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UK NEWS Dying patients are often not told of closeness of death, p 1176
news
World NEWS US
gene therapy trial is to restart despite patients death
, p 1172
bmj.com Screening

for bowel cancer halves number of deaths

GPs are struggling to match the services they


buy with the health needs of local people
Zosia Kmietowicz London but she was concerned that so many were ments for providing education programmes
Primary care trusts in England are failing to struggling to meet the standards expected to patients with diabetes in their area. And
plan and purchase services that are appropri- of them. Many trusts did not fully under- 2000 practices did not fulfil their trusts plans
ate to their local communities, says Englands stand the needs of their local people, mak- to establish registers for people at risk of
healthcare watchdog. ing it difficult to buy targeted services, the coronary heart disease, a system designed to
In its fourth annual report on the state of report says. prevent serious outcomes in this group.
health services the Healthcare Commission Last year GPs failed to record the body Despite overall improvements in the health
says that overall the quality of NHS services mass index of 2.3 million people, data that services in England and Wales and better
has improved in the last year, with 46% of provide important statistics on the preva- attention to safety, some significant gaps in
trusts rated as excellent or good in 2006-7, up lence of obesity. The number of diagnoses the delivery of health care remain. Lack of
from 40% in 2005-6. But primary care trusts of heart failure was also some 140000 less data on sexual health had made it difficult
performed the worst for the second year run- than expected, says the report. to target people with the greatest need; and
ning, with around three quarters (74%) rated Even where the needs of the community childrens services for the least well off fami-
as fair or weak for the quality of services they are known, trusts are not buying in the right lies were not improving quickly enough.
provide and 80% for the way they used their services. Altogether 5000 fewer patients than The commission also raised concerns that
resources. planned had received emergency mental the gap in health between rich and poor
Anna Walker, chief executive of the com- health care, because 41% of primary care people remains unaltered.
mission, acknowledged that primary care trusts had not bought sufficient crisis serv- State of Healthcare 2007 can be seen at www.
trusts had been reorganised in the past year, ices. Most trusts (85%) did not have arrange- healthcarecommission.org.uk.

US doctors are not following


ethical guidance, survey finds
Jeanne Lenzer New York doctor to a relevant authority cost, access, and quality in
Many doctors in the United (Annals of Internal Medicine the US healthcare system
States are failing to conform 2007;147:795-802). that have not been resolved
to professional guidelines. A The survey of 3167 through legislation or
survey sponsored by the US randomly selected and competition, the authors
Institute of Medicine found eligible doctors, 1662 wrote.
that doctors often fail to (52%) of whom responded, Over 90% of doctors
conform to accepted norms showed a substantial who responded
in areas of self regulation, gap between what the agreed with eight of 12
managing conflicts of doctors say they believe is statements regarding
interest, and ordering of appropriate professional professionalism. Despite
unnecessary tests. behaviour and how they act. this strong support, most Doctors are loth to report colleagues for incompetence
Moreover, although most The doctors were asked respondents said they
respondents thought they about their support of would, for example, refer Doctors were also reluctant Only 1% of doctors said they
should report colleagues professional norms as patients to a local imaging to report medical errors: had not been honest with
who were not competent, established by the charter facility in which they had 46% had direct personal patients and their families
almost a half said that in the on professionalism a financial interest, and knowledge of at least one about medical issues in the
past three years they had promulgated in 2002 by the a quarter said they would serious medical error in past three years, and three
known of a doctor who was American Board of Internal make the referral without the past three years that they quarters said they treated
impaired or incompetent Medicine and other groups informing the patient of did not report. poor patients without
but had failed to report the to address problems of the conflict of interest. There were bright spots. expecting payment.

BMJ | 8 December 2007 | Volume 335 1171


NEWS

UK government pledges 370m


to improve cancer care
Caroline White London screening will start at the age of 47 rather
All patients with symptoms in a breast, irre- than 50 and end at 73 rather than 70, and
spective of whether cancer is suspected, will by 2010 the upper threshold for bowel can-
be seen within two weeks of referral to a cer screening will be extended from 70 to
specialist under ambitious new government include those aged up to 75.
plans announced this week to achieve world The strategy also recommends a reduction
class services in England. in the time from when the decision is made to
The move is part of a raft of measures, out- treat a patient to the actual start of treatment.
lined in the five year cancer reform strategy, It says that the 31 day maximum delay for
to speed up the diagnosis and treatment of radiotherapy should also apply to other treat-
cancer. ments such as surgery and chemotherapy.
The strategy emphasises prevention. Michael Williams, vice president of the

