more_vertIn 2012, mortality rates for emergency laparotomies were reported to vary from 3·6% to 41·7% across 35 hospitals in England. Such shocking variation between health providers is one of the key problems facing emergency general surgery in England and little seems to have improved since 2012. A Nuffield Trust report commissioned by the Royal College of Surgeons aims to define these problems and outline potential solutions. With the challenges posed by the UK’s ageing population, declining numbers of doctors in training, and hospitals struggling to fill 24/7 staffing rotas, such solutions are needed now more than ever.
Preference: Emergency Medicine
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[Case Report] Acute myelitis due to Zika virus infection
In January, 2016, a 15-year-old girl with a history only of an ovarian cyst was admitted to hospital in Pointe-à-Pitre, Guadeloupe, with left hemiparesis. 7 days previously she had presented to the emergency department with left arm pain, frontal headaches, and conjunctival hyperaemia, but no fever, signs of meningeal irritation, or sensory or motor deficits. The day of admission, she developed acute lower back pain, paraesthesia on the left side of her body, and weakness in her left arm. On admission she had slight left-sided weakness and proximal pain of the left arm and leg, exacerbated on movement, but no fever or signs of meningism, and Glasgow Coma Score (GCS) 15.
Risk of hypoglycemia following intensification of metformin treatment with insulin versus sulfonylurea [Research]
Background:
Hypoglycemia remains a common life-threatening event associated with diabetes treatment. We compared the risk of first or recurrent hypoglycemia event among metformin initiators who intensified treatment with insulin versus sulfonylurea.
Methods:
We assembled a retrospective cohort using databases of the Veterans Health Administration, Medicare and the National Death Index. Metformin initiators who intensified treatment with insulin or sulfonylurea were followed to either their first or recurrent hypoglycemia event using Cox proportional hazard models. Hypoglycemia was defined as hospital admission or an emergency department visit for hypoglycemia, or an outpatient blood glucose value of less than 3.3 mmol/L. We conducted additional analyses for risk of first hypoglycemia event, with death as the competing risk.
Results:
Among 178 341 metformin initiators, 2948 added insulin and 39 990 added sulfonylurea. Propensity score matching yielded 2436 patients taking metformin plus insulin and 12 180 taking metformin plus sulfonylurea. Patients took metformin for a median of 14 (interquartile range [IQR] 5–30) months, and the median glycated hemoglobin level was 8.1% (IQR 7.2%–9.9%) at intensification. In the group who added insulin, 121 first hypoglycemia events occurred, and 466 first events occurred in the group who added sulfonylurea (30.9 v. 24.6 events per 1000 person-years; adjusted hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.06–1.59). For recurrent hypoglycemia, there were 159 events in the insulin group and 585 events in the sulfonylurea group (39.1 v. 30.0 per 1000 person-years; adjusted HR 1.39, 95% CI 1.12–1.72). In separate competing risk analyses, the adjusted HR for hypoglycemia was 1.28 (95% CI 1.04–1.56).
Interpretation:
Among patients using metformin who could use either insulin or sulfonylurea, the addition of insulin was associated with a higher risk of hypoglycemia than the addition of sulfonylurea. This finding should be considered by patients and clinicians when discussing the risks and benefits of adding insulin versus a sulfonylurea.
Two energy drinks a day may send a doctor your way
Many Australians turn to energy drinks to reduce fatigue, increase wakefulness, and improve concentration and performance, but a study has found that drinking more than two energy drinks a day can cause adverse heart reactions, including a fast heartbeat, heart palpitations, and chest pain.
Researchers from the University of Adelaide surveyed patients aged 13 to 40 years who attended an emergency department in South Australia with heart palpitations, and found 70 per cent had consumed some version of an energy drink.
Dr Scott Willoughby, co-author of the study, said that the study was able to find a direct link between energy drink consumption and hospital admissions for adverse heart reactions.
“Of the patients surveyed, 36 per cent had consumed at least one energy drink in the 24 hours prior to presenting at the hospital, and 70 per cent had consumed some sort of energy drink in their lifetime,” Dr Willoughby said.
“Those patients who were heavy consumers of energy drinks were found to have significantly higher frequency of heart palpitations than those who consumed less than one a day.
“And importantly, fast heartbeat, heart palpitations, and chest pain was seen in energy drink consumers who were healthy and had no risk factors for heart disease.”
