differentiated the high performers from the low was how they did things - a shared organisational culture that focused on communication and support to improve patient care.
According to a new study, conducted by Yale Global Health Leadership Institute at Yale University, published in the Annals of Internal Medicine, between 2005 and 2007, the 30-day mortality rates for Medicare heart attack patients ranged from 11.4%-14% among the high performers and 17.9%- 20% among the low.
Earlier studies suggested that the high mortality rates in low-performing hospitals could have been caused by factors such as hospital location, bed size, for-profit status, nurse staffing ratio and patient population, eg black, elderly. However, the Yale researchers found that these factors accounted for a small percentage of the variation between the high and low peforming hospitals.
They compared the characteristics of 11 hospitals ranking the top or bottom 5% measured by the 30-day mortality rates for acute myocardial infarction (AMI). They interviewed 158 key staff who were involved with AMI care at the hospitals and found few differences in protocols and processes used in treating heart attacks, but what differentiated the high performers from the low was how they did things - a shared organisational culture that focused on communication and support to improve patient care.
They found that high-performing hospitals were characterised by the followings :
- staff shared organisational values and goals of providing high quality care
- senior management involvement and commitment to high quality care
- broad staff presence and expertise in clinical decision making
- strong communication and coordination across disciplines and departments resulting in seamless transitions in care
- used adverse events and feedback as opportunities for problem solving that focused on nonpunitive learning
The study concluded that protocols and processes are not sufficient for achieving high performace in AMI care but "long-term investment and concerted efforts to create an organisational culture that supports full engagement in quality, strong communication and coordination .... problem solving and learning across the organisation" may be required.
Source: What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates? A Qualitative Study. Annals of Internal Medicine. March 14, 2011 vol. 154 no. 6 384-390 ( f/t via Athens)
Wednesday, March 16, 2011
Metformin still best first-line type 2 diabetes drug
According to a new review published online in Annals of Internal Medicine, there are numerous regimes of diabetes medications to treat type 2 diabetes in the US. Many of these patients need to take multiple medications to control their blood sugar levels, but they have side effects - hypoglycemia ( low blood sugar levels) is the the most common serious side effect, others include nausea or diarrhea.
Researchers at Johns Hopkins reviewed 166 studies that examined the efficacy of 6 classes of diabetes drugs. They found that most of the medications lowered blood sugar levels by a similar amount and that combination of 2 drugs improved blood sugar control, but no combination was shown to have significant benefits over another. The study found that metformin, an older drug approved in 1995 in the US, was consistently associated with fewer side effects and is cheaper than most newer drugs. Reserachers suggested metformin is probably the best first-line therapy for type 2 diabetes.
The study noted that 95 of the 166 studies reported drug company support, many of them were not long enough to study the side effects. The study leader said longer-term reserach into their impact on long-term outcome is needed .
Siurce: Comparative Effectiveness and Safety of Medications for Type 2 Diabetes: An Update Including New Drugs and 2-Drug Combinations. Annals of Internal Medicine, First published online on March 14, 2011 ( free f/t article)
Researchers at Johns Hopkins reviewed 166 studies that examined the efficacy of 6 classes of diabetes drugs. They found that most of the medications lowered blood sugar levels by a similar amount and that combination of 2 drugs improved blood sugar control, but no combination was shown to have significant benefits over another. The study found that metformin, an older drug approved in 1995 in the US, was consistently associated with fewer side effects and is cheaper than most newer drugs. Reserachers suggested metformin is probably the best first-line therapy for type 2 diabetes.
The study noted that 95 of the 166 studies reported drug company support, many of them were not long enough to study the side effects. The study leader said longer-term reserach into their impact on long-term outcome is needed .
Siurce: Comparative Effectiveness and Safety of Medications for Type 2 Diabetes: An Update Including New Drugs and 2-Drug Combinations. Annals of Internal Medicine, First published online on March 14, 2011 ( free f/t article)
Tuesday, March 15, 2011
Tamoxifen saves lives and costs
Research has shown that tamoxifen (Nolvadex) can protect against breast cancer but can have side effects including hot flashes, weight gain, abnormal menstrual periods and nausea.
To investigate those women who can most benefit from tamoxifen as a cancer preventive drug, US researchers analysed 4 randomised, placebo-controlled trials and assessed the effects that tamoxifen would have on breast cancer risk 10 years after the treatment.
Investigators used a mathematical model and found that in post-menopausal women under 55 who have an increased risk of developing breast cancer, the benefits of using tamoxifen to prevent cancer are sufficiently outweigh its side effects, it also saves costs.
Source: Cost-effectiveness of chemoprevention of breast cancer using tamoxifen in a postmenopausal US population. Cancer, 2011; published online 14 March 2011
To investigate those women who can most benefit from tamoxifen as a cancer preventive drug, US researchers analysed 4 randomised, placebo-controlled trials and assessed the effects that tamoxifen would have on breast cancer risk 10 years after the treatment.
Investigators used a mathematical model and found that in post-menopausal women under 55 who have an increased risk of developing breast cancer, the benefits of using tamoxifen to prevent cancer are sufficiently outweigh its side effects, it also saves costs.
Source: Cost-effectiveness of chemoprevention of breast cancer using tamoxifen in a postmenopausal US population. Cancer, 2011; published online 14 March 2011
Monday, March 14, 2011
Mediterranean diet reduces metabolic syndrome
Many studies have found that the Mediterranean diet reduces heart disease, but a new review, published in the Journal of the American College of Cardiology, examined the effects of the Mediterrean diet on the risk factors of cardiovascular diseases.