Neil McAllister/Alamy
Under consideration are a ban on cigarette Royal College of Radiologists, said that
vending machines, curbs on the display of although this standard for radiotherapy
tobacco products, and a review of sun bed had been set in 1993, in 2005 it was being
use by people aged under 18 years. achieved in only 50% of cases.
Age thresholds for screening services will The Cancer Reform Strategy is available at
also be extended. By 2012 breast cancer www.dh.gov.uk. The UK government is reviewing use of sun beds

Blame culture is still had fallen to 61% in 2006-7, the commis-


sions annual health check data showed. The
taken to ensure that the incident does not
happen again, she said.
a problem in tackling commission also found that a similar number
of independent sector providers had failed to
Communication failure was one of the
main causes of error, said Michael Leonard,
patient safety meet national minimum standards on safety,
Dr Moore told the conference on risk and
the physician lead for patient safety at Kaiser
Permanente, one of the largest health main-
Lisa Hitchen London patient safety, organised by the company tenance organisations in the United States.
A culture of blame still stops healthcare pro- Healthcare Events. Poor communication with clinicians over
fessionals from reporting patient safety inci- We still blame individuals rather than safety could create problems if managers
dents, a Department of Health expert told a look at what the causes of patient safety inci- wanted to engage them in change, he said.
conference in London last week. dents are, she said. This means people still What happens is the conversation gets
Jane Moore, director of healthcare quality find it difficult to report [incidents]. framed in the wrong way as . . . cookbook
at the department, said that the latest data The data had shown some improvements. medicine. [The doctor thinks] you are treat-
from the Healthcare Commission, Englands The number of staff who had seen an error ing me like an idiot and telling me what to
healthcare watchdog, showed that harm to in the past month fell over the period 2003 do. What we should say is: Here is the pat-
patients while in hospital was still a major to 2006, for example, while the number of tern of risk, here is where we know you will
problem. staff saying that the last error they had seen get in trouble, he explained.
In 2005-6 63% of organisations complied was reported had risen, she added. More details of the Risk and Patient Safety
with all core safety standards, but this figure But more are saying that no action is conference are at www.healthcare-events.co.uk.

US gene therapy trial is to restart, despite patients death


Janice Hopkins Tanne New York Seattle, Washington. investigation found that the drug Biotechnology Activities reported
The US Food and Drug Administration Targeted Genetics said in a did not contribute to her death, the that the patient died from a large
has allowed the resumption of press release that the FDA had company said. retroperitoneal haematoma (3.5 kg
clinical trials of an experimental form reviewed data on safety concerning The Recombinant Advisory at autopsy) and from disseminated
of gene therapy for inflammatory all 127 patients in the trial of the Committee of the National Institutes histoplasmosis. The source of the
arthritis. Trials were suspended treatment, which used tgAAC94, of Health (NIH) met on 3 December to bleeding could not be determined,
in July when a patient died after a an investigational gene therapy consider the patient who died. Voting and doctors were unable to control
second injection into the knee joint product developed to treat active on the findings was postponed to the it despite massive transfusions. The
of the gene based therapy developed inflammatory arthritis, as well as next meeting. report said it was unlikely that an
by Targeted Genetics Corporation of data from the patient who died. The At the meeting the NIHs Office of immune reaction had a role in her

1172 BMJ | 8 December 2007 | Volume 335


NEWS

Mortality from measles fell by 91% in Africa


and by 68% worldwide from 2000 to 2006
John Zarocostas Geneva 68% from 2000 to 2006from an estimated s trategy in South Asia, where the measles dis-
The number of deaths in Africa from measles 757000 deaths to 242000. The fall in Africa ease burden is now the highest in the world.
fell from an estimated 396000 in 2000 to accounted for 70% of this reduction. Between 2000 and 2006, the report says,
36000 in 2006, a fall of 91%, says a progress Big reductions were also registered in 478 million children aged between 9 months
report by the World Health Organization WHOs Western Pacific region, down by and 14 years received measles vaccine
and Unicef. It attributes the decrease 81% to 5000 deaths from 25000, and in the through supplementary campaigns in 46 of
largely to better coverage in routine Eastern Mediterranean region, by 76% the 47 priority countries.
immunisation programmes and from 96000 to 23000. In WHOs African region alone, between
targeted campaigns to ensure that However, in WHOs South East 2001 and 2006 more than 304 million chil-
children had a second chance to Asia region, which includes the dren in 40 countries were given a second
Alfred Pasieka/spl

be vaccinated. Indian subcontinent, the fall in vaccination through these campaigns.


