Varicella vaccine, MI and tonsillectomy

Too busy to read the journals? Dr Elisabeth Croton reviews the latest research

Loss of immunity to varicella over time
N Engl J Med 2007; 356: 1,121–9 

The US has been vaccinating all children against varicella as standard since 1995. Initially a single dose of live attenuated vaccine was given but last year the US Advisory Committee on Immunisation Practices recommended a second dose as it became apparent that the immunity of some children was waning.

This population-based study suggests that the incidence of varicella increases up to 12 times between the first and eighth year after vaccination.

The disease is also more severe in children between the ages of eight and 12 with increasing time from vaccination, and is associated with an increased risk of secondary complications. The committee propose that a second dose of the vaccine will maintain immunity for longer.

NHS walk-in centres and appointment waiting times
BMJ online, doi: 10.1136/bmj.39122.704051.55 (published 9 March 2007) 

Do walk-in centres reduce waiting times for a general practice appointment?

This study looked at over 2,000 general practices in England together with 32 nearby walk-in centres. The main outcome measure was the waiting time to the next GP appointment over the study period (April 2003 to December 2004).

The number of practices achieving the 48-hour access target increased from 67 per cent to 87 per cent over the study period.

Practices in more deprived areas were less likely to achieve the 48-hour access target. There was no evidence that increasing the distance from a walk-in centre decreased the odds of a practice achieving the target.

A centre nearby was not associated with increased odds of practices hitting the target. There is no evidence that walk-in centres shorten waiting times for access to primary care.

Tonsillectomy versus watchful waiting
BMJ online, doi: 10.1136/bmj.39140.632604.55 (published 8 March 2007) 

What is the short-term efficacy and safety of tonsillectomy in adults with recurrent streptococcal pharyngitis?

This study randomised 70 adults with recurrent group A streptococcal pharyngitis to either instant tonsillectomy or watchful waiting.

At 90 days, streptococcal pharyngitis recurred in 24 per cent of the non-tonsillectomy group and and recurred in 3 per cent of the operative group.

The NNT with tonsillectomy to prevent one recurrence was 5. In addition the rates of other episodes of pharyngitis and throat, pain were significantly lower in the operative group.

Throat pain was the most common morbidity related to tonsillectomy.

Weekend versus weekday mortality from MI
N Engl J Med 2007; 356: 1,099–109 

Mortality from heart attack is known to be higher for patients admitted to hospital at the weekend.

This US study suggests that this observation may be due in part to reduced access to invasive procedures such as percutaneous cardiac catheterisation.

Patients admitted at the weekends were half as likely to have timely cardiac catheterisation and around 40 per cent less likely to receive early percutaneous catheterisation.

Waiting times to treatment were also longer for these patients.

Weekend patients had greater mortality but this effect diminished as the poorer access to treatment was taken into account.  

Dr Croton is a GP registrar in Worcester and a member of our team who regularly review the journals 

Research of the week 

Mouth-to-mouth resuscitation
Lancet 2007; 369: 882–4, 920–6 

There is good evidence that chest compressions alone work just as well without mouth-to-mouth ventilation and as such passers-by may be more inclined to give assistance.

In over 4,000 cardiac arrests occurring out of hospital, any kind of cardiopulmonary resuscitation (conventional or compression only) was better than none, with similar neurological outcomes in survivors.

Compression-only CPR worked better for those patients with a shockable rhythm. Among survivors, compression-only CPR was an independent predictor of a good neurological outcome.

The author recommends that international guidelines should be changed to exclude mouth-to-mouth ventilation and concentrate on chest compressions.

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