The researchers reviewed and analysed the results of 50 studies in the English language with more than 500,000 participants, they also evaluated the quality of each study. They found that eating the Mediterranean diet reduced the development of the metabolic syndrome as well as all the individual components such as high blood pressure, high blood sugar, high blood fat, low levels of good cholesterol and large waist circumference - these are the risk factors often precede the development of cardiovascular diseases.
They concluded that thier findings have considerable public health importance but noted several limitations in the study, eg the considerable heterogeneity among the studies which could affect the results - only 8 studies addressed the effects on all the metabolic syndrome risk factors, of which 2 were RCTs, 2 cohort studies and 4 cross-sectional studies.
Source: Kastorini CM, Milionis HJ, Esposito K et al. The Effect of Mediterranean Diet on Metabolic Syndrome and its Components: A Meta-Analysis of 50 Studies and 534,906 Individuals. Journal of the American College of Cardiology, 2011; 57:1299-1313
The researchers reviewed and analysed the results of 50 studies in the English language with more than 500,000 participants, they also evaluated the quality of each study. They found that eating the Mediterranean diet reduced the development of the metabolic syndrome as well as all the individual components such as high blood pressure, high blood sugar, high blood fat, low levels of good cholesterol and large waist circumference - these are the risk factors often precede the development of cardiovascular diseases.
They concluded that thier findings have considerable public health importance but noted several limitations in the study, eg the considerable heterogeneity among the studies which could affect the results - only 8 studies addressed the effects on all the metabolic syndrome risk factors, of which 2 were RCTs, 2 cohort studies and 4 cross-sectional studies.
Source: Kastorini CM, Milionis HJ, Esposito K et al. The Effect of Mediterranean Diet on Metabolic Syndrome and its Components: A Meta-Analysis of 50 Studies and 534,906 Individuals. Journal of the American College of Cardiology, 2011; 57:1299-1313
Wednesday, March 09, 2011
Current fever management in children is challenged
A new clinical report prepared by the American Academy of Pediatrics (AAP) and published in Pediatrics highlights the need to educate patients and families about fever in children.
It is not a new research but an expert commentary with the aim to challenge current practice on fever management in children, ie fever reduction.
They said that fever is a physiological mechanism in fighting infection, there is no evidence that fever causes long-term neurological complications. The report emphasizes improving the child’s overall comfort rather than concentrating in normalizing the body temperature.
Paracetamol and ibuprofen are the most commonly used antipyretics, but there are adverse effects and toxicity. The report said that it is critical to administer a safe dosage of these drugs and the correct dosage is based on the child's weight. However, many parents do not understand dosing instructions resulting in potential inaccurate or overdosing.
The authors call for better information for parents and concluded that in fever management, fever reduction should not be the primary aim but parents and healthcare professionals should be more vigilant for signs of serious illnesses.
Source: Sullivan JE, Farrar HC and the Section on Clinical Pharmacology and Clinical Report. Fever and Antipyretic Use in Children. Pediatrics 2011 , published online Feb 28
It is not a new research but an expert commentary with the aim to challenge current practice on fever management in children, ie fever reduction.
They said that fever is a physiological mechanism in fighting infection, there is no evidence that fever causes long-term neurological complications. The report emphasizes improving the child’s overall comfort rather than concentrating in normalizing the body temperature.
Paracetamol and ibuprofen are the most commonly used antipyretics, but there are adverse effects and toxicity. The report said that it is critical to administer a safe dosage of these drugs and the correct dosage is based on the child's weight. However, many parents do not understand dosing instructions resulting in potential inaccurate or overdosing.
The authors call for better information for parents and concluded that in fever management, fever reduction should not be the primary aim but parents and healthcare professionals should be more vigilant for signs of serious illnesses.
Source: Sullivan JE, Farrar HC and the Section on Clinical Pharmacology and Clinical Report. Fever and Antipyretic Use in Children. Pediatrics 2011 , published online Feb 28
UK-trained doctors from ethnic minority groups underperform academically
A third of all UK medical students and junior doctors come from ethnic groups. In 2009, 36% of newly qualified doctors and 52% of all other NHS doctors were from these groups. A new study conducted by UCL researchers found that UK-trained medical students and doctors from ethnic minority groups underpeformed academically compared with their white counterparts. They systematically analysed 22 reports involving about 24,000 UK- trained medical students and doctors from different ethnic groups and found that the odds of failure in non-white candidates was 2.5 times higher than the white candidates. They said that ethnic differences in academic performance are widespread across different medical schools, different types of exams and in both undergraduate and postgraduate assessments. It was persistent for 30 years and "cannot be dismissed as atypical or local problems". They called for further research into the causes to ensure that all future doctors are assessed fairly. In an accompanying editorial, the author said that soultions will be found through critically appraising assessment methods, curricula and interactions with students.
What do you think may have caused the ethnic differences in attainment and how can they be resolved?
Source: Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ 2011; 342:d901 ( free access) Editorial - Ethnicity and academic performance in the UK. BMJ 2011; 342:d709 ( free access)
Thursday, February 03, 2011
Should I take statins as a preventive measure?
