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NCEPOD strikes again
1025
Although this work is preliminary, the results provide a satisfying explanation for a puzzling form of endocrine hypertension. Moreover, this is the first example of a major crossover event that leads to greatly increased expression of a gene rather than inactivation. These observations should encourage
research into the role of genetic factors in other forms of hypertension. more
1. Connell JMC, Fraser R. Adrenal corticosteroid synthesis and hypertension. J Hypertens 1991; 9: 107. 2. Ferriss JB, Brown JJ, Fraser R, Lever AF, Robertson JIS. Primary aldosterone excess: Conn’s syndrome and similar disorders. In: Robertson JIS, ed. Handbook of hypertension, vol 2. Amsterdam: Elsevier, 1983: 132-61. 3. Conn JW. Primary aldosteronism: a new clinical syndrome? J Lab Clin Med 1955; 45: 6-17. 4. Sutherland DJA, Ruse JL, Laidlaw JC. Hypertension, increased aldosterone secretion and low plasma renin activity relieved by dexamethasone. Can Med Assoc J 1966; 95: 1109. 5. Ganguly A. Glucocorticoid-suppressible hyperaldosteronism: a paradigm of arrested adrenal zonation. Clin Sci 1991; 80: 1-7. 6. Momet E, Dupont J, Vitek A, White PC. Characterisation of two genes encoding human steroid 11&bgr;-hydroxylase (P-45011&bgr;). J Biol Chem 1989; 264: 20961-67. 7. Yabu M, Senda T, Nonaka Y, Matsukawa N, Okamoto M, Fujita M. Localisation of the gene transcripts of 11 &bgr; hydroxylase and aldosterone synthase in the rat adrenal cortex by in situ hybridisation. Histochemistry 1991; 96: 391-94. 8. Shibata H, Ogishima T, Mitani F, et al. Regulation of aldosterone synthase cytochrome P450 in rat adrenals by angiotensin II and
potassium. Endocrinology 1991; 128: 2534-39. 9. Lifton RP, Dluhy RG, Powers M, et al. A chimaeric 11 &bgr;-hydroxylase/ aldosterone synthase gene causes glucocorticoid-remediable aldosteronism and human hypertension. Nature 1992; 355: 262-65.
NCEPOD strikes again "... inappropriate and unsupervised delegation to trainees; too many operations were done out-of-hours; and consultants were found to operate outside their area of proficiency ... Inadequate (or incorrect) notes and the data generated from them were also shown to confound official statistics." We make no apology for repeating this extract from a 1988 Lancet commentary1 on the Confidential Enquiry into Perioperative Deaths (CEPOD), which was written at the time the UK national enquiry (NCEPOD) was about to start. In the second annual NCEPOD report,for 1990, published this week "there are no new lessions" according to the preamble. The Enquiry collects data on patients who have died in hospital in the UK within 30 days of a surgical procedure; for 1990, 18 817 such deaths were reported. A more detailed assessment of surgical and anaesthetic practice was gained from a random sample of 3485 deaths. By comparison with Department of Health figures, there was a 16% shortfall in reporting to NCEPOD. Nevertheless, the departmental statistics contain some surprising anomalies--eg, no deaths at the National Hospital for Nervous Diseases or the Hospitals for Sick Children in London, whereas NCEPOD recorded 11 and 52, respectively. NCEPOD also noted that hospitals that coded their data efficiently were likely to report a higher number of surgical procedures and deaths to the Department, thereby producing apparently worse results.
