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UK guidelines to prevent postoperative clots
cal studies show that no effect of low-level lead found can stem from "overcontrol", in which some effects of lead poisoning are wrongly considered to be independent, and are used to exclude from the studies cases that ought to be included. Doubters also point to the modest degree of the IQ effects for low lead levels, but small effects on the mean imply substantial decreases in the number of geniuses, and increases in the incidence of retardation. In addition, the behavioural effects, :
UK
which
are
harder
quantify,
acid) is undergoing clinical trials; an advantage is that it can be given orally. Evidence to date suggests that early neurological effects of lead can be compensated for, but not reversed. Thus the Alliance hopes that in the future preventive measures will move beyond blood lead screencinic
may be
important. Average blood leads in the US have dropped from 17 to 5 µg/dL, which shows that although only a small percentage of world lead production ends up in petrol, it represents an efficient method of distributing fine lead dust just about everywhere. Chelation therapy saves lives in acute lead poisoning, but the benefit of chelation therapy in low-dose lead toxicity is not yet known. Succimer (dimercaptosuc-
guidelines to prevent postoperative
Representatives of the royal colleges and other professional medical associations in the UK have agreed to develop draft outline national guidelines for the prevention of postoperative venous thromboembolism. Meeting on June 6 at the Royal College of Surgeons, London, the delegates appointed a small working party that includes practitioners in general surgery, .,’ orthopaedics, obstetrics and gynaecology, urology, vascular surgery, and anaesthetics. A nurse is expected to join the group, which has undertaken to produce and publish draft outline guidelines by Sept 30, 1994. These guidelines will then be tested in practice, reworked, and periodi: cally updated. This initiative, funded by the Department of Health, has developed from the
to
more
ing,
Prevention of venous thromboembolism after orthopaedic, gynaecological, and urological operations received special attention at the meeting because total hip replacement, hysterectomy, and prostatectomy were each associated with several latest report of the National Confidential cases of fatal pulmonary embolism in the NCEPOD report. But little agreement Enquiry into Perioperative Deaths (NCEin POD) published September, 1993, and could be reached among the delegates on based on perioperative deaths in 1991-92. how to prevent postoperative thromboem18 132 perioperative deaths (within 30 blism. Evidence of the effectiveness and days of operation) were reported, of which safety of subcutaneous heparin, low-mole-
children
as
"mine
cular-weight heparin, and antiplatelet agents was presented, with the most convincing data in general surgical and orthopaedic patients. Delegates, however,
cases
specialties.
uses
Paul M Rowe
clots
detailed information is available for 1821 after 15 different surgical procedures. 119 proven cases of fatal pulmonary embolism occurred, but the low response rate to the NCEPOD questionnaires (68-9% for surgical and 61-2% for anaesthetic questionnaires) prevents analysis of the deaths in relation to the use or lack of use of prophylactic regimens. However, wide variations in the use of prophylaxis against venous thromboembolism were identified within and across
which
canaries", toward primary prevention, by cleaning up the environment.
