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British Medical Journal
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008
UKM Medical Centre Library
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 1
table of contents
NEWS Being “humorous without being disrespectful”.
Kmietowicz, Z.
One in five US soldiers have depression or post-trau-
matic stress disorder, study finds. UK government to spend £1bn on development re-
Charatan, F. search in next five years.
Kmietowicz, Z.
Palliative care toolkit developed for staff in develop-
ing countries. Women in academic medicine still have to battle
Coombes, R. against macho culture.
Kmietowicz, Z.
Radiographers increase cancer detection rate, but at
cost. Arguments for lowering the upper time limit for
Dobson, R. abortion are flawed, says Lord Steel.
Kmietowicz, Z.
Paediatricians “have grave concerns” about GMC pro-
cedures for child protection work. Pilot study shows cost effective approach to enable
Dyer, O. people to die at home.
Mayor, S.
UK hospitals that offer cord blood collection will need
licence from July. Haemoglobin based blood substitutes raise risk of
Dyer, O. myocardial infarction and death.
Mayor, S
Registrar who used excessive force in forceps deliv-
ery is struck off. Cancer centre provides space for patients to “ex-
Dyer, O. plore their thoughts”.
Mayor, S.
Polyclinics could close 1700 general practices, con-
servatives claim. Charity calls on governments to give 10% of fund-
Eaton, L. ing to people orphaned by AIDS.
Moszynski, P.
BMA rejects proposal that GPs should pay cost of pa-
tients’ unnecessary visits to emergency departments. A state run healthcare system is still relevant to-
Eaton, L. day, debate decides.
Richards, T.
MPs call for better safeguards on antipsychotic use
in care homes. Low reimbursement means US doctors with many
Eaton, L. ethnic minority patients have less time for each
consultation.
NHS managers call for calm in debate on polyclinics. Roehr, B.
Finch, R.
Primary care trusts provide poor information for
Nine out of 10 GPs accept government offer on ex- practice based commissioning.
tended hours but criticise direction of policy. Short, R.
Ferriman, A.
Health minister says data showing that child health
Revalidation needs proper testing before adoption in South Africa is not improving are unreliable.
throughout UK. Sidley, P.
Hitchen, L.
Most cases of research misconduct go undetected,
Canada’s drug advisory committee says emergency conference told.
contraception should be available over the counter. Smith, R.
Kermode-Scott, B.
Danish government turns to doctors to tackle ris-
New thinking is needed to increase local care for pa- ing absenteeism from work.
tients. Stafford, N.
Kmietowicz, Z.
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 2
MEPs shun cancer advocacy group because of indus- NEWS
try funding.
Stafford, N. Charatan, F. (2008). One in five US soldiers have
depression or post-traumatic stress disorder,
Surgeon who owned hospital faces 69 charges of study finds. British Medical Journal, 336
flawed treatment and four of manslaughter. (7650), 913.
Stafford, N. A study has found that 18.5% of current and former US
service personnel report symptoms of depression or
Children should have electrocardiography before post-traumatic stress disorder. And 19% report symp-
taking drugs for hyperactivity. toms that indicate traumatic brain injury, ranging from
Tanne, J.H. mild concussions to severe penetrating head wounds.
An estimated 7% have both probable traumatic brain
FDA works with US health insurers to identify drug injury and depression or stress disorder. The study, by
problems. the Rand Corporation, and sponsored by the California
Tanne, J. H. Community Foundation, an independent non-profit
making think tank, is thought to be the first large pri-
Move to split role of healthcare purchaser and pro- vate assessment of its kind. It included a survey of
vider may have to be abandoned, expert says. 1965 active and veteran military personnel; focus
Timmins, N. groups with service members and their families; and
interviews with key administrators and healthcare
Gene therapy is in danger of being overhyped, ex- providers throughout the United States. The Depart-
pert says. ment of Defense estimated that 1.6 million service
Watts, G. personnel have been deployed in the wars in Afghani-
stan and in Iraq. The study found that only about half
Food price rises will increase deaths from malnutri- of personnel with depression or post-traumatic stress .
tion, Swiss foundation warns. ..
Zarocostas, J.
Coombes, R. (2008). Palliative care toolkit developed
ARTICLES for staff in developing countries. British Medi
cal Journal, 336 (7650), 913.
Impact of rapid screening tests on acquisition of Two doctors and colleagues from the United Kingdom
meticillin resistant Staphylococcus aureus: cluster have this week launched a toolkit for healthcare pro-
randomised crossover trial. fessionals in poor countries that advises on palliative
Jeyaratnam, D., Christopher J M Whitty, Katie Phillips, care. The authors were struck that many countries
Dongmei Liu, Christina Orezzi, Uchechukwu Ajoku, struggle to provide even the most rudimentary control
and Gary L French. of symptoms and social support for patients with incur-
able conditions, chiefly AIDS and cancer. Vicky Lavy, a
Components of placebo effect: randomised controlled doctor at Helen and Douglas House Hospice, Oxford, and
trial in patients with irritable bowel syndrome. an author of the toolkit, said that one of the biggest
Kaptchuk, T.J., John M Kelley, Lisa A Conboy, Roger B problems in providing palliative care in many poor coun-
Davis, Catherine E Kerr, Eric E Jacobson, Irving Kirsch, tries is the lack of morphine. In her 10 years’ experi-
Rosa N Schyner, Bong Hyun Nam, Long T Nguyen, Min ence in Malawi, Dr Lavy said that the only painkillers
Park, Andrea L Rivers, Claire McManus, Efi Kokkotou, in reliable supply were paracetamol, aspirin, and “per-
Douglas A Drossman, Peter Goldman, Anthony J Lembo. haps a non-steroidal on a good day. But even ibuprofen
is not widely available. Codeine is very expensive.”
