Clin Risk 2008;14:230-231
doi:10.1258/cr.2008.080095
© 2008 Royal Society of Medicine Press
Spreading the risk: a look at what other medical journals are reporting
Harvey Marcovitch
Email: h.marcovitch{at}btinternet.com
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Single component vaccines more dangerous than MMR
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All vaccines carry a risk of anaphylaxis which may be life-threatening.
For mumps–measles–rubella vaccine (MMR) the estimated
rate is 1.4 cases/100,000 doses. Between 2003 and 2007, four
cases of anaphylaxis were reported due to single component vaccines
(either measles or rubella) obtained from private clinics by
parents anxious about the safety of MMR. These clinics, unlike
the NHS, do not have to report how many vaccines they administer,
but if all the single-component vials imported under special
licence during this period were used, the rate would be 18.9/100,000
cases. There is information to suggest only about 30% is used
which would increase the estimated rate still higher. The authors
of the report call for the Healthcare Commission to insist that
private clinics are subject to the same standard of vaccine
data reporting as are demanded of the NHS.
Archives of Disease in Childhood 2008; 93: 974–5
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The anaesthetist, not the patient, should be aware
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Successful litigation has been pursued by Claimants who were
conscious and aware during anaesthesia but unable to draw attention
to their plight because of the concomitant use of muscle paralysing
agents. The problem is sufficiently important for there to have
been an international symposium on memory and awareness in anaesthesia
in 2008. Moreover, it was the seventh such symposium. The meeting
has sparked a lively correspondence in the
British Journal of Anaesthesia: Dr J Ponte comments that little progress has been
made over 10 years in tackling this problem, given that the
‘gold standard’ for detection is muscle movement
– which is inhibited by neuromuscular blockers given in
the course of the anaesthetic. The baseline risk is not known
precisely but may be as high as 1% in high-risk patients and
one-fifth of that figure in those assessed as at low risk for
anaesthetic complications. However, a research team from Perth,
Australia questioned 5371 consecutive patients operated upon
in their institution and found just two cases (0.04%). Debate
rages over whether certain components of an anaesthetic regime,
such as nitrous oxide, reduces or increases the risk of awareness.
British Journal of Anaesthesia 2008; 101: 738–41
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Cervical screening – explanations are essential
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Every year, 3.4 million women in the UK undergo cervical screening.
While NHS screening centres are responsible for inviting and
reminding women to attend, the results may be communicated through
their general practices. Although there are nationally produced
explanatory leaflets, many practices prefer to generate their
own communication strategies on what can be a complex series
of explanations rather than what many people assume is a straightforward
yes/no dichotomy.
A team at Oxford recruited focus groups of women recently screened in three parts of England. Practice proved inconsistent with some learning by letter, others having to ring their GP to find out the result. A few received out-of-date screening materials and conflicting results from their GP and the local screening centre information. One woman was disturbed to receive a terse three-line statement simply telling her she did not have cancer but should return in three months (without explaining why that was advised). Others were dissatisfied with what they perceived as a casual dismissal of their fears and wished there was an intermediary outside primary care with whom they could discuss their uncertainty. The authors suggest remedial measures might include the use of diagrams to explain abnormalities detected and the inclusion of updates on previous screening results being immediately available for comparison.
Quality & Safety in Health Care 2008; 17: 334–8
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Making heart attack performance indicators more accurate
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Performance indicators are available by which hospitals can
assess their quality in managing acute myocardial infarction
(MI). Using these together with figures on prescribing medication
to prevent future events, many hospitals perform well consistently
and the management of MI is generally agreed to be better than
it was.
Recently announced changes in guidelines for managing MI will make many of the current indicators redundant. That is because they depend heavily on the efficiency of delivering thrombolysis (‘call to needle’ and ‘door to needle’ times) which is to be replaced nationally by a move to primary percutaneous coronary intervention, which is measurable instead by ‘call to balloon’ and ‘door to balloon’ times.
An editorial in Heart suggests instead developing composite indicators which aggregate interventions with the same aim and take into account the timeline of hospital care. These could be summarized as:
- Performance in the first 24 hours, to include use of appropriate medication and assessment by a consultant cardiologist;
- Timely reperfusion – such as ‘call to balloon’ time of no more than 2 hours;
- Risk assessment by use of lab tests, imaging, stress testing, et cetera;
- Performance at discharge, with regard to prescriptions and arrangements for rehabilitation;
- Risk-adjusted 30-day mortality.
The
author accepts that some dislike the whole concept because of
potential misuse of over-simplified data and the time-consuming
work of collecting it in the first place. Closer involvement
of professional bodies in setting the standards and ensuring
they comply with the evidence base might be one way to assure
compliance. Inevitably the time may come when financial incentives
might be necessary to encourage compliance.
Heart 2008; 94: 1397–401
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NICE pronounces on postoperative infection
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A summary of NICE guidance on preventing and managing surgical
site infection has been published in the
BMJ. It details the
information patients should be given on the risks, how they
might be mitigated, how to recognize infection, whom to tell
and how to look after their wound when they go home. It advises
clinical staff on preoperative, intraoperative and postoperative
care. Headings include:
- Preoperative: showering, hair removal, theatre clothing, nasal decontamination, bowel preparation, antibiotic use;
- Intraoperative: hand decontamination, gowns and glove sterility, use of drapes, antiseptic skin preparation, use of diathermy, wound irrigation, dressings;
- Postoperative: dressing changes, avoiding topical antibiotics, use of interactive dressings, tissue viability nurses, managing established surgical site infection.
The guideline acknowledges the strengths and
weaknesses of the evidence on which NICE has reached its conclusions.
Some of its advice is vague or simply advising reference to
local protocols. The summary authors point out the outstanding
question, of course, is how far adherence to the guidance will
reduce the risk of this common and costly problem.
BMJ 2008; 337: 1049–51
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Is that a hamster which I see before me?
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The American Academy of Pediatrics has turned its gaze on the
risks to children of what it politely calls ‘non-traditional
pets and animals in other settings’. They are not talking
cats and dogs here but rather such exotica as frogs, salamanders,
raccoons, ferrets, gerbils, hedgehogs, lizards and skunks(!).
A table describes the organisms they might harbour from TB in
giraffes encountered at zoos, through
E. coli in cattle contacted
at agricultural fairs to salmonella harboured by hamsters in
pet shops. Fortunately rabies in rodeo ponies is unlikely to
be a risk in Hertfordshire.
A detailed table lists guidelines to reduce the risk of acquiring infection from furry friends which look like a gift to those enamoured of health and safety. Helpfully it provides addresses of websites containing reliable information on preventing transmission of disease from animals to children.
Pediatrics 2008; 122: 876–83
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Footnotes
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Harvey Marcovitch FRCP Hon FRCPCH, Editor in Chief of
Clinical Risk, Royal Society of Medicine Press, 1 Wimpole Street, London
W1G 0AE, UK
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