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Physicians and patients need to talk more
THE LANCET
SCIENCE AND MEDICINE
Naevi count correlates with melanoma risk grouped by size, with a cutoff at atients with large numbers of 5 mm diameter for small lesions. normal naevi or any number of Congenital naevi were also recorded. dysplastic naevi are at greater risk Examination of patients was by exfor the development of malignant perienced clinicians. Lesions were melanoma than those without. But a photographed to crucial point of compare clinical contention remains: opinions between what is a dysplastic researchers; agreenaevus? Clinical ment occurred 87% descriptions vary and of the time. histological classificaPatients with even tion has been a a single dysplastic source of great naevus had a relative debate and disagreerisk of developing ment. malignant melanoma Now, researchers more than twice that at the US National Look for the odd naevi of controls (adjusted Institutes of Health relative risk 2·3; 95% CI 1·4–3·6). (Bethesda, MD, USA), the University The RR rose to 7·3 for patients with of Pennsylvania (Minneapolis, PA, two to four dysplastic naevi and to USA), and the University of 12·0 for patients with more than ten California at San Francisco (CA, such lesions. USA) conclude that by using a simPatients with many small naevi also ple, clinical description of dysplastic had an increased risk of developing naevi, the patient’s risk of malignant malignant melanoma compared with melanoma can be easily assessed controls. The risk was almost (JAMA 1997; 277: 1439–44). doubled for patients with 25–49 small The case-control study looked naevi, and tripled for patients with at 788 patients with malignant naevi counts of 50–99. The risk of melanoma and 1014 controls seen in malignant melanoma in patients with clinics for non-dermatological probnon-dysplastic naevi greater than lems between 1991 and 1993. Cases 5 mm in diameter was double that in were matched for age, race, sex, and control patients once the number of geographical distribution. The total naevi reached ten. Patients with number of naevi was determined for increased numbers of both small and all patients and dysplastic naevi large non-dysplastic naevi had a RR diagnosed if a lesion was greater than of nearly 4·0. Congenital naevi were 5 mm in diameter, at least partly flat, not associated with increased risk of and had two of the following traits: malignant melanoma. variable pigment; irregular, asymmetric outline; or indistinct borders. Naevi that were not dysplastic were David F Frankel Mike Wyndham
P
Pathway of E coli contamination elucidated
T
he initial results of an Irish research programme, tracking the path of Escherichia coli O157 from the arrival of cattle at an abattoir to final packaging as a burger, prove that bacteria are transferred from the hide to the carcass during slaughter. Importantly, the study shows that washing the animals with a power hose before slaughter, as recommended in the Pennington report into the recent deaths in Scotland caused by O157 infection, does not totally eliminate the bacteria, although their number is markedly reduced. Declan Bolton, research officer with the National Food Centre— Ireland’s food-safety agency— described the study in Dublin on May 6. His team injected a nontoxic E coli strain into faecal matter that was then rubbed onto the rumps of ten animals. The animals were swabbed 2, 4, and 24 hours later, then slaughtered shortly afterwards. After the hides had been removed and the carcasses split, the meat, tools, butcher’s hands, and area under the carcasses were swabbed. There was widespread bacterial contamination, averaging about 18 E coli per cm2 on the carcass—well above the infective dose. The next phase of the project aims to find ways to prevent bacterial spread and cross-contamination.
Karen Birchard
Physicians and patients need to talk more hysicians often assume their patients understand more than they really do about treatment requirements following a hospital stay, a US study reveals this week. “There’s always been some disconnection between physicians and patients around such areas as how often to take medicine after discharge and when to return to daily activities. Now that hospital stays are shorter than in years past, good communication is particularly important”, says lead author David Calkins of the University of Kansas (Kansas City, KS, USA). Calkins and colleagues interviewed 99 patients with pneumonia or acute myocardial infarction and their
P
Vol 349 • May 17, 1997
attending physicians approximately 2 weeks after the patients’ discharge from the hospital. The team compared the perceptions of both groups regarding the amount of time spent discussing the postdischarge treatment plan and the patients’ understanding of the plan. Overall, physicians reported spending more time talking about postdischarge care than did patients; in 43·1% of instances, the patient thought less time had been spent than the physician reported. Physicians believed that 88·9% of patients understood the potential side-effects of postdischarge medication, while only 57·4% of patients said they understood. Finally,
physicians thought 94·7% of patients knew when to resume normal activities, but only 57·9% of patients reported knowing when to do so (Arch Intern Med 1997; 157: 1026–30). Communication could be improved by taking more time during the discharge interview, providing written instructions, and making follow-up phone calls, suggest the authors. Calkins intends to investigate the impact of various interventions on patients’ understanding of postdischarge requirements, starting with a large-scale study of the use of nurses as case managers. Marilynn Larkin