Cumulative funnel plots for the early detection of Ironically, she said, powdered oral morphine was “dirt
interoperator variation: retrospective database cheap” to buy from manufacturers, but many African
analysis of observed versus predicted results of per- governments were resistant to . . .
cutaneous coronary intervention.
Babu Kunadian, Joel Dunning, Anthony P Roberts, Rob- Dobson, R. (2008). Radiographers increase cancer
ert Morley, Darragh Twomey, James A Hall, Andrew G detection rate, but at cost. British Medical
C Sutton, Robert A Wright, Douglas F Muir, and Mark Journal, 336 (7650), 913.
A de Belder. Breast cancer is more likely to be detected when
mammograms are read by two radiologists as well as
CLINICAL REVIEW two radiographers. But double reading by both groups of
professionals leads to more false-positive screens. Re-
Investigation of blunt abdominal trauma. search based on more than 140 000 mammograms
Jansen, J.O., Steven R Yule, and Malcolm A Loudon. shows that when both radiographers and radiologists
double read mammograms the rate of detection of can-
cer rises by 7% (European Journal of Cancer 2008 Apr
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 3
7; doi: 10.1016/j.ejca.2008.03.003). But the positive “grossly excessive force” in a forceps delivery was struck
predictive value of a referral for further investigation off by the General Medical Council last week. However,
falls from 47.5% to 36.6% (P<0.001). “Cancer detection he continues to evade police seeking to charge him
rates increased after the introduction of radiographer with manslaughter in the case. Vladan Visnjevac is
double reading in addition to radiologist double read- now in Sarajevo, and Surrey police say that the Bosnian
ing. This increase was the combined result of improved authorities are refusing to extradite him. He made no
cancer detection rates achieved by radiologists and submissions to the hearing. Newborn Hollie Dinning
additionally detected cancers after secondary referral died at St Peter’s Hospital, Chertsey, Surrey, two days
of radiographer positive readings,” say the authors. The after delivery in May 2002, from a fractured skull and
report says that although screening mammograms can “massive” brain injuries. Dr Visnjevac had made four
be assessed by a single reader, it has been . . . attempts to deliver her with forceps, using such force
that her mother feared that she would be pulled off the
Dyer, O. (2008). Paediatricians “have grave concerns” table. “He was yanking so hard I thought my baby’s head
about GMC procedures for child protection was going to be pulled off,” Tracey Dinning told the hear-
work. British Medical Journal, 336 (7650), ing in a statement. Dr Visnjevac should never have
911. attempted . . .
The annual meeting of the Royal College of Paediat-
rics and Child Health has chosen not to back a strongly Eaton, L. (2008). Polyclinics could close 1700 gen
worded motion that condemned the UK General Medi- eral practices, conservatives claim. British
cal Council’s handling of cases of misconduct in child Medical Journal, 336 (7650), 907.
protection work. But the meeting did pass a motion Polyclinics could lead to the closure of more than 1000
that voiced milder criticism of the GMC, which many surgeries in London, more than three quarters of the
paediatricians accuse of giving too much weight to total in the capital, and a further 600 in the rest of
vexatious and serial complaints against child protec- England, says the opposition leader David Cameron.
tion specialists. The proposed motion would have de- The Conservative party leader has warned that the clin-
clared that the college had “no confidence” in GMC pro- ics are a threat to general practices because “Gordon
cedures, but the motion that was passed refers only to Brown is trying to nationalise GP surgeries and to make
the college’s “grave concerns.” Apart from that change GPs salaried employees of the state,” he said in a
the motion was passed as originally written. Its con- speech to health specialists at the King’s Fund, in Lon-
clusion reads in part, “The college continues to have don on Monday. If the proposal for more polyclinics,
grave concerns over the current GMC procedures for which are expected to be recommended in the forth-
dealing with cases related to child protection. We call coming report from Ara Darzi, goes ahead, patients
upon the GMC to review these procedures as a matter would lose the one to one relationship that they have
of urgency and involve in . . . with their own GP, he added. “Labour has already tried
to bring about the end of the district general hospital.
Dyer, O. (2008). UK hospitals that offer cord blood Now they are trying to abolish the family doctor ser-
collection will need licence from July. Brit vice,” he . .
ish Medical Journal, 336 (7651), 981.
The fast growing practice of collecting blood from the Eaton, L. (2008). BMA rejects proposal that GPs
umbilical cords of newborn infants is to be regulated should pay cost of patients’ unnecessary vis
for the first time in the United Kingdom. Cord blood, a its to emergency departments. British Medi
source of very “naive” blood stem cells, is used to treat cal Journal, 336 (7650), 910.
