Coventina's Column

The furore over polyimplant prosthese (PIP) breast implants, which were discovered to have been filled with non-medical grade silicone, will have thrown tens of thousands of women across the world into panic. It is not acceptable that the distress of those affected has been exacerbated by confusion: while French health advice recommended that women with PIP implants should have them removed, the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK maintains that there is insufficient evidence to recommend routine removal. The National Health Service (NHS) Medical Director Professor Sir Bruce Keogh was asked to lead an expert group to investigate the evidence on these implants, and the Department of Health reported in early January 2012 that the original MHRA advice still stands. They did concede that those women whose implants had been inserted on the NHS – mostly women who had reconstructive surgery after mastectomy for breast cancer – would be entitled to implant removal and replacement on the NHS if they and their general practitioner (GP) agreed that it was the right course of action for them, and/or if ultrasound scan showed rupture. The Department of Health urged private clinics to do the same, but private clinics have argued that they lack the resources – financial and otherwise – to replace without charge, and that routine removal and replacement without charge would lead to bankruptcy.

This government response is unhelpful. The Department of Health declared the findings of the expert group thusly: ‘The expert group has not been able to establish if the rupture rate is higher for PIP implants than for others. Reports show that, of the PIP implants that have been tested, there is no risk of dangerous toxins leaking into the body if an implant did rupture. However, we are not confident that the manufacturer did not change the silicone in the implants, so cannot rule out the possibility that some are toxic.’ This fence-sitting statement is likely to lead to further anxiety. ‘Not being able to establish a higher rupture rate’ is a woolly statement and very different from a robust rebuttal of a higher rupture rate. Shifting the responsibility to GPs for women treated on the NHS will burden the already-strained primary healthcare teams. And saying private companies ‘should’ pay for removal is like saying cigarette companies ‘should’ pay compensation to people with smoking-related diseases. Legislation, not sanctimony, is what helps patients. All manufacturers of medical devices and medicines and all private health clinics should be obliged to pay a percentage of takings into an insurance fund for such eventualities. If you bought a faulty item from any other manufacturer, there should be no question of them not replacing or refunding it. It is a sad state of affairs when we have more legislative protection over a stale pie than over our health.

It is well known that atrial tachyarrythmias increase the risk of ischaemic stroke because of their propensity to allow clot to be thrown off from the atria. A recent study (N Engl J Med 2012;366:120–9) has investigated whether subclinical episodes of atrial tachydysrrhythmias, as detected by pacemakers, were associated with an increased risk of ischaemic stroke in patients not known to have atrial fibrillation. The study involved 2580 patients over the age of 65 who had known hypertension but with no history of atrial fibrillation and in whom a pacemaker or defibrillator had recently been implanted. The patients were monitored for over three months to detect episodes of atrial dysrrhythmias. Of these patients, 10.1% showed evidence of subclinical atrial tachyarrhthymias and had a significantly increased risk of ischaemic stroke. Preventing these dysrrhythmias and instituting prophylaxis against stroke (such as antiplatelet or anticoagulant drugs) for those in whom they persist may reduce morbidity and mortality in these patients.

Intensive care units, with their excellent facilities for monitoring, high resource allocation per patient and round-the-clock emergency care, offer a quality of care not available to patients on understaffed and crowded surgical wards. It is known that patients undergoing colorectal procedures are often elderly, with cardiac and/or respiratory co-morbidity, and that abdominal incisions, with their attendant pain, cause increased strain on heart and lungs, while the catabolic response after major surgery can increase patients’ vulnerability to complications at a time when they are already at risk of infection, malnutrition and, if allowed to dehydrate, renal problems. So, which patients should routinely be admitted to intensive care after open colorectal surgery? Recent research (Br J Surg 2012;99:295–9) suggests that screening via a cardiopulmonary exercise test can select patients who would benefit most. Less fit patients as determined by anaerobic threshold on exercise testing were randomly allocated to either ward (39 patients) or intensive care (51 patients) postoperatively. Cardiac events occurred in seven of the 39 ward patients but in none of the 51 intensive care patients. Managers in the NHS are often obsessed by shorttermism, but this simple preoperative screening test with a short postoperative intensive care stay could not only reduce patient morbidity and mortality, but also reduce costs in the long term.

Parkinson's disease is one of those wretched conditions in which the drugs are often as problematic as the disease. A new, effective therapy could, therefore, be a panacea to these patients. Reports that subthalamic deep brain stimulation with a constant current device (Lancet Neurol 2012 [in press] doi:10.1016/S1474-4422(11)70308-8) cause significant improvement in symptoms are a hopeful finding. However, the results should be interpreted cautiously, as some potentially catastrophic complications occurred after implantation of the deep brain stimulation device, including infection and intracranial haemorrhage. Once again, patients, their carers and doctors are faced with the dilemma of trying either invasive procedures that place the patient's life at risk or making do with a compromised quality of life. Hippocratic oath notwithstanding, it is not a choice that is ever easy.