This is a major public health measles mortality was substantially Overall in 2006 the worldwide campaign
success and a tribute to the com- smalleronly 26%, from 240000 to to improve vaccination coverage reached an
mitment of countries in the African 178000because reduction strategies estimated 80% of its target population for the
region, said Margaret Chan, director gen- in some large countries with a high burden of first time, up from 72% in 2000. The biggest
eral of WHO. the disease, such as India and Pakistan, were gains were recorded in the African region.
We need to sustain this success and inten- lagging behind those in other countries. Progress in Global Measles Control and Mortality
sify our efforts in other parts of the world, as Julie Gerberding, director of the CDC, Reduction, 2000-2006 can be found at www.who.
there are still far too many lives lost to this said, The next step is to fully implement the int/wer/2007/en.
disease, she said.
The executive director of Unicef, Ann
Veneman, also lauded the results in Africa
but went on to say: Measles is still killing
nearly 600 children under 5 every day, an
unacceptable reality when we have a safe,
effective, and inexpensive vaccine to pre-
vent the disease.
Of the deaths from measles in 2006, 90%
were among children aged under 5 years,
says the report by the Measles Initiative,
which is run by WHO and Unicef in con-
junction with the American Red Cross and
the US Centers for Disease Control and Pre-

Dieter Telemans/panos
vention (CDC).
WHOs objective is to achieve a 90%
worldwide reduction in the number of mea-
sles deaths by 2010, and officials are confi-
dent that this can be met.
Mortality from measles worldwide fell by In 2006 measles vaccination reached 80% of the target population, up from 72% in 2000

death. No evidence of contamination antagonist adalimumab. For her rheumatoid arthritis, which of inflammation. The vector was
of the product was found, and the The patient was identified as Jolee she had had for 15 years, she was injected directly into the joint.
vector was found only at extremely Mohr, 36, of Taylorville, Illinois, who taking adalimumab, methotrexate, Science magazine (2007;317:580)
low levels outside the knee. was married and had a 5 year old and prednisone, all of which are reported that existing drugs for
This patients unfortunate daughter. She was given the first immunosuppressive and a risk rheumatoid arthritis also inhibit this
death was primarily a result injection in February and the second factor for histoplasma infection, the mediator of inflammation, but they
of an opportunistic infection, on 2 July. She experienced vomiting company said. do not always penetrate all joints and
disseminated histoplasmosis with and fever soon after the second The trials used a recombinant, need to be injected frequently.
subsequent bleeding complications injection. When her symptoms adeno associated virus as a vector. In its press release Targeted
and multi-organ failure. Her apparent worsened she was admitted to An FDA press release said that the Genetics said that final molecular
risk factor . . . was her systemic RA hospital and later transferred to the vector delivers the gene for tumour test results had shown that there was
[rheumatoid arthritis] therapy, chiefly University of Chicago Hospital, where necrosis factor receptor, with the no amplification of the viral vector in
the TNF [tumour necrosis factor] she died on 24 July. aim of inhibiting a key mediator the patients body.