As
before, the use of vignettes in the report brings important messages home. Here are two examples. "A
53-year-old
woman was
operated
on
by
a
general
surgeon in order to drain a left pyonephrosis containing 5 litres of pus. There was considerable haemorrhage from the left renal artery which was controlled by several ligatures. Unfortunately these had unintentionally encircled the abdominal aorta. The subsequent ischaemia of the legs went unnoticed for over nine hours. When this lady was finally transferred to a vascular unit the vascular surgeon was faced with a delayed referral and a choice between bilateral high thigh amputations (or even disarticulation of the hips) or attempted revascularisation with its attendant hazards. The patient was subsequently managed in a cautious and thoughtful manner with repair of the aorta to re-establish circulation, and fasciotomies in the legs. Despite the care taken, when the legs were revascularised, the patient suffered a cardiac arrest due to hyperkalaemia." "An 86-year-old man had a laparotomy for small bowel intestinal obstruction in a district general hospital. He was described as ’shocked’ and ’shutdown’ on the anaesthetic record. A stomach tube was used before anaesthesia but aspiration of faeculent material occurred at intubation despite the application of cricoid pressure. A Consultant Anaesthetist was told about the patient beforehand but left a Registrar (with the DA) and a Senior House Officer to manage the patient who remained hypotensive (60/40 mm Hg) throughout the procedure (which took one hour at 2300 hours). The most senior surgeon involved before and during the operation was a locum Registrar. Fast atrial fibrillation was treated just before induction with digoxin, and inotropes (dopamine and dobutamine) were also given intravenously. He died ten days later on a general ward."
Reading these accounts, no-one could fail to be disturbed by the continuing lack of supervision of junior staff or worried by the failure of some surgeons to refer patients to more experienced specialist colleagues when appropriate. Although about half the anaesthetics for the group of patients who died were conducted "in the precise knowledge and (or) presence of a Consultant", this proportion is not thought to be satisfactory. NCEPOD also notes an "overwhelming" need for trained non-medically qualified assistants for anaesthetists: in 59% of deaths the anaesthetist was working without medical assistance. The Enquiry continues to be "alarmed" by the extent of lost case notes, commenting on the widespread habit of regarding notes of deceased patients as unimportant, so much so that they are not retained in a systematic fashion by some medical records departments. The lack of interest in necropsies is no less alanning-not only are too few examinations being carried out but also all too often the clinical team is not told when a hospital necropsy is to take place. Provision of dedicated and staffed emergency operating rooms and intensive care facilities likewise needs improvement. There should be no question about the continuing life of this Enquiry. 1. Anon. NCEPOD. Lancet 1988; ii: 1320. 2. Campling CA, Devlin HB, Hoite RW, Lunn JN. Report of the National Enquiry into Perioperative Deaths 1990. NCEPOD, 35-43 Lincoln’s Inn Fields, London WC2A 3PN.
Although this work is preliminary, the results provide a satisfying explanation for a puzzling form of endocrine hypertension. Moreover, this is the first example of a major crossover event that leads to greatly increased expression of a gene rather than inactivation. These observations should encourage
research into the role of genetic factors in other forms of hypertension. more
1. Connell JMC, Fraser R. Adrenal corticosteroid synthesis and hypertension. J Hypertens 1991; 9: 107. 2. Ferriss JB, Brown JJ, Fraser R, Lever AF, Robertson JIS. Primary aldosterone excess: Conn’s syndrome and similar disorders. In: Robertson JIS, ed. Handbook of hypertension, vol 2. Amsterdam: Elsevier, 1983: 132-61. 3. Conn JW. Primary aldosteronism: a new clinical syndrome? J Lab Clin Med 1955; 45: 6-17. 4. Sutherland DJA, Ruse JL, Laidlaw JC. Hypertension, increased aldosterone secretion and low plasma renin activity relieved by dexamethasone. Can Med Assoc J 1966; 95: 1109. 5. Ganguly A. Glucocorticoid-suppressible hyperaldosteronism: a paradigm of arrested adrenal zonation. Clin Sci 1991; 80: 1-7. 6. Momet E, Dupont J, Vitek A, White PC. Characterisation of two genes encoding human steroid 11&bgr;-hydroxylase (P-45011&bgr;). J Biol Chem 1989; 264: 20961-67. 7. Yabu M, Senda T, Nonaka Y, Matsukawa N, Okamoto M, Fujita M. Localisation of the gene transcripts of 11 &bgr; hydroxylase and aldosterone synthase in the rat adrenal cortex by in situ hybridisation. Histochemistry 1991; 96: 391-94. 8. Shibata H, Ogishima T, Mitani F, et al. Regulation of aldosterone synthase cytochrome P450 in rat adrenals by angiotensin II and
potassium. Endocrinology 1991; 128: 2534-39. 9. Lifton RP, Dluhy RG, Powers M, et al. A chimaeric 11 &bgr;-hydroxylase/ aldosterone synthase gene causes glucocorticoid-remediable aldosteronism and human hypertension. Nature 1992; 355: 262-65.
