BBC BLOGS - Fergus's Medical Files

Archives for February 2011

How to feel special - give blood

Fergus Walsh | 17:16 UK time, Friday, 18 February 2011

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It's not every morning you open a letter you that starts with these words: "This is a special message to a special person". But that's what happened to me today. It was not a rare item of fan-mail but a note of thanks from NHS Blood and Transplant (NHSBT) sent to recent O negative donors. People who are O negative are so-called universal donors, because anyone can receive their blood.

Just before Christmas NHSBT issued an urgent appeal for O neg donors. The appalling weather had meant many people had been unable to keep appointments and some donor sessions had to be cancelled. Stocks were running low.

I did a story about the appeal which ran on the Six O'Clock News and also online on Monday 20th December which included footage of me giving blood - the things I do to get myself on TV! NHSBT said donors "responded amazingly".

Jon Latham, Assistant Director of Blood Donation told me: "In the days after your broadcast we had record numbers of O negative donors turning up at our sessions across the country. We would like to thank everyone who gave blood when the weather was bad. We rely on the generosity and commitment of all our volunteer donors to help us maintain the vital supply of blood to hospitals."

On Wednesday 21st December, 1,119 units of O-negative blood were collected, the highest number in a single day since 2000.

Stocks of blood are now back up to healthy levels, but there is a constant need for donors of all blood groups as maintaining healthy stocks is essential for people in hospital and requiring treatment. The NHS needs 7,000 voluntary donations of blood daily across England and North Wales alone.

Blood donors can donate every 16 weeks - that's three times a year. First time donors should be aged between 17-65, weighing at least 50 kg (7 stone 12lbs) and in general good health. If you've donated before, you can start again up to your 70th birthday and there is no upper age limit for donors who have donated in the last two years. To book an appointment call the Donor Line on 0300 123 23 23 or visit www.blood.co.uk

So pat yourselves on the back if you gave blood. And if you want to to feel special, why not sign up to be a blood donor? 96% of the population rely on the 4% who donate. You don't get paid, but you do get a nice cup of tea, some biscuits, and the knowledge that every donation can save three lives.

Children's heart surgery review published

Fergus Walsh | 15:15 UK time, Wednesday, 16 February 2011

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The long-awaited review of children's heart surgery has finally been published, and as widely predicted, it suggests that at least four centres stop operating.

The fewer, bigger, better argument is accepted by all professional bodies. But the units facing the loss of surgery will be deeply unhappy. The review team presents four options - from A to D. Just four units are certain to survive the review procedure. Bristol, Liverpool and Birmingham are named in each option whilst Great Ormond Street in London is guaranteed to continue as a cardiac centre because its national role in other key services such as transplant and tracheal surgery.

All the other units are faced with another six months of uncertainty before a final decision is made. In London, the review team say the number of units should reduce from three to two and name the Evelina Children's Hospital over the Royal Brompton as their preferred centre.

Looking at the documents, one can't doubt the huge amount of work and analysis which has gone into this. Each unit is rated in a number of different ways. And every unit, bar Oxford, continues to survive in at least one of the scenarios. But this may give false hope to units like Leeds, which looks very unlikely to retain its surgery status. Some might argue that it would have been better for the review team to be more prescriptive and actually list the units they think should no longer do surgery rather than this variety pack scenario.

These are the four options for the future of children's heart surgery:

A: Newcastle, Liverpool, Leicester, Birmingham, Bristol +2 in London
B: Newcastle, Liverpool, Birmingham, Bristol, Southampton +2 in London
C: Newcastle, Liverpool, Birmingham, Bristol +2 in London
D: Leeds, Liverpool, Bristol, Birmingham +2 in London

You can see that A and B contain seven units while C and D contain 6 units. The final decision will be made in the autumn by a national committee representing all Primary Care Trusts. I am advised that it would be highly unlikely that they would opt for six units, ruling out C and D.

That means it is a straight choice between Southampton and Leicester. In London, the Royal Brompton will mount a spirited defence of its role as a paediatric surgical centre. If it loses heart surgery for children, then its paediatric intensive care unit will probably no longer be viable.

The changes will take a couple of years to happen. But many will argue that they are already a decade overdue.

Children's heart surgery to undergo major change

Fergus Walsh | 00:00 UK time, Wednesday, 16 February 2011

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Taking patient services away from hospitals is never going to be an easy sell. So proposals to reduce the number of units that are allowed to perform children's heart surgery are likely to come in for vocal opposition from parent groups.

Later today, plans will be outlined to cut the number of centres in England from 11, down to six or seven. Among those at risk are the units at Glenfield Hospital in Leicester, Leeds General Infirmary and the Royal Brompton in London. The unit at the John Radcliffe Hospital in Oxford has already stopped operating after a run of deaths last year. The "Safe and Sustainable" review team has already made it clear that Oxford will not be allowed to perform children's heart surgery in future.

All the units under threat - including Oxford - are generally very popular among parents. When I went to the inquiry into the deaths at Oxford, several parents turned up to voice their support for the unit and its surgeons.

So expect headlines and very negative comments about what will be billed as closures and the axing of services.

It is worth looking at the background to all this in order to see why the changes are being proposed. The Bristol heart scandal highlighted appalling lapses in the care of children with congenital cardiac problems. In 2001, the Inquiry report led by Professor Ian Kennedy explained the need for children to have heart surgery in fewer specialist centres. The report concluded:

"...standards should stipulate the minimum number of procedures which must be performed in a hospital over a given period of time in order to have the best opportunity of achieving good outcomes for children. Paediatric cardiac surgery must not be undertaken in hospitals which do not meet the minimum number of procedures. Considerations of ease of access to a hospital should not be taken into account in determining whether PCS should be undertaken at that hospital."