BMJ | 8 December 2007 | Volume 335 1173


NEWS

in brief GMC strikes Southall off


Exercise during early pregnancy may
increase miscarriage risk: A study
involving 92671 pregnant women showed
that the risk of miscarriage in the first 18
register for serious misconduct
weeks was higher among women who Owen Dyer London aggressive and sarcastic when question-
exercised more than seven hours a week The paediatrician David Southall has been ing her about the death. Jacqueline Mitton,
than among those who did not exercise struck off the medical register by the Gen- chairing the GMC panel, described Mrs M
(hazard ratio 3.7 (95% confidence interval
eral Medical Council after a hearing found as a clear, honest, and credible witness.
2.9 to 4.7)) (BJOG 2007;114:1419-26).
that he inappropriately accused a mother of Dr Southalls actions, the panel ruled,
More people in Gaza are denied travel murdering her 10 year old child. were inappropriate, added to the distress of
permits for treatment: The World Health Dr Southall, 59, was also found to have a bereaved person, and were an abuse of his
Organization says that people trying to removed childrens medical records from professional position.
leave Gaza to get specialist care in Israel hospital files and stored them where other Dr Southall was also found to have
or beyond are increasingly being denied care givers could not access them. The GMCs removed medical files from hospital records
travel permits. Since restrictions were disciplinary panel ruled that his acts amounted and stored them as special case files. This
imposed in June, 713 people have been
refused permits, with the proportion
to serious professional misconduct. was not in itself damaging, the panel ruled,
reaching 23% of applicants in October, It is the second time that the GMC has provided that there was sufficient internal
up from 11% in June. Twelve people have found Dr Southall guilty of making inappro- signposting to permit other hospital staff to
died since October because of the delays. priate accusations of murder against a parent. access the information. But the panel found
He was barred from child protection work that such access was lacking in the cases
Lack of nutrition blights HIV for three years in 2004 after he accused Steve of three children, effectively removing the
treatment: A report from the World Clark of murdering his son, having watched information from the health system. This
Food Programme (www.wfp.org) says
a television interview with the father. practice damaged the integrity of the chil-
that hidden hunger affects more than
two billion people. Even if a person has In the current case Dr Southall was found drens hospital records, the GMC found.
enough energy intake, the lack of a single to have accused a mother, called Mrs M Dr Southall further damaged the integ-
micronutrient can compromise their by the GMC, of suffocating rity of two childrens files,
immune system and allow infections to and strangling her child, who the GMC found, in bringing
take hold. People with HIV need 30% was found hanged in a closet. them with him from the Royal
to 100% more energy, says the report, Mrs M, who now lives in Aus- Brompton Hospital to the
but some people are not seeking HIV tralia, told her story to the North Staffordshire Hospital,
treatment as they worry that their appetite
Mail on Sunday newspaper this where the children had never
will return and they will not be able to feed
themselves. weekend. Her second son was been treated. But other files
taken into care on Dr South- stored on his computer were
Europe and US simplify application alls recommendation but later not being kept inappropriately,

Chris young/pa
for orphan drugs: The European returned home. the panel found, because the
Commission, the European Medicines She told the GMC hearing information in them was still
Agency, and the US Food and Drug that Dr Southall had been Struck off: Dr David Southall also in the hospital system.
Administration have adopted a common
application form for sponsors seeking
designation of drugs as orphan drugs in
the European Union and United States. The
aim is to simplify the process of obtaining
Pay rise next year is It depends on how you measure infla-
tion, said Mr Johnson. The chancellor [of
orphan status for drugs intended for rare
diseases in both jurisdictions.
not likely to top 2% the Exchequer] is right to ensure that we
dont build in an inflationary spiral that takes
Adrian ODowd London us back to the days of high interest rates.
A tenth of English patients are harmed An acceptable pay settlement for NHS staff I say on many occasions to nurses, GPs,
by stay in hospital: One in 10 NHS next year should be achievable, despite the and consultants: if you look at the record
patients come to harm while in hospital
as a result of their clinical care, says
fact that an increase will probably be only since 1997, and if you look at what happened
a study that reviewed the case notes around 2%, the health secretary has said. through Agenda for Change [the system of
of a random sample of just over 1000 Alan Johnson told MPs last week he was pay and conditions introduced in the NHS
patients admitted to a large teaching optimistic about the current difficult pay in 2004], no government has done more to
hospital in England in the first six months discussions taking place. try to establish decent pay for people.
of 2004. The commonest problems were Mr Johnson was giving evidence as part of In terms of how we maintain that pay we
unplanned admission or readmission the parliamentary health select committees are going into a difficult set of discussions
as a result of previous treatment in the
inquiry into public expenditure. and negotiations, but I am hopeful we will
hospital, followed by injuries, such
as falls or pressure sores, and other The committee tackled him on the govern- come out with a settlement.
complications, including heart attack and ments recent call for a 2% pay rise in 2008-9 Mr Johnson confirmed earlier speculation
deep vein thrombosis (Quality & Safety in for most NHS staff and asked whether pay that the NHS was on course for a surplus of
Health Care 2007;16:434-9). rises below the rate of inflation were going 1.8bn (2.5bn; $3.7bn) by the end of the
to be the norm. current financial year.