A new Cochrane systematic review conducted by London School of Hygiene and Tropical Medicine and the University of Bristol questioned the benefits of prescribing statins to people without heart disease.
Researchers reviewed 14 trials involving more than 34,000 patients with low risk of heart attack and strokes. They found that overall statins reduced mortality, but the effect was very small - 1000 people have to be treated for 1 year to prevent 1 death. Previous studies have found that statins have been associated with a range of side effects including kidney failure and muscle weakness, therfore not worth the risk in people without history of cardiovascular disease.
They pointed out that the findings of the trials were biased due to several shortcomings: 1/3 of the trials outcomes were selectively reported, 8 trials did not report on the adverse effects, 2 large trials were stopped prematurely, only 1 trial has been funded publicly while 9 trials were sponsored by drug companies partially or fully. They concluded "widespread use of statins in people at low risk of cardiovascular events ..... is not supported by the existing evidence".
Oxford researchers noted that the Cochrane review did not include the recent meta-analysis conducted by the Oxford group which was more reliable than the Cochrane review.
In an accompanying editorial, the author said that the current evidence supports the NICE guidance that statins should be used for the primary prevention of CVD for people with more than 20% risk of developing the disease. Given the limitations of the study, he suggested an alternative approach to focus on population-wide prevention.
Source:
Taylor F, Ward K, Moore THM et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2011, Issue
Editorial :Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease. Cochrane Library 2011, (January 19, 2011).
http://www2.cochrane.org/reviews/en/ab004816.html
Thursday, January 20, 2011
Behavioral therapy reduces postprostatectomy incontinence
According to a study published in JAMA, 65% of men experience urinary incontinence up to 5 years following radical prostatectomy.
American researchers conducted a randomized controlled trial involving 208 men aged 51 - 84 with incontinence persisting 1 to 17 years after radical prostatectomy, to evaluate the effectiveness of behavioral therapy for reducing post-prostatectomy incontinence and to determine whether biofeedback and electrical stimulation enhance its effectiveness. 24% of the men were black and 75 % white.
The researchers found that over the 8-week treatment period, those in the behavioral therapy group had an average reduction of incontinence episodes of 55 % (from 28 to 13 episodes per week), while the control group had an average reduction of only 24 % ( from 25 to 21 episodes per week). Those in the behavior-plus group experienced an average reduction of 51% (from 26 to 12 episodes per week), indicating that the addition of biofeedback and electrical stimulation did not improve the 8-week results compared with behavioral therapy alone.
Improvements were evident up to a year in the treatment groups, 50% reduction in the behavioral group and 59% in the behavior plus group. By the end of the treatment period, 15.7 % of men in the behavior therapy group, 17.1% in the behavior-plus group, and 5.9% in the control group achieved complete continence.
The researchers concluded that for men with incontinence following radical prostatectomy, behavioral therapy resulted in significant reduction in incontinence espisodes and that these findings have important implications for doctors and patients.
In an accompanying editorial, the author wrote that the optimal way to address postprostatectomy incontinence remains unanswered and that a better strategy would be primary prevention.
Source: Behavioral Therapy With or Without Biofeedback and Pelvic Floor Electrical Stimulation for Persistent Postprostatectomy Incontinence - A Randomized Controlled Trial. JAMA. 2011;305(2):151-159. (f/t via Athens)
Wednesday, January 12, 2011
General anesthesia is closer to coma than sleep
According to a review published in the NEJM, patients undergoing general anesthesia before surgery are not "going to sleep" as their doctors probably told them, they are placed in a “reversible coma".
Three US neuroscientists took 3 years to research studies in general anestheisa, sleep and coma to understand how anesthetic drugs induce and maintain the behavioral states of general anesthesia. They discussed the clinical and neurophysiological features of general anesthesia and their relationships to sleep and coma, focusing on the neural mechanisms of unconsciousness induced by selected anesthetic drugs.
They conclude that better understanding of the the different states of the process would lead to new approaches to general anesthesia and improved diagnosis and treatment for sleep problems and emergence from coma.
Source: "General Anesthesia, Sleep, and Coma". New England J of Medicine 2010; 363:2638-2650 ( f/t via Athens)
Three US neuroscientists took 3 years to research studies in general anestheisa, sleep and coma to understand how anesthetic drugs induce and maintain the behavioral states of general anesthesia. They discussed the clinical and neurophysiological features of general anesthesia and their relationships to sleep and coma, focusing on the neural mechanisms of unconsciousness induced by selected anesthetic drugs.
They conclude that better understanding of the the different states of the process would lead to new approaches to general anesthesia and improved diagnosis and treatment for sleep problems and emergence from coma.
Source: "General Anesthesia, Sleep, and Coma". New England J of Medicine 2010; 363:2638-2650 ( f/t via Athens)
Good cholesterol may reduce Alzhemier's risk
A new study claims that high levels of high-density lipoprotein (HDL) or ‘good’ cholesterol could lower the risks of developing Alzheimer’s disease in older adults,
US researchers studied 1,130 randomly selected elderly people aged 65 and over and had no history of memory trouble or dementia. The participants were follwoed for an average of four years. Researchers found that those with the highest HDL counts, over 55 mg/dL, had about a 60% reduced risk of developing the disease compared to those whose levels were under 39 mg/dL. The study author said that the result suggested that higher level of good cholesterol decreases the risk of Alzheimer's disease, but the mechanism is unknown.
