REDUCING EMERGENCY ADMISSIONS
J R Soc Med 2006; 99: 81-9
Hospital admission rates for chronic conditions are rising while at the same time primary care has become more organised in offering care to patients with long-term conditions. Why is this so?
This study of 31 PCTs in London throws some light on the problem. The researchers compared admission rates for asthma and diabetes and found higher admission rates from populations in areas of deprivation. Areas where there were well-developed chronic disease management programmes for diabetes had reduced admission rates. Asthma admissions were unaffected by differing primary care programmes.
Many PCTs hope that they will save money in limiting admissions by instigating schemes to improve primary care services. While improving care is always to be supported, the wish that money will be saved through reduced admissions may not always be realised.
POST-DELIVERY ANAL DAMAGE
BJOG 2006; 113: 195-200
OASIS stands for Occult Anal Sphincter Injury and refers to damage to the anal canal after giving birth which is undetected and therefore not repaired. About 40,000 women each year are known to develop incontinence due to OASIS and there may be many more who are too embarrassed to tell anyone.
The incidence of OASIS in mediolateral episiotomies is 0.4 per cent and 19 per cent in midline episiotomies. But is there anything else that can be done apart from using a mediolateral site for episiotomy?
This study tried an educational approach to help midwives and doctors to detect anal damage and repair it. The effectiveness of this was assessed using endoanal ultrasound. There was a significant improvement in repair techniques after teaching.
Much as the thought of ultrasound of the anal canal after delivery is unappealing, avoiding the risk of incontinence makes the test worthwhile.
It is also reassuring that this problem is largely preventable.
Anaesthesia 2006; 61: 123-6
A fast-acting topical local anaesthetic would be really useful for adults and children who say they have a needle phobia.
EMLA (prilocaine/lidocaine) cream and AMETOP gel (4% amethocaine) are effective but require time to work. It was therefore exciting to read of the development of a metered dose spray which can work in five minutes.
Two types of transdermal delivery systems (TDS alpha and TDS beta) were tried out on volunteers. TDS beta was found to be highly effective with no unwanted side-effects. Once it is available it will transform minor surgery sessions and the baby clinic, as well as venepuncture.
CAUSES OF DEATH IN PREGNANCY
CMAJ 2006; 174: 302-3
A recent report of maternal deaths from 1997 to 2000 in Canada showed that maternal mortality was 6.1 per 100,000 live births. Similarities were found with UK data.
The three most common causes of death were thromboembolism, cardiac events and suicide. Mental health problems before and during pregnancy were thought to be a factor in small-for-dates babies. Links were also made with poorer health in other children. Particular features associated with mental health problems were late booking for antenatal care and being subject to violence in the home.
Social measures to offer support to needy families will probably prove as useful as medical technology in preventing maternal mortality.
- Dr Merriman is a GP in Oxford and a member of our team who regularly review the journals
- Chronic disease schemes do not necessarily reduce hospital admissions.
- Anal sphincter injury after childbirth should be detected using endoanal ultrasound.
- Needle fear could be eliminated by the creation of transdermal delivery systems for local anaesthetic.
- Mental health problems are a significant factor in mortality levels during pregnancy.
RESEARCH OF THE WEEK
BEWARE OF OPIATE TOXICITY IN RENAL FAILURE
BMJ 2006; 332: 345-6
Two case reports of patients with renal failure with opiate toxicity make a good case for care with prescribing.
Both patients developed respiratory failure after modest doses of opiate, in one case morphine 50mg and codeine 76mg, and in the other after just four tablets of coproxamol. In both cases the patients only survived after prompt resuscitation.
Although we are all aware that opiates are metabolised and excreted much more slowly in renal failure, it is alarming that such modest doses of medication can cause respiratory failure.