AMA Vice President, Dr Stephen Parnis, told the Herald Sun that people did not realise the serious health repercussions of energy drinks, some of which have the same amount of caffeine as 10 or 20 cups of coffee.
“Poisoning is not too strong a word to use for the effects of these drinks on some people,” Dr Parnis said.
“I have seen teenagers present in emergency with heart rates of 200 beats per minute or who are so stimulated that their behaviour is extremely distressing to their parents and the people around them.
“At the bare minimum, energy drinks should come with warning labels.
“I think that preventing sales of these drinks to people under 18 is something that we need to look at very closely.”
The study was published in International Journal of Cardiology.
Kirsty Waterford
[Editorial] Yellow fever: a global reckoning
Angola is currently facing its worst outbreak of yellow fever in 30 years. Since December, 2015, when the outbreak was first declared in the capital of Luanda, there have been 178 deaths, more than 1000 suspected cases, and spread to several provinces. Imported cases have now been reported in China, Kenya, and the Democratic Republic of the Congo, posing a global health security risk. A mass vaccination campaign in Luanda began in February, but the emergency stockpile of the vaccine has already been exhausted.
[Comment] A breakthrough urine-based diagnostic test for HIV-associated tuberculosis
At the 44th World Health Assembly in 1991, the burgeoning, and now modern day, tuberculosis pandemic was brought to the world’s attention,1 reporting that 6 million new tuberculosis cases and 3 million associated deaths were occurring worldwide each year. The global HIV pandemic was recognised as a key factor fuelling the deterioration in tuberculosis control, and such were the grim portents of the emerging tuberculosis and HIV co-epidemic in sub-Saharan Africa that, in 1991, three London academics posed the pointed question, “Is Africa lost?”2 Now, almost a quarter of a century after tuberculosis was declared “a global emergency”, roughly 9·6 million new cases of tuberculosis and 1·5 million deaths (0·4 million deaths in HIV-positive individuals) still occur annually.
Patients pay for hobbled hospitals
Since the Commonwealth’s unilateral changes to public hospital funding announced in the 2014-15 Budget, the AMA has highlighted the impact of dramatically reduced funding on an already underperforming public hospital system.
In May 2014, the Australian Government walked away from the National health Reform Agreement, abandoning its promise to make public hospital funding sustainable and contribute an equal share towards growth in public hospital costs.
From July 2017, the Commonwealth will instead limit its contribution to public hospital costs based on a formula of the Consumer Price Index (CPI) and population growth only. This represents the lowest Commonwealth contribution to public hospital funding since the Second World War.
According to Treasury, the indexation change will reduce Commonwealth funding to the states and territories by $57 billion between 2017-18 to 2024-25.
The CPI measures changes in prices faced by households only, and is not an appropriate measure of increases in hospital costs. Increasing funding on the basis of population growth does not address cost increases associated with changing demographics, or the costs of new health technologies.
The Finance and Economics Committee resolved last year that the Commonwealth’s contribution to public hospital funding must be sufficient to address real increases in actual costs of the goods and services used by hospitals, and provide for demographic change – not only for population growth, but also for changes associated with ageing and health needs.
The Government’s ongoing justification for its extreme health savings measures, including cuts to public hospital funding, has been that Australia’s health spending is unsustainable.
This is simply not substantiated by the evidence.
The Government’s own figures show that health spending grew by 3.1 per cent in 2013-14. This is almost 2 percentage points lower than the average growth over the last decade (5 per cent). The previous year (2012-13) growth was even slower – just 1.1 per cent, which was the lowest annual increase since Government began reporting on health spending in the mid-1980s.
Clearly, total health spending is not out of control. The health sector is doing more than its share to ensure health expenditure is sustainable.
There have now been two years where growth in health expenditure has been well below the long-term average annual growth of 5 per cent over the last decade.
As part of this slowdown, growth in Commonwealth funding for public hospitals in 2013-14 was just 0.9 per cent, well below inflation and virtually stagnant. This is off the back of a 2.2 per cent reduction in Commonwealth funding of public hospitals in 2012-13.
This austerity has come at a cost, and has been reflected in the performance of our public hospitals. The AMA’s Public Hospital Report Card 2016 shows that, against key measures, the performance of our public hospitals is virtually stagnant or, in many cases, declining. This is the direct effect on patient care of reduced growth in hospital funding and capacity.