It was noted that a previous study published in Neurology in 2001 found that Japanese-American men with higher HDL cholesterol were more likely to have Alzheimer's-related plagues and tangles in their brains.
Alzheimer's Society (UK) said until now, studies have focused on the associations between 'good' cholesterol and vascular dementia....... More research is needed to fully understand the link between HDL cholesterol and the processes that lead to Alzheimer's Disease.
Source:'Association of Higher Levels of High-Density Lipoprotein Cholesterol in Elderly Individuals and Lower Risk of Late-Onset Alzheimer Disease'. Archives of Neurology. 2010;67(12):1491-1497. doi:10.1001/archneurol.2010.297
US researchers studied 1,130 randomly selected elderly people aged 65 and over and had no history of memory trouble or dementia. The participants were follwoed for an average of four years. Researchers found that those with the highest HDL counts, over 55 mg/dL, had about a 60% reduced risk of developing the disease compared to those whose levels were under 39 mg/dL. The study author said that the result suggested that higher level of good cholesterol decreases the risk of Alzheimer's disease, but the mechanism is unknown.
It was noted that a previous study published in Neurology in 2001 found that Japanese-American men with higher HDL cholesterol were more likely to have Alzheimer's-related plagues and tangles in their brains.
Alzheimer's Society (UK) said until now, studies have focused on the associations between 'good' cholesterol and vascular dementia....... More research is needed to fully understand the link between HDL cholesterol and the processes that lead to Alzheimer's Disease.
Source:'Association of Higher Levels of High-Density Lipoprotein Cholesterol in Elderly Individuals and Lower Risk of Late-Onset Alzheimer Disease'. Archives of Neurology. 2010;67(12):1491-1497. doi:10.1001/archneurol.2010.297
Wednesday, December 22, 2010
UK cancer survival rate lags behind other countries
According to a new study, published in The Lancet today, cancer patients in England, Wales and Northern Ireland have lower survival rates than those in Australia, Canada, Sweden and Norway.
This is the first study in a programme to investigate international survival disparities, with the aim of informing health policy to raise standards and reduce inequalities in survival.
The scientists analysed data on 2.4 million cancer patients in the UK (not including Scotland), Australia, Canada, Denmark, Norway and Sweden focusing on cancers of breast, bowel, lung and ovarian. They examined the survival rate at 1 and 5 years between 1995 and 2007 and found that in some cases survival rates in the UK are more than 10% lower than Europe, Australia and Canada particularly in the first year after diagnosis. In the 5-year survival rate, UK was the worst in bowel, lung and breast cancer. Denmark also lags behind, though generally its outcomes were not as bad as the UK's.
The authors said, "Differences in individual, health-system and clinical factors - such as public awareness of cancer, diagnostic delay, stage, comorbidity and access to optimum treatment - are all potential explanations for the overall differences in relative survival. The patterns are consistent with late diagnosis or differences in treatment, particularly in Denmark and the UK, and in patients aged 65 years and older".
Cancer Research UK urges the government to focus on early diagnosis and on improving equitable access to treatment. It also urges collecting reliable and good quality information nationally in order to understand the extent of the problem and identify the causes of the survival gap within the UK and other countries.
Source: Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995—2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. The Lancet, Early Online Publication, 22 December 2010
This is the first study in a programme to investigate international survival disparities, with the aim of informing health policy to raise standards and reduce inequalities in survival.
The scientists analysed data on 2.4 million cancer patients in the UK (not including Scotland), Australia, Canada, Denmark, Norway and Sweden focusing on cancers of breast, bowel, lung and ovarian. They examined the survival rate at 1 and 5 years between 1995 and 2007 and found that in some cases survival rates in the UK are more than 10% lower than Europe, Australia and Canada particularly in the first year after diagnosis. In the 5-year survival rate, UK was the worst in bowel, lung and breast cancer. Denmark also lags behind, though generally its outcomes were not as bad as the UK's.
The authors said, "Differences in individual, health-system and clinical factors - such as public awareness of cancer, diagnostic delay, stage, comorbidity and access to optimum treatment - are all potential explanations for the overall differences in relative survival. The patterns are consistent with late diagnosis or differences in treatment, particularly in Denmark and the UK, and in patients aged 65 years and older".
Cancer Research UK urges the government to focus on early diagnosis and on improving equitable access to treatment. It also urges collecting reliable and good quality information nationally in order to understand the extent of the problem and identify the causes of the survival gap within the UK and other countries.
Source: Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995—2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. The Lancet, Early Online Publication, 22 December 2010
Thursday, December 09, 2010
Should healthy middle-aged people take daily aspirin ?
Studies have shown that aspirin, a commonly used painkiller, is linked to reductions in heart attacks and strokes, but it can irirtate the stomach and cause serious internal bleeding particularly in elderly people.
According to a new Oxford Univeristy study, published in The Lancet last week, taking a daily low dose of aspirin for reduced cancer deaths during and after the trials and the benefit increased with duration of treatment.
The researchers examined the data of 8 trials that looked at the effects of daily dose of aspirin on preventing heart attacks involving over 25,000 people. They found that aspirin reduced cancer deaths by 20% during the trial, but after 5 years, death rates were 34% lower for all cancer deaths. They also found the risk of all cancer deaths over a period of 20 years remained 20% lower for those who had taken aspirin, about 40% for bowel cancer, 30% for lung cancer, 10% for prostate cancer and 60% for oesophageal cancer. But there were not enough women participants to determine if daily aspirin could reduce breast, ovarian or endometrial cancer deaths.