some types of anaemia and leukaemia and may hold GPs’ leaders have criticised the suggestion that pri-
promise in treating other diseases. The Human Tis- mary care trusts should be able to recoup from general
sue Authority announced this week that all maternity practices the costs of any unnecessary visits made by
units, whether NHS or private, that collect cord blood their patients to emergency departments or walk-in
must be operating under a licence by 5 July. An un- clinics. The proposals, apparently passed to the gov-
known number of private companies are currently of- ernment for consideration in the review being carried
fering a cord blood collection service. They too will need out by the health minister Ara Darzi, suggest that
a licence under the new regulations and must give an charges are imposed if a patient uses emergency ser-
undertaking that cord blood will be collected by people vices because they cannot see their own doctor in nor-
with specialist training on premises that meet set stan- mal surgery hours. Laurence Buckman, chairman of
dards. The authority estimates that between 100 and the BMA’s General Practitioners Committee, said that
250 public and private organisations will apply for a the proposal, from the NHS Confederation and NHS
licence under the new rules. Employers, could mean that many general practices
would lose all their funds. Those in areas where there
Dyer, O. (2008). Registrar who used excessive force was a culture of patients tending to go to emergency
in forceps delivery is struck off. British Medi departments would be the hardest hit, he said. “These
cal Journal, 336 (7651), 983. tend to be in the more deprived areas,” Dr Buckman
A locum registrar who killed a baby girl when he used told the BMJ, suggesting that doctors whose . . .
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 4
Eaton, L. (2008). MPs call for better safeguards on of the 27,000 GPs who participated also agreed with
antipsychotic use in care homes. British Medi the proposition that “the direction of government policy
cal Journal, 336 (7651), 983. (in England) to expand private commercial provision of
The government should take action to stop dangerous NHS general practice will be detrimental to patients
prescribing of antipsychotic drugs to people with de- and the service as a whole.”
mentia, says a report from a group of MPs. The all party
parliamentary group on dementia says that the gov- Hitchen, L. (2008). Revalidation needs proper test
ernment should use its national dementia strategy, ing before adoption throughout UK. British
which is due to be published in October, to tackle the Medical Journal, 336 (7650), 913.
problem and that the National Institute for Health and Thorough trials of revalidation are needed to test the
Clinical Excellence should review use of the drugs. new system for assessing doctors’ fitness to practise
“Antipsychotics can double the risk of death and triple before it is introduced everywhere, says the Depart-
the risk of stroke in people with dementia, heavily se- ment of Health. Bruce Keogh, the NHS medical direc-
date them, and accelerate cognitive decline,” said Jer- tor, said, “This needs to be piloted. A big bang approach
emy Wright, the group’s chairman. “Best practice guide- is going to be an utter disaster.” He said that a “whole
lines are not enough: safeguards must be put in place system trial” is needed that tests the system in a num-
to ensure antipsychotics are always a last resort.” A ber of different specialties and settings. He was speak-
lack of support from appropriate specialists can lead to ing at a conference of the British Association of Medi-
people going for a long time without any review of their cal Managers and Healthcare Events on the topic in
treatment, says the report. As a result, prescriptions London last week. Una Lane, assistant director for re-
are not . . . validation at the General Medical Council, agreed that
a phased approach was needed. A recent audit by the
Finch, R. (2008). NHS managers call for calm in de company KPMG showed that the current appraisal sys-
bate on polyclinics. British Medical Journal, tem was patchily implemented geographically and in
336 (7650), 911. primary care, she said. Staff grades and locums were
The NHS Confederation last week called on interested also often not included in the appraisal. This indicated
parties to keep calm and consider the evidence when that . . .
evaluating the proposal for polyclinics made by the
health minister Ara Darzi last summer (BMJ Kermode-Scott, B. (2008). Canada’s drug advisory
2007;335:61; doi: 10.1136/bmj.39273.467697.DB). Its committee says emergency contraception
report was attacked by opposition politicians for “miss- should be available over the counter. British
ing the point” and was criticised by senior GPs. The Medical Journal, 336 (7651), 982.
confederation’s anonymous report blames “misconcep- Canadian women are one step closer to being able to
tions” about polyclinics for impeding the consideration get the emergency contraceptive levonorgestrel over
of their benefits. Far from disrupting continuity of care the counter without a prescription or counselling by a
or undermining general practice, it says, polyclinics pharmacist. Currently a woman in Canada who wishes
can improve access as well as allow patients to see to have levonorgestrel for emergency contraception can
their own doctor. The confederation also says that poly- either seek a prescription from a doctor or buy it in a
clinics are not appropriate in every area and that there pharmacy after a consultation with a pharmacist.
need be “no national blueprint for how polyclinics should (Emergency contraception has “behind the counter”
work.” Nigel Edwards, director of policy at the NHS Con- status, similar to “pharmacy only” status in the United
federation, lambasted opponents of polyclinics, saying Kingdom.) Paladin Labs, a Canadian specialty drug com-
that “knee jerk reactions” based on “pre-existing agen- pany, applied for full over the counter status for the
das” could jeopardise future patients’ outcomes. He said, emergency contraceptive, known as Plan B in Canada
“We . . . and the United States. The company pointed out that
many leading Canadian healthcare organisations, in-
Ferriman, A. (2008). Nine out of 10 GPs accept gov cluding the Society of Obstetricians and Gynecologists
ernment offer on extended hours but criticise of Canada, the Canadian Federation of Medical Women,
direction of policy. British Medical Journal, and the Canadian Association for Adolescent Health,
336 (7651), 983. support making emergency contraception available over
More than nine out of 10 GPs who took part in the BMA’s the counter to reduce the number of unwanted preg-
opinion poll voted in favour of accepting the first of the nancies . . .