1174 BMJ | 8 December 2007 | Volume 335


NEWS

antenatal care who died were


overweight or obese, she said,
in comparison to estimates
of 10-11% in the general
population.
Some women had arms so
big that the standard blood
pressure cuff would not go
round.
However, death during
pregnancy or within 42 days of
delivery continues to be rare in
S.I.U. school of medicine/spl

the UK, the report says, with


only 295 women dying out
of two million mothers who
gave birth in the three year
period. The overall maternal
death rate in 2003-5 was 14 per
The overall maternal death rate14 per 100000did not change from 2000-2 to 2003-5 100000 (whether the death was
directly or indirectly related

Deaths related to obesity take over from to the pregnancy), a figure not
significantly different from that

suicide as leading cause of maternal death in the previous report.


A rise in the number of
women from overseas giving
Lisa Hitchen London which found that suicide was deaths from congenital heart birth in the UK has had an
Deaths from cardiac causes, often the leading cause of overall disease fell from nine (20% of effect on maternal mortality, the
linked to obesity, are now the mortality. The number of all cardiac deaths) in 2000-2 to report shows. New immigrants,
commonest type of death among suicides fell from 58 in 2000-2 four (8%) in 2003-5. refugees, asylum seekers, and
women during pregnancy and to 37 in 2003-5. Most cardiac deaths health tourists may have
childbirth, finds the latest three Deaths from acquired are completely and utterly more complicated pregnancies,
year report into why mothers die ischaemic and other acquired associated with lifestyle. It is a poorer health, and more serious
in pregnancy and childbirth in cardiac disease accounted for big finding, she said. underlying medical conditions
the United Kingdom. 44 of all the 48 deaths from Of direct causes, than mothers born in the UK,
The report from the cardiac causes (91%), up from thromboembolism is top. Both it says.
Confidential Enquiry into 35 out of 44 cardiac deaths this cause and cardiac disease Saving Mothers Lives: The 7th
Maternal and Child Health, (79%) in the last report, said are linked to obesity, Dr Lewis Confidential Enquiry into Maternal
covering 2003-5, reports a Gwyneth Lewis, director of said. Fifty two per cent of and Child Health can be found at
shift from the last report, the inquiry. The number of mothers who had booked for www.cemach.org.uk.

This is a dramatic improvement, he said,


and I think its testament to the tremendous
NHS doctors and finance staff have a negative
efforts of NHS staff over the last year and
a half.
view of each other, says Audit Commission
Its reasonable for a large organisation Adrian ODowd London They interviewed staff at 16 different
with a 100bn turnover to have a 2% sur- Doctors must be involved in financial deci- NHS sitesacute, foundation, and primary
plus. I dont think the NHS could function sion making in the NHS to avoid repeating care trustsin preparing the report, which is
on a break even basis. the cash disasters of recent times, Englands aimed at clinicians, managers, and finance
MPs asked him about the consultants public spending watchdog says. professionals.
contract and whether or not it was a mis- The Audit Commission has published a Their work showed that the two professional
take for Mr Johnsons predecessors to give report calling for much better communication groups held some firm negative stereotypes
consultants extra pay before they had made and working relationships between clinical of each other, say the authors, but they also
changes to their way of working. and finance staff. The NHS will become more found good examples of clinical and financial
I am a supporter of that deal, he said. I efficient and will improve services for patients staff working together to improve the quality
think consultants ought to get decent pay; only if relationships between these two groups and efficiency of services.
so should GPs and nurses. The trouble is of staff are stronger, says the report. The report identifies several practical
people forget what life was like before that Failure to engage doctors and other clini- measures to promote better joint working.
contract. cal staff in managing budgets is at the heart A Prescription for Partnership: Engaging Clinicians
Trusts now knew what their consultants of financial problems in the NHS, say the in Financial Management can be seen at www.
were doing, he argued. authors. audit-commission.gov.uk.