NCEPOD strikes again "... inappropriate and unsupervised delegation to trainees; too many operations were done out-of-hours; and consultants were found to operate outside their area of proficiency ... Inadequate (or incorrect) notes and the data generated from them were also shown to confound official statistics." We make no apology for repeating this extract from a 1988 Lancet commentary1 on the Confidential Enquiry into Perioperative Deaths (CEPOD), which was written at the time the UK national enquiry (NCEPOD) was about to start. In the second annual NCEPOD report,for 1990, published this week "there are no new lessions" according to the preamble. The Enquiry collects data on patients who have died in hospital in the UK within 30 days of a surgical procedure; for 1990, 18 817 such deaths were reported. A more detailed assessment of surgical and anaesthetic practice was gained from a random sample of 3485 deaths. By comparison with Department of Health figures, there was a 16% shortfall in reporting to NCEPOD. Nevertheless, the departmental statistics contain some surprising anomalies--eg, no deaths at the National Hospital for Nervous Diseases or the Hospitals for Sick Children in London, whereas NCEPOD recorded 11 and 52, respectively. NCEPOD also noted that hospitals that coded their data efficiently were likely to report a higher number of surgical procedures and deaths to the Department, thereby producing apparently worse results.
As
before, the use of vignettes in the report brings important messages home. Here are two examples. "A
53-year-old
woman was
operated
on
by
a
general
surgeon in order to drain a left pyonephrosis containing 5 litres of pus. There was considerable haemorrhage from the left renal artery which was controlled by several ligatures. Unfortunately these had unintentionally encircled the abdominal aorta. The subsequent ischaemia of the legs went unnoticed for over nine hours. When this lady was finally transferred to a vascular unit the vascular surgeon was faced with a delayed referral and a choice between bilateral high thigh amputations (or even disarticulation of the hips) or attempted revascularisation with its attendant hazards. The patient was subsequently managed in a cautious and thoughtful manner with repair of the aorta to re-establish circulation, and fasciotomies in the legs. Despite the care taken, when the legs were revascularised, the patient suffered a cardiac arrest due to hyperkalaemia." "An 86-year-old man had a laparotomy for small bowel intestinal obstruction in a district general hospital. He was described as ’shocked’ and ’shutdown’ on the anaesthetic record. A stomach tube was used before anaesthesia but aspiration of faeculent material occurred at intubation despite the application of cricoid pressure. A Consultant Anaesthetist was told about the patient beforehand but left a Registrar (with the DA) and a Senior House Officer to manage the patient who remained hypotensive (60/40 mm Hg) throughout the procedure (which took one hour at 2300 hours). The most senior surgeon involved before and during the operation was a locum Registrar. Fast atrial fibrillation was treated just before induction with digoxin, and inotropes (dopamine and dobutamine) were also given intravenously. He died ten days later on a general ward."
Reading these accounts, no-one could fail to be disturbed by the continuing lack of supervision of junior staff or worried by the failure of some surgeons to refer patients to more experienced specialist colleagues when appropriate. Although about half the anaesthetics for the group of patients who died were conducted "in the precise knowledge and (or) presence of a Consultant", this proportion is not thought to be satisfactory. NCEPOD also notes an "overwhelming" need for trained non-medically qualified assistants for anaesthetists: in 59% of deaths the anaesthetist was working without medical assistance. The Enquiry continues to be "alarmed" by the extent of lost case notes, commenting on the widespread habit of regarding notes of deceased patients as unimportant, so much so that they are not retained in a systematic fashion by some medical records departments. The lack of interest in necropsies is no less alanning-not only are too few examinations being carried out but also all too often the clinical team is not told when a hospital necropsy is to take place. Provision of dedicated and staffed emergency operating rooms and intensive care facilities likewise needs improvement. There should be no question about the continuing life of this Enquiry. 1. Anon. NCEPOD. Lancet 1988; ii: 1320. 2. Campling CA, Devlin HB, Hoite RW, Lunn JN. Report of the National Enquiry into Perioperative Deaths 1990. NCEPOD, 35-43 Lincoln’s Inn Fields, London WC2A 3PN.