Then in 2003 a review group led by Professor James Munro, President of the Society of Cardiothoracic Surgeons, recommended that surgical centres should do no fewer than 300 operations a year. That would have meant about half the centres closing. Action was not taken. In 2007 the Royal College of Surgeons called for fewer, larger surgical centres. A year later, Professor Sir Bruce Keogh, NHS medical director, instigated the current review. Last year the "Safe and Sustainable" steering group proposed new national standards (opens pdf) which would see a minimum of 4 surgeons working together. The review team will argue that units must carry out a minimum of 400 operations per year, with a recommendation that it should be at least 500. Only a couple of units currently meet those criteria. Now, finally we will have the detailed proposals setting out which units should lose their status are surgical centres.

In order to bolster the need for change, Professor Sir Ian Kennedy was asked to visit all 11 units and assess their standards. His report will also be published today.

The need for surgery to be concentrated in fewer, bigger centres is supported by a huge range of organisations, among them: the Society for Cardiothoracic Surgery in Great Britain and Ireland, the British Congenital Cardiac Association, The Royal College of Surgeons, the Royal College of Paediatrics and Child Health, the Paediatric Intensive Care Society and the Children's Heart Federation - an umbrella group of 20 charities which represent families.

Given that level of support, the real question is why it has taken this long to change things? Even today, the proposals are not final, but will be put out for consultation. Whilst there is broad support for change, individual hospitals have strong reasons for wanting to retain their surgical service. Take London as an example. There are three units which perform children's heart surgery: Great Ormond Street Hospital (GOSH), Evelina Children's Hospital, which is on the St Thomas' Hospital site overlooking the Houses of Parliament, and the Royal Brompton Hospital.

Under the current review it seems the Royal Brompton is the most vulnerable. GOSH does more paediatric cardiac surgery than any unit in England. Evelina is a purpose-built unit which opened in 2005. But the Royal Brompton and Harefield Trust is the largest specialist heart and lung centre in the UK and an acknowldged centre of excellence in Europe. It will argue that it defies logic for it to lose its role as a children's heart surgery unit. Furthermore, the Royal Brompton meets the standard of having four surgeons and does around 450 children's heart operations a year.

I understand that more than one option for the structure of services in London and elsewhere will be set out, so expect some vigorous negotiations in the coming months of the consultation period.

The review team will argue that change is essential. It will stress that no units are going to close and all will continue to offer diagnostic and outpatient services. But for hospitals with proud reputations and strong local support, the proposals will not be palatable.

Prototype blood test for vCJD

Fergus Walsh | 14:34 UK time, Thursday, 3 February 2011

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Variant Creutzfeldt-Jakob disease is a terrible legacy of the BSE outbreak. The fatal degenerative brain disorder is the human form of Bovine Spongiform Encephalopathy, commonly referred to as "mad-cow disease". It first emerged in 1995. The disease, which affects the brain, is believed to have passed from cattle to humans through consumption of meat products contaminated with BSE.

The issue gets little publicity these days, but news in The Lancet medical journal of a prototype blood test for the condition is a significant moment. Researchers at the Medical Research Council Prion Unit at University College London have managed to devise a test which can spot the infectious proteins - prions - responsible.

The blood test was able to detect blood laced with a solution of vCJD to within one part per ten billion. It was around 70% accurate, so clearly there is work still to do, but the scientists are confident that accuracy will improve rapidly in the near future.

An accurate blood test would have far-reaching implications. Firstly, it would speed up diagnosis. Patients with vCJD are usually diagnosed late, only when they have begun to display symptoms. A sample of tonsils can usually tell doctors if they infected, but for a definitive diagnosis, a biopsy of brain tissue is required. So a blood test would mean simple and rapid diagnosis.

It would also provide the first accurate assessment of the extent of vCJD in Britain. This is a disease which began in Britain and most of those affected are here: out of 220 cases worldwide, 174 are British. Four of the British patients are still alive. Cases outside Britain are likely to be a significant underestimate, because doctors elsewhere often don't actively look for the condition.

Prions, which cause vCJD and other fatal diseases, can inhabit a person's body for 50 years before presenting symptoms. So there has always been a suspicion that the true scale of the vCJD infection has remained hidden. A study of tonsil samples suggested that 1 in 4,000 Britons might have the disease, but no-one really knows whether that is an accurate estimate (opens pdf). One positive fact is that the number of deaths from vCJD has been falling steadily since a peak of 28 in 2000.

An accurate blood test would also have implications for the National Blood Service. Currently, white blood cells are removed from donations and plasma products are imported. Blood donations are screened for HIV and Hepatitis B and C. If detected, donors are advised to speak to their doctor. But what if you were found to be infected with vCJD? If the test was not 100% accurate then it would raise the issue of so-called false-positive results. A commentary on the Lancet article says: "Communication to the public of the uncertainty around a positive test result will be challenging and could result in fewer donors as well as causing unnecessary anxiety to deferred uninfected donors."

The knowledge that you are harbouring vCJD, would be an extremely difficult issue to address. Some of those identified might never go on to develop to condition, so would have to confront an issue they would otherwise never have to face.

Variant CJD is a fatal condition for which there no proven treatment - although a number of experimental therapies have been tried. But there is scope for optimism here as well. Professor John Collinge, Director of the MRC Prion Unit was interviewed on Today on Radio 4 (listen again here). He said his team has been able to create human antibodies to the prion protein which blocked the disease in mice. Human clinical trials will begin in due course. Professor Collinge said: "There is an opportunity if we find people who are incubating the disease, in principle, to rescue them before they develop the disease itself."

That really would be a remarkable achievement.

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