BMJ | 8 December 2007 | Volume 335 1175


NEWS

Dignitas is forced to offer its Mistakes in deciding


services from a former factory
Clare Dyer bmj Mr Minelli, 75, then offered the living
Dignitas, the Swiss organisation that helps room of his own home in Maur, a village 12
people with terminal illnesses to end their km from Zurich, but local officials stepped in
lives, has had to begin offering its services in and banned its use for assisted suicides. Dig-
a former factory after being forced to leave nitas, which blames its problems on a not
the flat it was using in Zurich. in my back yard attitude, had to resort to
The owner of the block of flats asked Dig- hotel rooms, and one man decided he would
nitas to leave by the end of September after prefer to die in his car.
opposition from residents and the media. After the organisation found the former
The organisation, founded by the human bowling ball factory in the village of

rex
rights lawyer Ludwig Minelli, found another Schwerzenbach, 22 km from Zurich, the Some partners accused women of forging the
flat but was unable to use it after the local local council tried to ban assisted suicides report when the child turned out to be a girl
council took action. there, but the administrative court for the
canton of Zurich ruled that Dignitas could
use it, pending a final court decision. Assisted suicide is legal in Switzerland as
Mr Minelli, who runs Dignitas as a non- long as the helper is not acting from selfish
profit organisation, told a press briefing in motives. In England and Wales anyone who
London last weekend: If you look at it aids and abets a suicide commits a criminal
from the outside its a commercial building, offence that carries a maximum 14 year sen-
but inside the two rooms that we use are tence. However, Mr Minelli said that the
very cosy. He was invited to London by UK Crown Prosecution Service had never
the Glasgow based organisation Friends at prosecuted a relative in England for helping
the End. a loved one get to Zurich to visit Dignitas.
Dignitas, which has around 6000 mem- Despite this, relatives of British people
bers in 57 countries, is the only Swiss organ- who use the services of Dignitas still fear
isation that offers a doctor assisted suicide prosecution if they make the arrangements
service to people from abroad. Mr Minelli or accompany their loved ones. Debbie
said that 808 people from 26 countries Purdy, 44, from Bradford, who has multiple
had used its services, including 84 British sclerosis, has asked the director of public
people, the third largest group. Most had prosecutions, Ken Macdonald, for an assur-
terminal cancer, multiple sclerosis, or motor ance that her husband will not be prosecuted
chris ison/pa

neurone disease. if he helps her go to Zurich. Without that


More than half of those who have been helped assurance, she says, she will feel obliged to
to commit suicide by Dignitas are German go there much earlier than she otherwise
Founder of Dignitas Ludwig Minelli offered the use 464 or 57%. The next biggest national group would, while she is still capable of going
of his own home for assisted suicides is the Swiss, just ahead of the British at 94. without him.

Dying patients are hospitals are achieving high standards of clini-


cal care for dying patients. For example, non-
whereas 53% of carers had theirs assessed.
For the audit the researchers looked at data
often not told of essential drug treatment was stopped in 93% of
patients, and 91% of patients were given pain
from the records of 2672 patients who died
in 118 hospitals in England from the start of
closeness of death relief in the last few days or hours of their life. September to the end of November 2006.
But hospitals were less good at deliver- The researchers point out, however, that the
Zosia Kmietowicz London ing bad news. Only 57% of the patients had audit may underestimate the level of care
English hospitals are generally doing what been told that they did not have long to live, being given, because some care may have
they should be for people who are dying, in and only 45% recognised the nature of their been delivered without being documented.
terms of stopping some drug treatments and condition. However, over 80% of carers were Mike Richards, who chairs the advisory
initiating others, but patients psychosocial aware of the diagnosis, indicating that staff board to the Department of Healths end of
welfare is less well catered for, shows an find it easier to discuss the issue of dying life care strategy, said, Care of the dying is
audit of the care of dying patients. with relatives and friends. urgent carewith only one opportunity to get
The audit, which was carried out by the The spiritual needs of patients also tended it right to create a potential lasting memory
Marie Curie Palliative Care Institute in to be more neglected than those of their for relatives and carers.
Liverpool, with the support of the Royal carers. Records showed that only a third of National Care of the Dying AuditHospitals can be
College of Physicians, found that, overall, patients had their spiritual needs assessed, seen at www.rcplondon.ac.uk.