,
remained unconvinced. Many gaps in knowledge were identified, including the effectiveness and risk of combinations of preventive therapies, the length of time that prophylaxis should be maintained, which type of low-molecularweight heparin is most effective, and which regimen is best for different procedures. Drug-industry sponsorship was blamed for the scarcity of large studies in the UK of the effectiveness of mechanical methods of prevention, such as graduated stockings and intermittent pneumatic calf compression. Nevertheless, support for mechanical methods was strong, particularly since "mechanical methods do not bleed". Whether the data are robust enough to allow the development of guidelines or whether the need for further research in some areas will have to be met first remains to be seen. Astrid James
All Clalit contracts have been frozen help Clalit by shedding assets, but Hevrat Ha’ovdim, the Hisleading to an immediate shortage of mednearly bankrupt? tadrut holding company, will not be ications and disposables at Clalit hospi"forced to sell shares nor properties to covtals, which is expected to become severe The entire executive council of Israel’s er the Histadrut’s commitments to the within days. Teva, Israel’s largest pharmahealth fund". Clalit’s deficit is NIS 2-5 ceutical industry, which is owed more largest health fund, Kupat Cholim Clalitwhich serves over two-thirds of the populabillion. : than NIS 180 million, has been supplying on 6 after the admitted that It is now tion-resigned June approval : widely everyone only what is "absolutely necessary"of a loan of NIS 400 million (approximateintravenous solutions, dialysis equipment, in the government kept the near-bankanticancer medicines. Teva has taken a of the health fund a secret from the ly £100 million) by Israel’s governing ruptcy Labour cabinet. The health-fund directorlien on health fund properties, including for a Prime Minister nearly year. public Meir Hospital in Kfar Saba, which "will Yitzhak Rabin is said to have been congeneral Avigdor Kaplan said that the government realised that the loan would cerned about public backlash that might . be sold if warranted". deter the government’s efforts in the "barely cover" current operating costs and some debts to suppliers and that services Rachelle H B Fishman peace process and about further jeopardiswould "have to be cut back". He said that ing his fractionating coalition with the Clalit, which is owned by Histadrut religious parties. Yet even without public (Israel’s Federation of Trade Unions), had disclosure, Labour lost the Histadrut leadNews in brief been "deserted" by its owner and "left by ership for the first time in 73 years, a the government to fall into bankruptcy". virtual coup d’etat by former health minisHe approved of receivership now "before ter MK Haim Ramon (see Lancet Feb 12, US strep threat? The first two US cases irreparable damage is done". In effect, the p 409). Ironically, by orchestrating the of necrotising fasciitis asociated with official receiver could legally require that defeat of Ramon’s version of the national group A streptococcal infection were the profit-making Histadrut underwrite health insurance bill, the pluripotent reported at a hospital in Norwalk, and make good the debts of its indentured Histadrut wing of Labour gave him the Connecticut, last week. A man and a "sick fund" instead of forcing the nation to platform he needed to unseat the party woman, both in their early thirties, were pay in the form of bailout loans or a global (see Lancet May 21, p 1280). Ramon now admitted with necrotising fasciitis and tax on income such as that in the new demands that the government continue to pyomyositis, respectively. The Centers national health insurance bill. The outgosubsidise the Clalit health fund "as it did for Disease Control and Prevention said ing Histadrut leadership now claims that it ’ before the election".: there was "no cause for concern".
Israel’s main health fund
wants to
just
1496
cannot:
UK
which
are
harder
quantify,
acid) is undergoing clinical trials; an advantage is that it can be given orally. Evidence to date suggests that early neurological effects of lead can be compensated for, but not reversed. Thus the Alliance hopes that in the future preventive measures will move beyond blood lead screencinic
may be
important. Average blood leads in the US have dropped from 17 to 5 µg/dL, which shows that although only a small percentage of world lead production ends up in petrol, it represents an efficient method of distributing fine lead dust just about everywhere. Chelation therapy saves lives in acute lead poisoning, but the benefit of chelation therapy in low-dose lead toxicity is not yet known. Succimer (dimercaptosuc-
guidelines to prevent postoperative
Representatives of the royal colleges and other professional medical associations in the UK have agreed to develop draft outline national guidelines for the prevention of postoperative venous thromboembolism. Meeting on June 6 at the Royal College of Surgeons, London, the delegates appointed a small working party that includes practitioners in general surgery, .,’ orthopaedics, obstetrics and gynaecology, urology, vascular surgery, and anaesthetics. A nurse is expected to join the group, which has undertaken to produce and publish draft outline guidelines by Sept 30, 1994. These guidelines will then be tested in practice, reworked, and periodi: cally updated. This initiative, funded by the Department of Health, has developed from the
to
more
ing,
Prevention of venous thromboembolism after orthopaedic, gynaecological, and urological operations received special attention at the meeting because total hip replacement, hysterectomy, and prostatectomy were each associated with several latest report of the National Confidential cases of fatal pulmonary embolism in the NCEPOD report. But little agreement Enquiry into Perioperative Deaths (NCEin POD) published September, 1993, and could be reached among the delegates on based on perioperative deaths in 1991-92. how to prevent postoperative thromboem18 132 perioperative deaths (within 30 blism. Evidence of the effectiveness and days of operation) were reported, of which safety of subcutaneous heparin, low-mole-
children
as
"mine
cular-weight heparin, and antiplatelet agents was presented, with the most convincing data in general surgical and orthopaedic patients. Delegates, however,
cases
specialties.
