“All screening programmes do harm; some do good as well and, of these, some do more good than harm”. This is the leading statement in an article by Gray et al discussing the introduction of the UK national breast screening programme 20 years ago (BMJ 2008;336:480-3). To maximise the good - early detection - and minimise harm - unnecessary investigations - any programme has to have ongoing quality assurance to ensure minimum standards and set improvement targets. The quality of any service depends on the skill and experience of those running it, as well as the resources allocated, especially the equipment.
The UK scheme aims to detect 5 breast cancers for every 1 000 women screened and send less than 70 per 1 000 for unnecessary further testing. All women aged 50 - 70 years are offered screening every 3 years with 2 views now the norm, resulting in more than 18 million sets of mammograms since the programme's inception. It is estimated that 100 000 breast cancers have been detected with the saving of about 1 400 lives per year (Mayor p 527).
Multidisciplinary centres have replaced diagnostic clinics and employ radiography experts, pathologists, surgeons, radiotherapists and oncologists, resulting in better comprehensive services with faster turn-around times and improved data collation. Since the screening programme was introduced, breast cancer in the UK is no longer the most common cause of death from cancer in women.
25 June, 2008
08 June, 2008
Overweight in pregnancy
Being overweight or obese is endemic in the United States. A body mass index between 25 and 30 is overweight, over 30 obese, over 35 grossly obese and over 40 morbidly obese. According to these criteria, more than 25% of women are obese when they conceive. There are 4 million births each year in the US, so about a million deliveries involve obese women.
The consequences are enormous. Routine care is more difficult starting with basic clean-catch urine specimens and venipuncture no longer being straightforward. Palpation, blood pressure measurement and ultrasound readings are compromised so monitoring presents problems. Co-morbid conditions of diabetes and hypertension are exacerbated or develop during pregnancy so these pregnancies move towards the high-risk category with increasing surveillance requiring more frequent visits, wider investigations and greater expense.
As BMI increases, so do complications and caesarean section rates, both of which add to costs according to an in-depth study by Chu et al (NEJM 2008;358:1444-153). Their research showed the increased use of all antenatal facilities with rising obesity and these strongly favoured doctors rather than nurses as well as more frequent outpatient attendance and longer in-patient stays. The greater the BMI, the greater the complications and the costs, which is a huge concern to health management organisations.
There is a strong association of rising BMI with decreasing socio-economic status in the US, so it appears those who can least afford to are placing themselves at risk and need most medical care at greater financial hardship.
The consequences are enormous. Routine care is more difficult starting with basic clean-catch urine specimens and venipuncture no longer being straightforward. Palpation, blood pressure measurement and ultrasound readings are compromised so monitoring presents problems. Co-morbid conditions of diabetes and hypertension are exacerbated or develop during pregnancy so these pregnancies move towards the high-risk category with increasing surveillance requiring more frequent visits, wider investigations and greater expense.
As BMI increases, so do complications and caesarean section rates, both of which add to costs according to an in-depth study by Chu et al (NEJM 2008;358:1444-153). Their research showed the increased use of all antenatal facilities with rising obesity and these strongly favoured doctors rather than nurses as well as more frequent outpatient attendance and longer in-patient stays. The greater the BMI, the greater the complications and the costs, which is a huge concern to health management organisations.
There is a strong association of rising BMI with decreasing socio-economic status in the US, so it appears those who can least afford to are placing themselves at risk and need most medical care at greater financial hardship.
05 June, 2008
May Jass Out
These are genuinely interesting times as new means of investigating old problems are being found. The work on the genetic signatures of breast tumours, the anti-immune treatment of vulvar neoplasia and the detection of the fetus' Rh blood group are all developments that could have implications for practice - and all published in one month.
Equally important is the information about the acceptability of medical evacuation after a miscarriage and advice about HPV screening as a routine. These articles could inform a change in our practice.
Also practically, it seems safe to prescribe bisphosphonates to post-menopausal women but giving testosterone to pre-menopausal women with unhappy sex lives looks unpromising.
Finally, the trends in exclusive breast feeding appear to be improving in developed countries and we can all influence attitudes in this regard. Perhaps in 10 years time mothers will regard 4-6 months of breast feeding as a positive action to benefit their children. Let us hope so.
Click on the link to JASS Online on the right, and sign up to subscribe to read the latest issue.
Equally important is the information about the acceptability of medical evacuation after a miscarriage and advice about HPV screening as a routine. These articles could inform a change in our practice.
Also practically, it seems safe to prescribe bisphosphonates to post-menopausal women but giving testosterone to pre-menopausal women with unhappy sex lives looks unpromising.
Finally, the trends in exclusive breast feeding appear to be improving in developed countries and we can all influence attitudes in this regard. Perhaps in 10 years time mothers will regard 4-6 months of breast feeding as a positive action to benefit their children. Let us hope so.
Click on the link to JASS Online on the right, and sign up to subscribe to read the latest issue.
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