1176 BMJ | 8 December 2007 | Volume 335


NEWS

fetal sex from ultrasonography can lead to domestic abuse


Roger Dobson Abergavenny scans to determine foetal sex should about the sex of their fetus. They misinformation, and nine said they
Incorrect determination of the sex be made known to women and their used questionnaires and in-depth had been physically assaulted by
of a fetus from ultrasonography can partners, the authors write. interviews to gauge the womens their partner. All these women had
result in marital conflict, domestic The authors, who cite other studies responses. incorrectly been told they had a male
abuse, and economic hardship, says indicating that the accuracy of Asked about their immediate fetus. None of the women said that
a study carried out in Nigeria, where ultrasonography to determine fetal reactions to their newborn, 28 of they had previously experienced
male offspring are highly desirable. sex ranges from 87% to 99%, say the 102 women reported positive violence from their partner.
The psychological and physical that despite the widespread use of feelings, 12 had mixed feelings, The authors wrote, The issues
health of the mother and the the technique little is known about and 62 had negative feelings. All identified as the immediate factors
upbringing of the child can be the effect on parents of incorrect the women with negative feelings behind the marital conflicts included
affected by such misinformation, information. wanted a boy, and all had been told accusations from the womens
says the report (International Journal The authors looked at a total of wrongly that the sex of the fetus was partners of forging the ultrasound
of Gynecology and Obstetrics: doi: 2860 deliveries and recruited 102 male. report and increased economic
10.1016/j.ijgo.2007.09.021). women into the study who had Thirty nine women reported pressure placed on the family by the
The failure rate of ultrasound been given incorrect information marital conflicts as a result of the incorrect result.

Most US emergency departments are poorly


prepared to treat children, study shows
Janice Hopkins Tanne New York Medicines report Emergency Care for Children:
A study of how well prepared US emer- Growing Pains, published in 2006.
gency departments are to treat children has Hospitals that were more prepared tended
shown that only 6% had all the equipment to be urban, to have higher volumes, to have
and supplies recommended in 2001 by the a separate care center for paediatric patients,
American Academy of Pediatrics (AAP) and to have physicians and nursing coordina-
the American College of Emergency Physi- tors for paediatrics, [and] to be aware of the
cians (ACEP) and endorsed by 17 national AAP/ACEP guidelines, the authors say.
organisations (Pediatrics 2007;120:1229-37). Only 6% of the hospital emergency
The study was based on a questionnaire departments surveyed reported that they
and follow-ups posted in 2003 to the medi- had all 118 recommended equipment and
cal directors of 5144 emergency depart- supplies and 22 drugs. Some departments
ments; 1489 useable surveys were returned. lacked laryngeal mask airways, which may
The survey questions were weighted by an be crucial as a rescue device when usual
expert panel, which judged the importance ways of opening an airway, such as a mask
of various criteria of paediatric care. The and bag or inserting a tube into the trachea,
andy sacks/getty images

results were presented on a scale from 0 to are not successful, Professor Gausche-Hill
100 (perfect). The median score was 55. said. When this criterion was excluded, 8%
The study is by Marianne Gausche-Hill, of emergency departments met the recom-
professor of medicine, David Geffen School mended criteria.
of Medicine at the University of California She said that hospitals, especially those
in Los Angeles (UCLA), and director of that saw few paediatric patients, were afraid
emergency medical services and paediatric of the cost of the full complement of recom- Only 6% of emergency departments said they had
emergency medicine fellowships, Harbor- mended equipment and supplies. The actual all the recommended equipment and drugs
UCLA Medical Center, Los Angeles, and cost would be only about $1000 (500;
colleagues. 700), she said, although some drugs would were more likely to see a higher volume of
Professor Gausche-Hill told the BMJ that need to be replaced when they reach their paediatric patients.
only 59% of the hospitals that answered expiry date. Almost all hospitals said that their
the survey were aware of the guidelines, The surveys showed that 89% of 27 mil- r adiology departments and laboratories
which were originally published in Pediatrics lion emergency department visits by chil- could provide imaging studies of infants and
(2001;107:777-81) and the Annals of Emergency dren were to general hospitals rather than children and perform necessary laboratory
Medicine (2001;17:423-8). Another problem childrens hospitals. Most often, children tests. They also said that they had a plan
was that hospitals had not assigned a doctor were seen in the main emergency depart- to transfer paediatric patients who need
and a nurse to tackle problems in paediat- ment with adult patients. Hospitals that had intensive care and that they had a policy
ric care, as recommended in the Institute of a separate paediatric emergency department on possible child maltreatment.

BMJ | 8 December 2007 | Volume 335 1177

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