uses
Paul M Rowe
clots
detailed information is available for 1821 after 15 different surgical procedures. 119 proven cases of fatal pulmonary embolism occurred, but the low response rate to the NCEPOD questionnaires (68-9% for surgical and 61-2% for anaesthetic questionnaires) prevents analysis of the deaths in relation to the use or lack of use of prophylactic regimens. However, wide variations in the use of prophylaxis against venous thromboembolism were identified within and across
which
canaries", toward primary prevention, by cleaning up the environment.
,
remained unconvinced. Many gaps in knowledge were identified, including the effectiveness and risk of combinations of preventive therapies, the length of time that prophylaxis should be maintained, which type of low-molecularweight heparin is most effective, and which regimen is best for different procedures. Drug-industry sponsorship was blamed for the scarcity of large studies in the UK of the effectiveness of mechanical methods of prevention, such as graduated stockings and intermittent pneumatic calf compression. Nevertheless, support for mechanical methods was strong, particularly since "mechanical methods do not bleed". Whether the data are robust enough to allow the development of guidelines or whether the need for further research in some areas will have to be met first remains to be seen. Astrid James
All Clalit contracts have been frozen help Clalit by shedding assets, but Hevrat Ha’ovdim, the Hisleading to an immediate shortage of mednearly bankrupt? tadrut holding company, will not be ications and disposables at Clalit hospi"forced to sell shares nor properties to covtals, which is expected to become severe The entire executive council of Israel’s er the Histadrut’s commitments to the within days. Teva, Israel’s largest pharmahealth fund". Clalit’s deficit is NIS 2-5 ceutical industry, which is owed more largest health fund, Kupat Cholim Clalitwhich serves over two-thirds of the populabillion. : than NIS 180 million, has been supplying on 6 after the admitted that It is now tion-resigned June approval : widely everyone only what is "absolutely necessary"of a loan of NIS 400 million (approximateintravenous solutions, dialysis equipment, in the government kept the near-bankanticancer medicines. Teva has taken a of the health fund a secret from the ly £100 million) by Israel’s governing ruptcy Labour cabinet. The health-fund directorlien on health fund properties, including for a Prime Minister nearly year. public Meir Hospital in Kfar Saba, which "will Yitzhak Rabin is said to have been congeneral Avigdor Kaplan said that the government realised that the loan would cerned about public backlash that might . be sold if warranted". deter the government’s efforts in the "barely cover" current operating costs and some debts to suppliers and that services Rachelle H B Fishman peace process and about further jeopardiswould "have to be cut back". He said that ing his fractionating coalition with the Clalit, which is owned by Histadrut religious parties. Yet even without public (Israel’s Federation of Trade Unions), had disclosure, Labour lost the Histadrut leadNews in brief been "deserted" by its owner and "left by ership for the first time in 73 years, a the government to fall into bankruptcy". virtual coup d’etat by former health minisHe approved of receivership now "before ter MK Haim Ramon (see Lancet Feb 12, US strep threat? The first two US cases irreparable damage is done". In effect, the p 409). Ironically, by orchestrating the of necrotising fasciitis asociated with official receiver could legally require that defeat of Ramon’s version of the national group A streptococcal infection were the profit-making Histadrut underwrite health insurance bill, the pluripotent reported at a hospital in Norwalk, and make good the debts of its indentured Histadrut wing of Labour gave him the Connecticut, last week. A man and a "sick fund" instead of forcing the nation to platform he needed to unseat the party woman, both in their early thirties, were pay in the form of bailout loans or a global (see Lancet May 21, p 1280). Ramon now admitted with necrotising fasciitis and tax on income such as that in the new demands that the government continue to pyomyositis, respectively. The Centers national health insurance bill. The outgosubsidise the Clalit health fund "as it did for Disease Control and Prevention said ing Histadrut leadership now claims that it ’ before the election".: there was "no cause for concern".
Israel’s main health fund
wants to
just
1496
cannot: