Abstract
Single component vaccines more dangerous than MMR
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.
The anaesthetist, not the patient, should be aware
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.
Cervical screening – explanations are essential
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.
Making heart attack performance indicators more accurate
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.
NICE pronounces on postoperative infection
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.
Is that a hamster which I see before me?
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.