two government options on extended hours. They chose
the option under which an average practice of three Kmietowicz, Z. (2008). New thinking is needed to in
GPs would initially lose £18,000 and would have to earn crease local care for patients. British Medi
the money back by providing extended hours. They re- cal Journal, 336 (7650), 907.
jected the option under which practices would lose The government needs to rethink the way it funds hos-
£36,000 and the money would be given to the primary pital care if patients are to be looked after closer to
care trust, with no guarantee that it could be retained their homes, says a report out this week. The system
by local practices or earned back. Ninety two per cent of payment by results, which has been gradually intro-
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 5
duced into hospital trusts over the past four years as a Kmietowicz, Z. (2008). Women in academic medicine
means of linking payments to activity, may actually still have to battle against macho culture.
hamper government plans to deliver care closer to pa- British Medical Journal, 336 (7651), 979.
tients’ homes, says a working party made up of repre- Women trying to carve out a career in academic medi-
sentatives from the Royal College of Physicians, the cine in the United Kingdom continue to face a domi-
Royal College of General Practitioners, and the Royal nant male “club culture,” misplaced competition, ex-
College of Paediatrics and Child Health. Instead of the clusion, and lack of support, says a report out this week.
block payments hospitals used to receive to provide Despite the fact that women have made up more than
certain services, payment by results means that money 40% of medical graduates in the past 20 years and now
follows patients and allows those hospitals with greater account for 60% of medical students, women doctors
throughput to earn more. But “perverse incentives” at are still strikingly under-represented in the univer-
the heart of payment by results can make it seem easier sity sector, especially in senior posts, says the report
financially to admit patients rather than manage . . . from the women in academic medicine project, a re-
search venture funded by a variety of sources, includ-
Kmietowicz, Z. (2008). Being “humorous without be ing the government and the BMA. The report makes a
ing disrespectful”. British Medical Journal, raft of recommendations for government, institutions,
336 (7650), 910. professionals, and journals aimed at rectifying the
Anyone with children will have no trouble putting a imbalance, which currently leaves one in five medical
name to the sketchy strokes that have brought stories schools without a female professor. Of the 33 heads of
to life for millions of children worldwide. Quentin Blake, UK medical schools only two are women, says the re-
who has illustrated and written more than 200 port, and 11% of professorships . . .
children’s books in the past 50 years, has for the past
three years also been involved with the Nightingale Kmietowicz, Z. (2008). Arguments for lowering the
Project (www.nightingaleproject.org), a charity set up upper time limit for abortion are flawed, says
to get art and music into hospitals that care for people Lord Steel. British Medical Journal, 336
with mental health problems. An exhibition of new work, (7651), 983.
called Hand Tinted, is showing at the South Kensington David Steel, whose private member’s bill led to the
and Chelsea Mental Health Centre, the project’s base. legalisation of abortion in England, Scotland, and Wales
Mr Blake said that he was drawn to the project because in 1967, this week defended women’s right to request
the pictures were directed at the centre’s staff and its an abortion up to the current time limit of 24 weeks’
users, psychiatric patients, who, like himself, are get- gestation. Speaking ahead of the second reading of the
ting on in years. “I thought it would be interesting to Human Tissue and Embryo Bill in the House of Com-
find a way of being humorous without being disrespectful mons later this month, Lord Steel said that the argu-
to older . . . ments of many people who are campaigning for a re-
duced time limit for abortion were flawed. The bill is
Kmietowicz, Z. (2008). UK government to spend £1bn expected to be open to amendments from backbench
on development research in next five years. MPs to alter the current limit on abortion. “A lot of the
British Medical Journal, 336 (7650), 913. people who are pressing for a reduction in the time
Development research in the United Kingdom won sup- limit are doing it to reduce the number of abortions,”
port from three sources this week with the publication he said, speaking at a press briefing at the House of
of the United Kingdom’s first five year strategy on re- Lords. “But the number [of abortions] that take place
search, new research funding, and the opening of the after 24 weeks is tiny, so it . . .
UK’s largest academic centre in the discipline. Speak-
ing at the opening of the London International Devel- Mayor, S. (2008). Pilot study shows cost effective
opment Centre, Douglas Alexander, the secretary of approach to enable people to die at home.
state for international development, stressed the in- British Medical Journal, 336 (7650), 912-913.
creasingly important role that research would play Considerably more people have been able to die at home
in providing longer term support to people in develop- at no additional cost to the NHS by means of a pilot
ing countries who have to adapt to a changing world. programme designed to improve liaison between hos-
With increasing food prices very much on his mind Mr pitals and community services, according to an assess-
Alexander said that he hoped more anticipatory re- ment published this week. The UK cancer charity
search would help to recognise future challenges and Marie Curie started the Delivering Choice programme
how to deal with them. “The number of people in hun- in 2004 in Lincolnshire, in the east of England, to over-
ger is growing for the first time,” he said. Research come many of the barriers that currently prevent ter-
that focuses on early warning systems could help to minally ill people from dying in their own homes. Com-
prevent such situations in the future and ascertain munity link nurses were appointed at two hospitals in
the . . . the area to help the speedy discharge of palliative care
patients to their preferred place of care and to coordi-
nate home care. A community based rapid response
team was set up to provide planned and emergency visits
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 6
to patients in their homes between 3 pm and 7 am. A ciation François-Xavier Bagnoud, which established an
descriptive analysis of the impact and costs of the annual world AIDS orphans day in 2002, claims that
programme published this week by the . . . fewer than one in 10 orphans receives support from
anyone outside their family. Figures from Unicef show
Mayor, S. (2008). Haemoglobin based blood substi that more than 15 million children worldwide have lost
tutes raise risk of myocardial infarction and one or both parents to AIDS. By 2010 the number of
death. British Medical Journal, 336 (7651), AIDS orphans is expected to climb to an estimated 20-
977. 25 million. Advocates of the orphans’ plight, who will
Haemoglobin based blood substitutes are associated be highlighting the problem on world AIDS orphans day
with a nearly threefold increase in the risk of myocar- on 7 May, say that in addition to the psychological
dial infarction and a 30% higher risk of death in com- trauma of losing a parent, orphans are less likely to
parison with other solutions used in blood replacement, receive health care, education, and . . .