1455
SCIENCE AND MEDICINE
Naevi count correlates with melanoma risk grouped by size, with a cutoff at atients with large numbers of 5 mm diameter for small lesions. normal naevi or any number of Congenital naevi were also recorded. dysplastic naevi are at greater risk Examination of patients was by exfor the development of malignant perienced clinicians. Lesions were melanoma than those without. But a photographed to crucial point of compare clinical contention remains: opinions between what is a dysplastic researchers; agreenaevus? Clinical ment occurred 87% descriptions vary and of the time. histological classificaPatients with even tion has been a a single dysplastic source of great naevus had a relative debate and disagreerisk of developing ment. malignant melanoma Now, researchers more than twice that at the US National Look for the odd naevi of controls (adjusted Institutes of Health relative risk 2·3; 95% CI 1·4–3·6). (Bethesda, MD, USA), the University The RR rose to 7·3 for patients with of Pennsylvania (Minneapolis, PA, two to four dysplastic naevi and to USA), and the University of 12·0 for patients with more than ten California at San Francisco (CA, such lesions. USA) conclude that by using a simPatients with many small naevi also ple, clinical description of dysplastic had an increased risk of developing naevi, the patient’s risk of malignant malignant melanoma compared with melanoma can be easily assessed controls. The risk was almost (JAMA 1997; 277: 1439–44). doubled for patients with 25–49 small The case-control study looked naevi, and tripled for patients with at 788 patients with malignant naevi counts of 50–99. The risk of melanoma and 1014 controls seen in malignant melanoma in patients with clinics for non-dermatological probnon-dysplastic naevi greater than lems between 1991 and 1993. Cases 5 mm in diameter was double that in were matched for age, race, sex, and control patients once the number of geographical distribution. The total naevi reached ten. Patients with number of naevi was determined for increased numbers of both small and all patients and dysplastic naevi large non-dysplastic naevi had a RR diagnosed if a lesion was greater than of nearly 4·0. Congenital naevi were 5 mm in diameter, at least partly flat, not associated with increased risk of and had two of the following traits: malignant melanoma. variable pigment; irregular, asymmetric outline; or indistinct borders. Naevi that were not dysplastic were David F Frankel Mike Wyndham
P
Pathway of E coli contamination elucidated
T
he initial results of an Irish research programme, tracking the path of Escherichia coli O157 from the arrival of cattle at an abattoir to final packaging as a burger, prove that bacteria are transferred from the hide to the carcass during slaughter. Importantly, the study shows that washing the animals with a power hose before slaughter, as recommended in the Pennington report into the recent deaths in Scotland caused by O157 infection, does not totally eliminate the bacteria, although their number is markedly reduced. Declan Bolton, research officer with the National Food Centre— Ireland’s food-safety agency— described the study in Dublin on May 6. His team injected a nontoxic E coli strain into faecal matter that was then rubbed onto the rumps of ten animals. The animals were swabbed 2, 4, and 24 hours later, then slaughtered shortly afterwards. After the hides had been removed and the carcasses split, the meat, tools, butcher’s hands, and area under the carcasses were swabbed. There was widespread bacterial contamination, averaging about 18 E coli per cm2 on the carcass—well above the infective dose. The next phase of the project aims to find ways to prevent bacterial spread and cross-contamination.
Karen Birchard
Physicians and patients need to talk more hysicians often assume their patients understand more than they really do about treatment requirements following a hospital stay, a US study reveals this week. “There’s always been some disconnection between physicians and patients around such areas as how often to take medicine after discharge and when to return to daily activities. Now that hospital stays are shorter than in years past, good communication is particularly important”, says lead author David Calkins of the University of Kansas (Kansas City, KS, USA). Calkins and colleagues interviewed 99 patients with pneumonia or acute myocardial infarction and their
P
Vol 349 • May 17, 1997
attending physicians approximately 2 weeks after the patients’ discharge from the hospital. The team compared the perceptions of both groups regarding the amount of time spent discussing the postdischarge treatment plan and the patients’ understanding of the plan. Overall, physicians reported spending more time talking about postdischarge care than did patients; in 43·1% of instances, the patient thought less time had been spent than the physician reported. Physicians believed that 88·9% of patients understood the potential side-effects of postdischarge medication, while only 57·4% of patients said they understood. Finally,
physicians thought 94·7% of patients knew when to resume normal activities, but only 57·9% of patients reported knowing when to do so (Arch Intern Med 1997; 157: 1026–30). Communication could be improved by taking more time during the discharge interview, providing written instructions, and making follow-up phone calls, suggest the authors. Calkins intends to investigate the impact of various interventions on patients’ understanding of postdischarge requirements, starting with a large-scale study of the use of nurses as case managers. Marilynn Larkin
1455