The lead researcher said this study confirms the results of the previous study that found aspirin has preventive effect against cancer and has demonstrated a major new benefit of the drug. He believes that the findings have implications for guidelines on use of aspirin and the most benefit would be seen for those start taking aspirin between the age of 40 - 50 and continue for 25 years.
The previous study by the same authors, also published in The Lancet in October 2010, showed that a low dose of aspirin, 75mg per day taken for several years, reduced deaths due to colorectal cancer. However, opinions were divided on the result of the study.
Some said that the study did not give a balanced view of the effect of the treatment because it did not report the potential harms. The protective effects against cardiovascular disease were thought to be small for healthy adults. Some advised that aspirin should not be used to prevent heart attacks and strokes in "healthy" people as the risks outweigh potential benefits. Others said more research is needed before recommending taking aspirin to reduce cancer deaths.
Source: Rothwell PM, Fowkes FGR, Belch JFF, et al. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. The Lancet. 2010 Jan 7. [Epub ahead of print] Online publication 7 December 2010 ( f/t via Athens)
Previous studies :
Rothwell PM, Wilson M, Elwin C-E et al. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. The Lancet 2010, Early Online Publication, October 22 (f/t via Athens)
Benamouzig R, Uz B. Aspirin to prevent colorectal cancer: time to act? The Lancet 20110, Early Online Publication, 22 October (f/t via Athens)
Have you washed your hands - another study on patient safety
Since the report by the Institute of Medicine in 2000 that found high rates of medical mistakes in the US, most US hospitals had made efforts to improve patient safety. A new study, published in the NEJM found that patient harm in hospitals has not decreased over time!
Harvard researchers reviewed 2341 admission records obtained from 10 randomly selected hospitals in North Carolina between 2002 and 2007, they found 588 incidents of patient harm, ie 25.1 harms per 100 admissions, resulting from medical procedures, medications, or other causes.
The study found that infections was one of the most common complications, 42.7% required longer hospital stay for treatment, eg infected surgical incision. The types of patient harm varied widely and included falls, injury during surgery, low blood pressure and low blood sugar. Most of the complications were temporary and treatable, but 3% were permanent, eg brain damage from a stroke ( could have been prevented after an operation), 8.5% were life-threatening and 2.4% "caused or contributed to a patient's death."
The study's lead author, Dr. Christopher Landrigan, said "these harms are still very common, and there's no evidence that they're improving". Many of the problems were caused by the hospitals' failure to use protective measures that have been proven to improve care including computerizing patient records and drug prescription orders, using checklists for surgical procedures and other methods. He noted that the frequency of medical errors and injuries has been underestimated and there is a need for a mandatory monitoring system.
Some experts on hospital safety said heathcare providers should have a culture of strong communication and teamwork and it is essential that hospitals be more open about reporting problems. Some suggest that patients need cultural change too in ensuring their own safety, eg discussing about drug interactions with the doctor or asking if the doctor has washed his/her hands!
In the US, 27 state laws require public reporting of hospital-acquired infection rates. In 2005, all hospitals in New York were required by legislation to report hospital-acquired infections to the NY State Department of Health. In 2009, the NY Department of Health issued a state-wide report on hospital-by-hospital infection rates. They said that the information will help patients make more informed choices and allow hospitals to compare with other providers.
In the UK, despite promoting hand hygiene among staff, patients and visitors in NHS Trusts in England and Wales to reduce hospital acquired infections, infection rates and resulting harm are still very high.
In June 2010, the Health Secretary, Andrew Lansley, announced that as part of the new government's information revolution, infection figures for all hospitals in England will be published on a weekly basis from July on the government website . By making the data available to patients as well as hospital managers, he said people can make comparisons between different hospitals and healthcare organisations.
Have you washed your hands? Would you be offended if a patient or a colleague asks if you have washed your hands? What's your veiw?
Source : Temporal Trends in Rates of Patient Harm Resulting from Medical Care. N Engl J Med 2010; 363:2124-2134 ( full text via Athens )
Harvard researchers reviewed 2341 admission records obtained from 10 randomly selected hospitals in North Carolina between 2002 and 2007, they found 588 incidents of patient harm, ie 25.1 harms per 100 admissions, resulting from medical procedures, medications, or other causes.
The study found that infections was one of the most common complications, 42.7% required longer hospital stay for treatment, eg infected surgical incision. The types of patient harm varied widely and included falls, injury during surgery, low blood pressure and low blood sugar. Most of the complications were temporary and treatable, but 3% were permanent, eg brain damage from a stroke ( could have been prevented after an operation), 8.5% were life-threatening and 2.4% "caused or contributed to a patient's death."
The study's lead author, Dr. Christopher Landrigan, said "these harms are still very common, and there's no evidence that they're improving". Many of the problems were caused by the hospitals' failure to use protective measures that have been proven to improve care including computerizing patient records and drug prescription orders, using checklists for surgical procedures and other methods. He noted that the frequency of medical errors and injuries has been underestimated and there is a need for a mandatory monitoring system.
Some experts on hospital safety said heathcare providers should have a culture of strong communication and teamwork and it is essential that hospitals be more open about reporting problems. Some suggest that patients need cultural change too in ensuring their own safety, eg discussing about drug interactions with the doctor or asking if the doctor has washed his/her hands!