concludes a meta-analysis published this week. The
authors of the study, published in JAMA (doi: 10.1001/ Richards, T. (2008). A state run healthcare system is
jama.299.19.jrv80007), argue that if the results of in- still relevant today, debate decides. British
dividual trials had been made public as they became Medical Journal, 336 (7651), 978.
available to researchers, patients may not have expe- A debate to consider whether the NHS still meets the
rienced adverse events in subsequent studies. No fur- needs of the population 60 years after it was estab-
ther phase III studies of the products should be carried lished decided that it still does. In fact the proportion of
out for the time being, say commentators in an ac- the audience who thought it was still a suitable sys-
companying editorial (doi: 10.1001/ tem today rose by seven percentage points during the
jama.299.19.jed80027). A large proportion of blood sub- course of the debate. The debate was organised by Capse
stitutes—products with a long shelf life that can be used Health Knowledge Systems, a private company that
to replace blood lost by trauma patients or patients measures the performance of UK hospitals, and was
undergoing surgery—currently in development are held at the Tate Britain art gallery, in front of an in-
based on haemoglobin. Even though early trials raised vited audience of around 160 hospital managers, aca-
questions about the safety of these products and failed demics, healthcare economists, clinicians, and jour-
to . . . nalists. The wording of the motion was “This house
believes that a state run healthcare system can no
Mayor, S. (2008). Cancer centre provides space for longer meet the needs of the population and that greater
patients to “explore their thoughts”. British competition will improve the quality of care and se-
Medical Journal, 336 (7651), 978. cure its future.” The case for the motion was put by
A new support centre for people with cancer, the latest Nick Bosanquet, professor of health policy at . . .
in a series of Maggie’s Caring Centres around Britain,
has opened at Charing Cross Hospital in west London.
The centres are based on the vision of the late Maggie Roehr, B. (2008). Low reimbursement means US doc
Keswick Jencks, a writer on Chinese gardens, of places tors with many ethnic minority patients have
to provide high quality support for people with cancer. less time for each consultation. British Medi
While being treated for cancer she identified a need cal Journal, 336 (7650), 908-909.
for patients to receive emotional and psychological sup- Low levels of compensation from Medicaid programmes
port and practical information in an uplifting environ- in the United States contribute to racial and ethnic
ment. The London centre is the first of seven new car- disparities in health care, a study has shown (Health
ing centres planned for England and Wales, bringing Affairs 2008 Apr 22; doi: 10.1377/hlthaff.27.3.w222).
the total to 13 by 2012. It was designed by architects The federal-state programmes serve poor Americans
from the Richard Rogers’ partnership, Rogers Stirk who meet their eligibility criteria. Primary care doc-
Harbour and Partners. Other leading architects—in- tors with predominately black and Latino patients see
cluding Richard Murphy, Frank Gehry, and Zaha more patients and provide more charity care. They also
Hadid—are designing further centres. Maggie’s Car- earn less than colleagues who treat fewer patients from
ing Centres aim to provide help, information, and sup- ethnic minority groups. The study, by James
port for people with cancer to enable them to . . . Reschovsky and Ann O’Malley at the Center for Study-
ing Health System Change, was based on responses
Moszynski, P. (2008). Charity calls on governments from 3320 primary care doctors who participated in the
to give 10% of funding to people orphaned by 2004-5 community tracking study physician survey.
AIDS. British Medical Journal, 336 (7650), They stratified medical practices into those with low
912. (<30%), medium (30%-70%), and high (>70%) minority
A Swiss charity that campaigns on behalf of people or- populations. The study found that doctors in practices
phaned by AIDS has launched a campaign to persuade with high minority populations spent about 30% less
governments around the world to devote 10% of the time with each patient than in low minority practices
money they spend on the disease to help the children ...
left vulnerable in the wake of the epidemic. The Asso-
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 7
Short, R. (2008). Primary care trusts provide poor forms, including poor design, incomplete literature re-
information for practice based commission view, failure to report some evidence, unreported out-
ing. British Medical Journal, 336 (7650), 910- comes, failure to declare conflicts of interest, and re-
911. dundant publication. Later in the conference, Onora
Practice based commissioning is being “sabotaged” by O’Neill, president of the British Academy, said that she
the failure of primary care trusts to provide good infor- regarded poor research and research that wasn’t needed
mation to practices, an expert in commissioning said or was poor value for money as being a matter of re-
last week. Michael Dixon, chairman of NHS Alliance, search integrity. Ian Kennedy, chairman of the UK
an independent body that brings together GPs and pri- Panel for Research Integrity in Health .
mary care trusts, says that the latest survey carried
out by the Department of Health shows that progress Stafford, N. (2008). Danish government turns to doc
towards practice based commissioning has been slow. tors to tackle rising absenteeism from work.