The most recent data shows waiting times are largely static, with only very minor improvement. Emergency Department (ED) waiting times have worsened. The percentage of ED patients treated in four hours has not changed, and is well below target. Elective surgery waiting times and treatment targets are largely unchanged. Bed number ratios have also deteriorated.
The Commonwealth’s funding cuts are already having a real impact as a result of almost $2 billion being sliced from programs to reduce emergency department and elective surgery waiting times.
But the most acute impact will be felt from July next year, when the new funding arrangements take effect.
Without sufficient funding to increase capacity, public hospitals will never meet the performance targets set by governments, and patients will wait longer for treatment, putting lives at risk.
Despite these warnings, we have yet to see a solution to the serious and rapidly approaching crisis in public hospital funding.
This is a crisis that has been created by political and budgetary decisions. It is one that will require political leadership to resolve.
– Brian Owler
News briefs
UK experts want ban on tackling in school rugby
More than 70 UK doctors and health experts have written an open letter addressed to government ministers, chief medical officers and children’s commissioners, calling for a ban on tackling in school rugby games, The Guardian reports. “The majority of all injuries occur during contact or collision, such as the tackle and the scrum,” the letter says. “These injuries, which include fractures, ligamentous tears, dislocated shoulders, spinal injuries and head injuries, can have short-term, life-long and life-ending consequences for children.” Rugby is a compulsory part of the UK physical education curriculum from the age of 11 in many boys’ schools, particularly in the independent sector, The Guardian says. The letter’s authors urged schools to move to touch and non-contact versions of the game. “Repeat concussions have been found to have a link to cognitive impairment, and an association with problems such as depression, memory loss and diminished verbal abilities. Children also took longer to recover to normal levels on measures of memory, reaction speed and post-concussive symptoms.” The Rugby Football Union said it took player safety “extremely seriously” and that recent changes meant young players underwent a “gradual and managed” introduction to the contact version of the game.
PLOS ONE paper provokes social media backlash
Retraction Watch reports that a paper on the biomechanics of the hand published in PLOS ONE has provoked a social media backlash for using apparently religious language in the abstract, introduction and conclusion. “In conclusion, our study can improve the understanding of the human hand and confirm that the mechanical architecture is the proper design by the Creator for dexterous performance of numerous functions following the evolutionary remodeling of the ancestral hand for millions of years.” Some commentators on Twitter described the publication of the paper as “an absolute joke” and “a big problem”. A spokesperson for PLOS was quoted by Retraction Watch as saying: “PLOS has just been made aware of this issue and we are looking into it in depth. Our internal editors are reviewing the manuscript and will decide what course of action to take. PLOS’ publishing team is also assessing its processes.” The corresponding author is listed as Cai-Hua Xiong, based at Huazhong University of Science and Technology in China.
Australian health system “underprepared” for heatwaves
A Climate Council report has found Australia’s health system is underprepared to deal with longer, hotter and more intense heatwaves, the ABC reports. “The Climate Council report … found nursing homes and medical centres across the country may not be equipped with necessary back-up energy and water supplies in extreme heat. The council noted several states had upgraded heat and health warning systems since the deadly heatwaves in 2009, but the lack of a streamlined response system was putting lives at risk. The report found heatwaves put pressure on health services, with emergency call-outs jumping almost 50 per cent and heart attacks almost tripling in the heatwaves of January and February 2009. By 2030, Australia’s annual average temperature is predicted to rise by 0.6 to 1.3 per cent, with the globe continuing to heat up to the end of the century, the report said. The report highlights the global problem of heatwaves, pointing to 55 700 deaths during the Russian heatwave in 2010, and 3700 killed in India and Pakistan in May 2015.”
Astronaut Scott Kelly and his twin a boon to science
Commander Scott Kelly has returned to Earth after 340 days on board the International Space Station (ISS) and a raft of scientists and doctors can’t wait to get their hands on him, Forbes reports. Any astronaut coming home is scrutinised, but Cmdr Kelly’s return was particularly anticipated because he has a twin brother. Retired astronaut Mark Kelly has spent the past year on Earth, providing scientists conducting NASA’s Twins Study with the chance to conduct the ultimate “controlled experiment”. Weightlessness can lengthen the spine and body by up to 3%, can cause loss of muscle — most notably in the heart — and bone mass; cause the head to swell; and cause dizziness and fainting on return to Earth. There are also issues of radiation exposure without the shield of the Earth’s atmosphere.