In the US, 27 state laws require public reporting of hospital-acquired infection rates. In 2005, all hospitals in New York were required by legislation to report hospital-acquired infections to the NY State Department of Health. In 2009, the NY Department of Health issued a state-wide report on hospital-by-hospital infection rates. They said that the information will help patients make more informed choices and allow hospitals to compare with other providers.
In the UK, despite promoting hand hygiene among staff, patients and visitors in NHS Trusts in England and Wales to reduce hospital acquired infections, infection rates and resulting harm are still very high.
In June 2010, the Health Secretary, Andrew Lansley, announced that as part of the new government's information revolution, infection figures for all hospitals in England will be published on a weekly basis from July on the government website . By making the data available to patients as well as hospital managers, he said people can make comparisons between different hospitals and healthcare organisations.
Have you washed your hands? Would you be offended if a patient or a colleague asks if you have washed your hands? What's your veiw?
Source : Temporal Trends in Rates of Patient Harm Resulting from Medical Care. N Engl J Med 2010; 363:2124-2134 ( full text via Athens )
Thursday, November 18, 2010
Antibiotics for pediatric ear infections - benefits and risks
Middle ear infections, known as acute otitis media (AOM), are the most common childhood illness in the US where antibiotics are routinely prescribed. According to a new study published in JAMA, using antibiotics to treat newly diagnosed acute ear infections among children is modestly more effective than no treatment, but causes adverse effects.
US researchers, requested by the American Academy of Pediatrics, to update practice guidelines for treating children's ear infections, reviewed 125 published previous on the effect of antibiotics and found that 80% of children with ear infections would recover within about 3 days without antibiotics. If all of the children were treated with antibiotics, an additional 12 would improve in 3 days, but 5 to 10% of the children would develop diarrhea.
They found no evidence that higher- priced antibiotics work better in general than generic ones and there is a wide variation in diagnosis and management of AOM, they suggested that using an otoscope may help improve the accuracy of diagnosis.
The authors concluded that doctors need to weigh the risks and benefits "before prescribing immediate antibiotics for uncomplicated AOM" and further research is needed.
Source: Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children - A Systematic Review. JAMA. 2010;304(19):2161-2169. (f/t via Athens)
US researchers, requested by the American Academy of Pediatrics, to update practice guidelines for treating children's ear infections, reviewed 125 published previous on the effect of antibiotics and found that 80% of children with ear infections would recover within about 3 days without antibiotics. If all of the children were treated with antibiotics, an additional 12 would improve in 3 days, but 5 to 10% of the children would develop diarrhea.
They found no evidence that higher- priced antibiotics work better in general than generic ones and there is a wide variation in diagnosis and management of AOM, they suggested that using an otoscope may help improve the accuracy of diagnosis.
The authors concluded that doctors need to weigh the risks and benefits "before prescribing immediate antibiotics for uncomplicated AOM" and further research is needed.
Source: Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children - A Systematic Review. JAMA. 2010;304(19):2161-2169. (f/t via Athens)
Wednesday, November 17, 2010
Do you need to find information for patients?
According to NHS Evidence, a recent research shows that 53% of professionals are most likely to be looking for patient information specifically when conducting a search for health and social care information.
NHS Evidence provides access to more than 8,000 pieces of accredited patient and public information including fact sheets, patient health questionnaires and guidance on conditions, treatment choices and support to help patints and carers make informed choices.
You can browse the leaflets by subject, alphabet or publisher and you can print them.
NHS Evidence provides access to more than 8,000 pieces of accredited patient and public information including fact sheets, patient health questionnaires and guidance on conditions, treatment choices and support to help patints and carers make informed choices.
You can browse the leaflets by subject, alphabet or publisher and you can print them.
Tuesday, November 16, 2010
Using pre-surgery checklists can reduce medical errors
At the end of a long day, Dr David Ring, a hand surgeon at Massachusetts General Hospital, walked into the operating room and performed the last operation - he did a carpal-tunnel release on his trigger finger patient!
In an extraordinary open admssion of performing wrong surgery in this week's NEJM, Dr Ring said leading up to the wrong surgery were a series of events and mistakes that occurred during the course of the day, such as poor scheduling and staffing, the patient's left arm was marked at the wrist, not at the finger, and the marking was washed away etc.
Dr. Ring realized his error while dictating the report, and immediately notified both the hospital and the patient of the error. He performed the correct procedure that day without complication. However, the patient lost faith in him and sought treatment elsewhere. The hospital waived all her charges and paid a financial settlement shortly after the event.
Dr. Ring asked the case be presented at the departmental conference and published in the Case Records of the Massachusetts General Hospital because he wanted to encourage others to follow procedures that would prevent similar errors in the future. He said "I hope that none of you ever have to go through what my patient and I went through. I no longer see these protocols as a burden. That is the lesson." Dr Ring was praised for his courage by patient safety advocates and his counterparts.
In the same issue of the NEJM, a team of Dutch researchers published a study showing the dramatic effect of implementing surgical safety checklists in reducing surgical errors. Comparing hospitals that use pre-surgery checklists with those that do not, the researchers found that surgical complications fell dramatically from a level of 27% to just 17%. In- hospital mortality decreased from 1.5 to 0.8%, but the outcomes in the 5 control hospitals did not change.