In the system local practices rather than primary care British Medical Journal, 336 (7650), 908-909.
trusts commission secondary services for their pa- The Danish government is concerned about an increase
tients. “Despite small but significant improvements in in the number of employees who are missing work be-
the numbers of practices that are commissioning new cause of illness. It has enlisted the help of the Danish
services and those that have agreed a commissioning Medical Association to devise a plan to help keep people
plan with their primary care trust, practice based com- working and to cut disability payments. A recent study
missioning cannot properly get off the ground until com- coordinated by the Danish Ministry of Employment cal-
missioners have access to accurate, meaningful, real culated that the national cost of missed work because
time information,” he said. Such information had not of illness in wages and sick benefits in 2006 was 37bn
been provided, he claimed. The survey, carried out from Danish kroner or about 2.3% of gross domestic prod-
January to March this year, showed that . . . uct. Particularly worrisome is the finding that the num-
ber of people who take at least 14 weeks’ sick leave
Sidley, P. (2008). Health minister says data showing rose by 25% in 2007 compared with 2005. Jens Winther
that child health in South Africa is not im Jensen, president of the Danish Medical Association,
proving are unreliable. British Medical Jour told the BMJ that the vibrant Danish economy is fac-
nal, 336 (7650), 913. ing a labour shortage and that he had discussed the
South Africa’s health minister, Dr Manto Tshabalala- matter with Claus Hjort Frederiksen, the employment
Msimang, has become embroiled in a dispute over sta- minister. “We have . . .
tistics surrounding the country’s poor performance in
crucial areas of maternal and child health. At the re- Stafford, N. (2008). MEPs shun cancer advocacy
cent conference on mother and child health in Cape group because of industry funding. British
Town, Countdown to 2015 Maternal Newborn and Child Medical Journal, 336 (7651), 980.
Survival, she dismissed figures compiled and presented A group of members of the European parliament with a
to the conference by the World Health Organization and special interest in breast cancer has cut its ties with
other UN organisations, which show that South Africa a breast cancer advocacy group, Europa Donna, because
has higher child mortality now than it did in the apart- of the group’s acceptance of financial support from drug
heid years, citing problems with baseline data. The fig- companies. Karin Jöns, chairman of the European par-
ures produced by WHO show that between 1990 and liamentary group on breast cancer (EPGBC), issued a
2006 the mortality rate of children under 5 increased press release last week announcing the decision, say-
by 15%. If South Africa wants to achieve the millen- ing that 86% of Europa Donna’s income of about (£330
nium development goal of reducing under-5 mortality 000; $660 000) in 2007 came from the industry. “We at
by two thirds between 1990 and 2015, it will need to EPGBC reject further cooperation with Europa Donna
reduce child mortality by 14% a year until 2015. South because the board of the European umbrella group be-
Africa was ranked among the 10 . . . came more and more a lobby instrument for the mar-
ket interests of the big pharmaceutical companies,”
Smith, R. (2008). Most cases of research misconduct said Mrs Jöns, an MEP representing the Bremen re-
go undetected, conference told. British Medi gion in Germany. Europa Donna’s executive director,
cal Journal, 336 (7650), 913. Susan Knox, rejected the press statement from Mrs
Questionable research practices are common and prob- Jöns, saying that it had “always denied a financial de-
ably do more damage to science than the “big three” of pendency from the pharmaceutical industry.”
fabrication, falsification, and plagiarism, said Nick
Steneck, consultant to the US Office of Research In- Stafford, N. (2008). Surgeon who owned hospital faces
tegrity, last week at a conference on the governance of 69 charges of flawed treatment and four of
good research conduct in the United Kingdom. The pri- manslaughter. British Medical Journal, 336
ority in the United States had been to eliminate seri- (7651), 983.
ous research misconduct, said Professor Steneck, but A chief surgeon who also owned the village hospital in
now much more attention is being paid to preventing Germany where he practised is in jail awaiting trial in
“questionable research practices,” which take many connection with the deaths of seven patients. Arnold
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 8
Pier, 52, has been accused by prosecutors in a 400 page system will scan the insurance companies’ huge data-
court document of making incorrect diagnoses and bases of prescriptions collected and medical claims
carrying out unnecessary operations (such as remov- filed. Patients’ identities will be removed. James Gavin,
ing appendices or gall bladders) at the St Antonius a spokesperson for Wellpoint, told . . .
Clinic in Wegberg, in the western state of North Rhine-
Westphalia. In addition, Dr Pier, who was also chief Timmins, N. (2008). Move to split role of healthcare
administrator at the hospital, allegedly followed lax stan- purchaser and provider may have to be aban
dards of hygiene, including using lemon juice as a dis- doned, expert says. British Medical Journal,
infectant during surgery. Prosecutors issued a state- 336 (7651), 979.
ment on 21 April announcing that Dr Pier faces 69 Plans to turn the NHS into a “world class” commissioner
charges of flawed treatment of 17 patients between the of health care are highly unlikely to work, a former
ages of 50 and 92. The most serious charges include health department head of strategy has warned. But if
four counts of involuntary manslaughter, three counts the government does succeed, its achievement will be
of causing bodily harm leading to death, and one count “a world first,” said Chris Ham, professor of health ser-
of causing major . . . vices management at Birmingham University and
former head of the Department of Health’s strategy unit.