[Correspondence] control in Brazil
On Nov 12, 2015, faced with the increased incidence of cases of microcephaly and the possible association with Zika virus, the Ministry of Health in Brazil declared a public health emergency. On Dec 5, the Brazilian Government decided that measures should be aggressively implemented to reduce the risk of exposure to Zika virus by eliminating the vector mosquito Aedes aegypti.
Turnbull’s hospital pass
Prime Minister Malcolm Turnbull has indicated financial relief for the nation’s beleaguered public hospitals will depend on finding additional sources of revenue, delivering a blow to hopes of averting a multi-billion dollar funding crisis set to hit the system from next year.
Mr Turnbull told a meeting of the AMA Federal Council that hospital funding was “a big issue”, and he fuelled speculation of a pre-election spending boost after revealing he was “in discussions” with premiers and chief ministers on the matter.
But the Prime Minister gave no sign his Government was contemplating a major change in the policy course set by the Coalition in 2014 when it announced funding changes that would rip $57 billion out of the public hospital system between 2017 and 2025.
Instead, he reinforced the need for more effective health spending, signalling there would be no let-up in the pressure on doctors, nurses and other health professionals to deliver greater efficiencies.
“Hospital funding is a big issue,” Mr Turnbull said. “It is something I am in discussions with chief ministers and state premiers [about], and we have COAG before not very long, where we will seek to take that issue forward.”
“[But], the big issue is where additional funding will come from.”
Several premiers, most notably Mike Baird in NSW and Jay Weatherill in South Australia, had proposed an increase in the GST – partially offset by other tax changes – to increase the health budget, but the Prime Minister reiterated his Government would not contemplate an increase in tax revenue.
“We have to recognise that Australians already pay high taxes,” Mr Turnbull said. “This is not a low-tax country, so getting better value [for health spending] is vital.”
Instead, while praising advances in the quality and effectiveness of health care, he exhorted health service providers to greater efficiency.
The Prime Minister said rising health expenditure was “often seen as an admission of failure, [but] the reality is that we are getting a lot more for it”, in terms of longer and healthier lives.
However, funding constraints meant that “the pressure is to get better and more effective outcomes” for the same outlay.
Q&A at AMA House
Following one-on-one talks with AMA President Professor Brian Owler, Mr Turnbull was joined by Health Minister Sussan Ley in meeting with AMA Federal Councillors, who grilled the pair on significant aspects of Federal Government health policy including public hospital funding, the Medicare rebate freeze, pathology and diagnostic imaging bulk billing incentives, medical workforce training and emergency department performance targets.
Several AMA Federal Councillors including Dr Tim Greenaway, Dr Saxon Smith and Dr David Mountain challenged the PM and Health Minister on the scale of the Federal Government’s cuts to hospital funding, pointing out the sharp growth in demand for hospital services occurring around the country.
Mr Turnbull questioned why there was a sharp rise in the number of patients showing up at hospital emergency departments, speculating that some of it may be due to a failure in primary care.
But Dr Mountain and Dr Smith explained that as people lived longer, they developed multiple health problems that could compound one another and quickly escalate, requiring expensive and complex emergency care.
Questioned on the Medicare rebate freeze, Ms Ley said on-going Budget deficits meant the Government was not in a position to restore rebate indexation, and was instead examining new models of primary care arising out of the recent review.
Addressing the cut to bulk billing incentives, the Health Minister said it was “not healthy” that the pathology sector was dominated by two providers, and said the major issue raised by pathologists she consulted with was not the incentive cut, but rents charged to co-locate with medical practices.
Ms Ley added that bulk billing incentives for concession card radiology patients had not been touched, supporting their access to care.
On medical training, Ms Ley said she was concerned to find ways to get more “generalist” practitioners into rural areas. The Minister said she did not believe in using Medicare provider numbers and other methods to bond doctors to work in particular areas, but the problem of luring more doctors into rural practice was one that “we do have to collectively solve”.
The Minister said the Government understood concerns around the establishment of a third medical school in Perth, but expressed doubts that the decision could be “unravelled”.
Adrian Rollins