In an accompanying editorial, the author said studies have shown the use of surgical checklists can have dramatic effect in reducing both complications and mortality and believed that they have "crossed the threshold from good idea to standard of care".
Studies have found that serious errors such as wrong-site surgery or wrong patient did occur, often due to simple mistakes or surgical team failing to perform pre-operation checks. Wrong-site surgery occurs in all surgical specialties, 68% of claims in the US related to orthopedic surgery. The American Academy of Orthopaedic Surgeons (AAOS) developed the "Sign Your Site" initiative in 1998 advising surgeons to mark the surgical site with their initials in order to avoid errors.
In the UK, more than 129,000 surgical incidents were reported to the National Patient Safety Agency (NPSA) in 2007. Over 1,000 resulted in severe harm and 271 death. The NPSA issued a patient safety alert in January 2009, requiring NHS organisations to implement the WHO Surgical Safety Checklist for every patient undergoing a surgical procedure. All hospitals in England and Wales must implement use of the Surgical Checklist by February 2010.
The checklist focuses on basic good practice before anaesthesia is administered, before a patient is cut open, and before a patient is removed from the operating theatre, and is designed to promote effective teamwork and prevent infection and unnecessary blood loss. NHS organisations can adapt it for their own use.
Source:
"Case 34-2010 — A 65-Year-Old Woman with an Incorrect Operation on the Left Hand". NEJM 2010; vol 11, 363:1950-1957 ( full text via Athens )
"Effect of a Comprehensive Surgical Safety System on Patient Outcomes". NEJM 2010; vol 11, 363:1928-1937 ( Netherlands trial, full text via Athens)
Editorial : "Strategies for Improving Surgical Quality — Checklists and Beyond". NEJM 2010; vol 11, 363:1963-1965 ( full text via Athens)
In an extraordinary open admssion of performing wrong surgery in this week's NEJM, Dr Ring said leading up to the wrong surgery were a series of events and mistakes that occurred during the course of the day, such as poor scheduling and staffing, the patient's left arm was marked at the wrist, not at the finger, and the marking was washed away etc.
Dr. Ring realized his error while dictating the report, and immediately notified both the hospital and the patient of the error. He performed the correct procedure that day without complication. However, the patient lost faith in him and sought treatment elsewhere. The hospital waived all her charges and paid a financial settlement shortly after the event.
Dr. Ring asked the case be presented at the departmental conference and published in the Case Records of the Massachusetts General Hospital because he wanted to encourage others to follow procedures that would prevent similar errors in the future. He said "I hope that none of you ever have to go through what my patient and I went through. I no longer see these protocols as a burden. That is the lesson." Dr Ring was praised for his courage by patient safety advocates and his counterparts.
In the same issue of the NEJM, a team of Dutch researchers published a study showing the dramatic effect of implementing surgical safety checklists in reducing surgical errors. Comparing hospitals that use pre-surgery checklists with those that do not, the researchers found that surgical complications fell dramatically from a level of 27% to just 17%. In- hospital mortality decreased from 1.5 to 0.8%, but the outcomes in the 5 control hospitals did not change.
In an accompanying editorial, the author said studies have shown the use of surgical checklists can have dramatic effect in reducing both complications and mortality and believed that they have "crossed the threshold from good idea to standard of care".
Studies have found that serious errors such as wrong-site surgery or wrong patient did occur, often due to simple mistakes or surgical team failing to perform pre-operation checks. Wrong-site surgery occurs in all surgical specialties, 68% of claims in the US related to orthopedic surgery. The American Academy of Orthopaedic Surgeons (AAOS) developed the "Sign Your Site" initiative in 1998 advising surgeons to mark the surgical site with their initials in order to avoid errors.
In the UK, more than 129,000 surgical incidents were reported to the National Patient Safety Agency (NPSA) in 2007. Over 1,000 resulted in severe harm and 271 death. The NPSA issued a patient safety alert in January 2009, requiring NHS organisations to implement the WHO Surgical Safety Checklist for every patient undergoing a surgical procedure. All hospitals in England and Wales must implement use of the Surgical Checklist by February 2010.
The checklist focuses on basic good practice before anaesthesia is administered, before a patient is cut open, and before a patient is removed from the operating theatre, and is designed to promote effective teamwork and prevent infection and unnecessary blood loss. NHS organisations can adapt it for their own use.
Source:
"Case 34-2010 — A 65-Year-Old Woman with an Incorrect Operation on the Left Hand". NEJM 2010; vol 11, 363:1950-1957 ( full text via Athens )
"Effect of a Comprehensive Surgical Safety System on Patient Outcomes". NEJM 2010; vol 11, 363:1928-1937 ( Netherlands trial, full text via Athens)
Editorial : "Strategies for Improving Surgical Quality — Checklists and Beyond". NEJM 2010; vol 11, 363:1963-1965 ( full text via Athens)
Tuesday, November 09, 2010
Could stronger statins save lives?
Statin is one of the world's biggest selling drug for lowering LDL cholesterol, a new research suggests using more potent doses of statin could prevent thousands more heart attacks and strokes.
40,000 high-risk patients were assessed for major vascular events after one year of randomisation to either regular or intensive treatment statin. The results, published in The Lancet, found that stronger treatments reduced major heart attacks and strokes by 15%. This included a 13% cut in heart-related death or non-fatal heart attacks, a 19% drop in bypass and other coronary treatments, and a 16% drop in strokes.