Tanne, J.H. (2008). Children should have electrocar Separating the role of purchasing from the provision of
diography before taking drugs for hyperactiv health care has now been tried in various ways in sev-
ity. British Medical Journal, 336 (7651), 980- eral European countries, in New Zealand, and in the
981. United States, Professor Ham said in a paper on inter-
Children with attention deficit hyperactivity disorder national experience of the exercise. It was introduced
should have an electrocardiogram taken and a cardiac into the NHS in 1991 by the then health secretary,
evaluation before they begin to take drugs for the dis- Kenneth Clarke. But “in no system is commissioning
order, the American Heart Association said in a scien- done consistently well,” Professor Ham said, and the
tific statement published on 21 April. The stimulant government faces “huge obstacles” to make it work. A
drugs used to treat the disorder can increase heart better answer may be to go for competing integrated . .
rate and blood pressure and may be a concern if chil- .
dren have a heart condition, says the statement, pub- Watts, G. (2008). Gene therapy is in danger of being
lished online in Circulation (doi: 10.1161/ overhyped, expert says. British Medical Jour
circulationaha.107.189473). As many as 2% of appar- nal, 336 (7651), 977.
ently healthy school age children have potentially se- Two reports published online this week by the New
rious undiagnosed heart conditions that can be identi- England Journal of Medicine have described the use of
fied by electrocardiography but that may not be detected gene therapy to correct the causes of one form of con-
on routine physical examination, said Victoria Vetter, genital blindness. Although the gains in both cases
head of the committee that wrote the statement and were modest, media reports have greeted them with
professor of paediatrics at the University of Pennsylva- jubilation and the suggestion that the results can be
nia School of Medicine, Philadelphia. An electrocar- extrapolated to a wide range of eye conditions. This
diogram is needed to detect conditions such as hyper- reaction has prompted one researcher who recognises
trophic cardiomyopathy, long QT syndrome, and Wolff- the value of the new work to regret that, once again,
Parkinson-White syndrome, the statement says. enthusiasm for gene therapy may be running danger-
ously ahead of its actual achievements. Infants born
Tanne, J. H. (2008). FDA works with US health insur with Leber’s congenital amaurosis have profound vi-
ers to identify drug problems. British Medi sual impairment throughout childhood and become
cal Journal, 336 (7650), 913. completely blind by early middle age. Previous work has
The US Food and Drug Administration is joining with shown that in patients with this condition seven genes
health insurance companies to try to identify adverse normally active in the cells of the retinal pigment epi-
drug events faster. At present the FDA relies on volun- thelium (RPE) show mutations. The two research
tary reporting of problems by doctors, drug companies, groups—one based at the University of Pennsylvania’s
and the public. Doctors and patients have been calling Scheie Eye . . .
for a better reporting system after well publicised prob-
lems with some drugs, such as rofecoxib (Vioxx), which Zarocostas, J. (2008). Food price rises will increase
was withdrawn in September 2004 (BMJ 2004;329:816; deaths from malnutrition, Swiss foundation
doi: 10.1136/bmj.329.7470.816-a); rosiglitazone warns. British Medical Journal, 336 (7650),
(Avandia); and antidepressants in children and teen- 912.
agers. Health insurance companies, such as Wellpoint, The health of at least 100 million people in poor na-
which insures about 35 million people, and tions could be adversely affected by the sharp increase
UnitedHealth, another large health insurer, will work in international prices for staple foods unless steps are
with the FDA. They will develop monitoring programmes taken to tackle the problem, a Swiss foundation has
to discover safety risks, such as unusual numbers of warned. Malnutrition kills about 3.5 million mothers
cardiovascular events among people taking a drug. The and children under 5 years old every year, and this
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 9
figure could rise. “We think the malnutrition death fig- irritable bowel syndrome. British Medical
ures will go up, and you will see some other figures, Journal, 336 (7651), 999-1003.
like the 178 million children stunted each year, that Global improvement scale (range 1-7), adequate relief
will increase as well,” said Marc Van Ameringen, ex- of symptoms, symptom severity score, and quality of
ecutive director of the Global Alliance for Improved life. At three weeks, scores on the global improvement
Nutrition, a foundation that aims to fight malnutrition scale were 3.8 (SD 1.0) v 4.3 (SD 1.4) v 5.0 (SD 1.3) for
by mobilising public-private partnerships. Violent dem- waiting list versus “limited” versus “augmented,” re-
onstrations and riots have recently broken out in more spectively (P<0.001 for trend). The proportion of patients
than a dozen poor countries in protest at the rise in reporting adequate relief showed a similar pattern: 28%
prices, which for some commodities, such as rice, have on waiting list, 44% in limited group, and 62% in aug-
increased by more than 100%. Mr Van Ameringen, mented group (P<0.001 for trend). The same trend in
whose organisation . . . response existed in symptom severity score (30 (63) v
42 (67) v 82 (89), P<0.001) and quality of life (3.6 (8.1) v
ARTICLES 4.1 (9.4) v 9.3 (14.0), P<0.001). All pairwise compari-
sons between augmented and limited patient-practi-
tioner relationship were significant: global improve-
Jeyaratnam, D., Christopher J M Whitty, Katie
ment scale (P<0.001), adequate relief of symptoms
Phillips, Dongmei Liu, Christina Orezzi,
(P<0.001), symptom severity score (P=0.007), quality of
Uchechukwu Ajoku, and Gary L French.
life (P=0.01).Results were similar at six week follow-
(2008). Impact of rapid screening tests on ac
up. Factors contributing to the placebo effect can be
quisition of meticillin resistant Staphylococ
progressively combined in a manner resembling a
cus aureus: cluster randomised crossover
graded dose escalation of component parts. Non-spe-
trial. British Medical Journal, 336 (7650),
cific effects can produce statistically and clinically sig-
927-930.
nificant outcomes and the patient-practitioner rela-
All patients admitted to the study wards who were MRSA
tionship is the most robust component.
negative on admission and screened for MRSA on dis-
charge. Rapid polymerase chain reaction based screen-
ing test for MRSA compared with conventional culture.
Babu Kunadian, Joel Dunning, Anthony P Roberts,
Of 9608 patients admitted to study wards, 8374 met
Robert Morley, Darragh Twomey, James A
entry criteria and 6888 had full data (82.3%); 3335 in
Hall, Andrew G C Sutton, Robert A Wright,
the control arm and 3553 in the rapid test arm. The
Douglas F Muir, and Mark A de Belder. (2008).
overall MRSA carriage rate on admission was 6.7%.
Cumulative funnel plots for the early detec
Rapid tests led to a reduction in median reporting time
tion of interoperator variation: retrospective
from admission, from 46 to 22 hours (P<0.001). Rapid
database analysis of observed versus pre
testing also reduced the number of inappropriate pre-
dicted results of percutaneous coronary in
emptive isolation days between the control and inter-
tervention. British Medical Journal, 336
vention arms (399 v 277, P<0.001). This was not seen
(7650), 931-934.
in other measurements of resource use. MRSA was
In-hospital major adverse cardiovascular and cere-
acquired by 108 (3.2%) patients in the control arm and
brovascular events (in-hospital death, Q wave myocar-
99 (2.8%) in the intervention arm. When predefined
dial infarction, emergency coronary artery bypass graft
confounding factors were taken into account the ad-
surgery, and cerebrovascular accident) analysed
justed odds ratio was 0.91 (95% confidence interval 0.61
against the logistic north west quality improvement
to 1.234). Rates of MRSA transmission, wound infec-
programme predicted risk, for each operator. Results
tion, and bacteraemia were not statistically different
are displayed as funnel plots summarising overall per-
between the two arms. A rapid test for MRSA led to the
formance for each operator and cumulative funnel plots
quick receipt of results and had an impact on bed us-
for an individual operator’s performance on a case se-
age. No evidence was found of a significant reduction
ries basis. Results The funnel plots for 5198 patients
in MRSA acquisition and on these data it is unlikely
undergoing percutaneous coronary interventions
that the increased costs of rapid tests can be justified
showed an average observed rate for major adverse
compared with alternative control measures against
cardiovascular and cerebrovascular events of 1.96%
MRSA.
overall. This was below the predicted risk of 2.06% by
the logistic north west quality improvement programme
Kaptchuk, T.J., John M Kelley, Lisa A Conboy, Roger
risk score. Rates of in-hospital major adverse cardio-
B Davis, Catherine E Kerr, Eric E Jacobson,
vascular and cerebrovascular events for all operators
Irving Kirsch, Rosa N Schyner, Bong Hyun
upper warning limit of 2.49%. The overall in-hospital
Nam, Long T Nguyen, Min Park, Andrea L Riv
major adverse cardiovascular and cerebrovascular
ers, Claire McManus, Efi Kokkotou, Douglas
events rates were under the predicted event rate. In-
A Drossman, Peter Goldman, Anthony J
hospital rates after percutaneous coronary interven-
Lembo. (2008). Components of placebo effect:
tion procedure can be monitored successfully using
randomised controlled trial in patients with
funnel and cumulative funnel plots with control limits
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 10
to display and publish each operator’s outcomes. It
could be used for internal monitoring. The main ad-
vantage of these charts is their transparency, as they
show observed and predicted events separately. By this
approach individual operators can monitor their own
performance, using the predicted risk for their patients
but in a way that is compatible with benchmarking to
colleagues, encapsulated by the funnel plot. This meth-
odology is applicable regardless of variations in indi-
vidual operator case volume and case mix.
CLINICAL REVIEW
Jansen, J.O., Steven R Yule, and Malcolm A Loudon.
(2008). Investigation of blunt abdominal
trauma. British Medical Journal, 336 (7650),
938-942.
Summary points
The diagnosis of abdominal injury by clinical exami-
nation is unreliable
Blunt abdominal trauma requires decisive investiga-
tion and management
Ultrasound is the investigation of choice in
haemodynamically unstable patients
Computed tomography is the investigation of choice
in haemodynamically stable patients
Solid organ injury in haemodynamically stable
patients can often be managed without surgery
Concealed haemorrhage is the second most common
cause of death after trauma,1 and missed abdominal
injuries are a frequent cause of morbidity and late
mortality in patients who survive the early period
after injury. Appropriate and expeditious investiga-
tion facilitates definitive management and
minimises the risk of complications, so it is crucially
important.
Sources and selection criteria
We searched the Medline database for reviews and
clinical trials using the terms “blunt abdominal
trauma”, “blunt abdominal injury”, “investigation”,
“computed tomography”, “ultrasound”, “FAST”, and
“diagnostic peritoneal lavage”. Search results were
individually reviewed and manually cross referenced.
We also searched the Cochrane Library and Clinical
Evidence . . .
Volume 336, Number 7650 & 7651 - April 26 & May 3, 2008 11