However, the study warned that simply raising the dose of simvastain might lead to health problem as muscle weakness and muscle damage are some of the known side effects.
Source: "Intensive lowering of LDL cholesterol with 80 mg versus 20 mg simvastatin daily in 12 064 survivors of myocardial infarction: a double-blind randomised trial". The Lancet, Early Online Publication, 9 November 2010 (full text via Athens)
40,000 high-risk patients were assessed for major vascular events after one year of randomisation to either regular or intensive treatment statin. The results, published in The Lancet, found that stronger treatments reduced major heart attacks and strokes by 15%. This included a 13% cut in heart-related death or non-fatal heart attacks, a 19% drop in bypass and other coronary treatments, and a 16% drop in strokes.
However, the study warned that simply raising the dose of simvastain might lead to health problem as muscle weakness and muscle damage are some of the known side effects.
Source: "Intensive lowering of LDL cholesterol with 80 mg versus 20 mg simvastatin daily in 12 064 survivors of myocardial infarction: a double-blind randomised trial". The Lancet, Early Online Publication, 9 November 2010 (full text via Athens)
Monday, November 08, 2010
Does vitamin E increase stroke risk?
Previous studies suggested taking vitamin E can protect the heart from coronary heart disease, but a BMJ study found that taking vitamin E could slightly increase the risk of haemorrhagic stroke - bleeding in the brain. Stroke is the third biggest cause of death in the UK
Researchers identified 9 studies with about 119,000 people randomised either to vitamin E or placebo on the outcome of stroke. They found that vitamin E increased the risk of haemorrhagic stroke by 22%, also found that vitamin E reduced the risk of ischaemic stroke by 10%. Given the small reduction in the risk of ischaemic stroke is exceeded by the incraese in the risk of haemorrhagic stroke, the researchers concluded that the widespread use of vitamin E should be avoided.
Critics say the findings are of small statistical significance, more research is needed to determine the level of Vitamin E that can become harmful. They "urge people to maintain a lifestyle of a balanced diet, regular exercise and monitoring their blood pressure to reduce their risk of a stroke."
Source: "Effects of vitamin E on stroke subtypes: meta-analysis of randomised controlled trials". BMJ 2010; 341:c5702 (Published 4 November 2010) free f/t.
Researchers identified 9 studies with about 119,000 people randomised either to vitamin E or placebo on the outcome of stroke. They found that vitamin E increased the risk of haemorrhagic stroke by 22%, also found that vitamin E reduced the risk of ischaemic stroke by 10%. Given the small reduction in the risk of ischaemic stroke is exceeded by the incraese in the risk of haemorrhagic stroke, the researchers concluded that the widespread use of vitamin E should be avoided.
Critics say the findings are of small statistical significance, more research is needed to determine the level of Vitamin E that can become harmful. They "urge people to maintain a lifestyle of a balanced diet, regular exercise and monitoring their blood pressure to reduce their risk of a stroke."
Source: "Effects of vitamin E on stroke subtypes: meta-analysis of randomised controlled trials". BMJ 2010; 341:c5702 (Published 4 November 2010) free f/t.
Alcohol is more harmful than heroin or crack cocaine
A new study, published in the Lancet, found that alcohol is the most harmful drug above heroin and crack cocaine based on harm caused to the user and others.
The investigation was led by David Nutt, former government drugs adviser sacked after criticising government policies on cannabis. The team reviewed a range of drug harms using the multicriteria decision analysis modelling, drugs were scored with 100 being the most harmful and 0 being no harm at all. They found that overall alcohol scored 72, heroin 55 and crack cocaine 54. The authors said "the present drug classification systems have little relation to the evidence of harm" and that the findings showed that ‘aggressively targeting alcohol harms is a valid and necessary public health strategy."
Some newspapers reported the DH said it is determined to prevent alcohol abuse without disadvantaging those who drink sensibly.
In an accompanying commentary, "Ranking of drugs: a more balanced risk-assessment" The Lancet, 376(9752): 1524-25, the Dutch experts said "the new data provide a valuable contribution for the re-evaluation of current drug classification in the UK", but the study did not address the polydrug use which can make some drugs much more dangerous. However this was outside the scope of the study.
Source: Drug harms in the UK: a multicriteria decision analysis. The Lancet 376(9752):1558-1565 ( full text va Athens)
The investigation was led by David Nutt, former government drugs adviser sacked after criticising government policies on cannabis. The team reviewed a range of drug harms using the multicriteria decision analysis modelling, drugs were scored with 100 being the most harmful and 0 being no harm at all. They found that overall alcohol scored 72, heroin 55 and crack cocaine 54. The authors said "the present drug classification systems have little relation to the evidence of harm" and that the findings showed that ‘aggressively targeting alcohol harms is a valid and necessary public health strategy."
Some newspapers reported the DH said it is determined to prevent alcohol abuse without disadvantaging those who drink sensibly.
In an accompanying commentary, "Ranking of drugs: a more balanced risk-assessment" The Lancet, 376(9752): 1524-25, the Dutch experts said "the new data provide a valuable contribution for the re-evaluation of current drug classification in the UK", but the study did not address the polydrug use which can make some drugs much more dangerous. However this was outside the scope of the study.
Source: Drug harms in the UK: a multicriteria decision analysis. The Lancet 376(9752):1558-1565 ( full text va Athens)
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