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Medic’s warning: prescribed medication caused a 50% increase in emergency admissions & nearly 100,000 hospitalisations a year in England

10 Feb

 

An article by Dr Mark Porter (December 2018) opens, “The first thing I do when faced with a poorly patient is to look at their medication to see if it could be responsible. You would be surprised how often it is”. Polypharmacy is rife: 1 in 18 of the population is taking ten medicines or more and potent pharmaceuticals carry risks as well as benefits. Millions of people are taking medication such as blood pressure pills and statins to prevent problems they may never have.

The really important message that reducing your risk of heart disease is best done by an improved diet and lifestyle is getting ‘crowded out’

Repeated campaigns have advocated mass medication – for example the February 2014 drive by the National Institute for Health and Care Excellence (the ‘health watchdog’) saying that the vast majority of men aged over 50 and most women over the age of 60 should take the drugs to guard against strokes and heart disease – though studies have suggested that up to one in five patients taking statins suffers some kind of ill-effect, including muscle aches, memory disturbance, cataracts and diabetes.

The Times reported on February 1st that a study published in the Lancet says all men over 60 and women over 75 are at high enough risk of cardiovascular problems to be eligible for the drugs. Professor Colin Baigent from Oxford University, a ‘co-investigator’, says “The risk of heart attacks and strokes increases markedly with age, and yet statins are not utilised as widely in older people as they should be”.

Dr Porter writes: “it is not illegal drug use in older people that concerns me most. I am embarrassed to report that prescribed medication exacts a far bigger toll on the nation’s health. Since 2008 there has been a 50% increase in the number of emergency admissions to hospitals for adverse drug events caused by medicines. In England alone such reactions are responsible for nearly 100,000 hospitalisations a year”.

He explains that anti-inflammatories such as ibuprofen and naproxen can work wonders for aches and pains from arthritic joints, but they have worrying side-effects and don’t mix well with many drugs commonly prescribed to treat high blood pressure (BP). They can damage the lining of the stomach, causing life-threatening bleeds (responsible for thousands of admissions every year) and can lead to kidney failure (on their own and when taken with BP drugs).

More subtle reactions impairing the quality of life are far more common and much easier to miss. Dr Porter gives a few examples from an ‘endless list’:

  • Blood pressure and heart pills that cause coughs (e.g. ramipril) and erectile dysfunction.
  • The prostate drug tamsulosin that can make you light-headed and increase the risk of falling.
  • Statins that cause aches and pains and reduce mobility.
  • Sleeping tablets that lead to addiction.
  • Cramp pills (quinine) that can cause heart problems.

He gave a striking case history:

“An elderly man with “early dementia” and diabetes was admitted to a residential home on our patch, where the staff reported that their new resident just sat in the corner all day looking vacant. His drug chart revealed he was taking an old-fashioned treatment for diabetes (gliclazide) that was pushing his blood sugars too low. It was stopped and two weeks later he was a new man and back in his own home. It is a lesson I have never forgotten”.

In October, an analysis in the British Medical Journal cautioned against any expansion in prescribing. One of its authors, Dr John D Abramson, clinical lecturer in primary care, from Harvard Medical School, last night said: “I think we have become victims of the drug companies. All the research is funded by them, and the really important message – that reducing your risk of heart disease is best done by an improved diet and lifestyle – is getting crowded out.”

 

 

 

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Following today’s news about emergency admissions & hospitalisations a year in England due to medical error, we turn to iatrogenic disease and death

10 Feb

Up-to-date figures for iatrogenic disease and deaths (inadvertently caused by a surgeon or physician or by a medical or surgical treatment or a diagnostic procedure) are not readily available in UK or USA. the US Department of Health and Human Services Office of the Inspector General examining the health records of hospital inpatients in 2008, reported 180 000 deaths due to medical error a year among Medicare beneficiaries alone.

Paul Wearn from the Office for National Statistics – 9 June 2011 – finally answered a FOI request for information about the number of iatrogenic deaths each year: “ONS do not have a National Statistics definition for iatrogenic The causes most closely fitting this concept are ‘complications of medical and surgical care’, ICD 10 codes Y40-Y84. Table 5.19, from the annual ‘Mortality Statistics’ publication shows that there were 236 male deaths and 226 female deaths where the underlying cause was a complication of medical and surgical care, in England and Wales, for 2009”.

In the British Medical Journal (2016, sometinmes requires reader to login) Professor Martin A Makary, department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA explains that a major limitation of the death certificate is that it relies on assigning an International Classification of Disease (ICD) code to the cause of death so causes of death not associated with an ICD code, such as human and system factors, are not captured. can directly result in patient harm and death.

  • communication breakdowns,
  • diagnostic errors,
  • poor judgment,
  • and inadequate skill

Currently, deaths caused by errors are unmeasured and discussions about prevention occur in limited and confidential forums

Hospital committees undertake internal root cause analysis and departments hold morbidity and mortality conferences but these review only a fraction of detected adverse events and the lessons learnt are not disseminated beyond the institution or department.

Strategies to reduce death from medical error should include:

  • making errors more visible when they occur so their effects can be intercepted;
  • having remedies at hand to rescue patients
  • and making errors less frequent by following principles that take human limitations into account
  • death certificates could contain an extra field asking whether a preventable complication stemming from the patient’s medical care contributed to the death.
  • hospitals could carry out a rapid and efficient independent investigation into deaths to determine the potential contribution of error.
  • Standardized data collection and reporting processes are needed to build up an accurate national picture of the problem. 

World Health Organisation statistics show that strategies to reduce the rate of adverse events in the European Union alone would lead to the prevention – on average – of more than 750 000 harm-inflicting medical errors per year, leading in turn to over 3.2 million fewer days of hospitalization, 260 000 fewer incidents of permanent disability, and 95 000 fewer deaths per year.

 

 

 

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Mass-medication 3: is compulsory fortification of all flour with folic acid imminent?

17 Oct

The Guardian reports that senior government sources say compulsory fortification of all flour with folic acid will be introduced within weeks.  

Theresa May, who was opposed to the measure, has been persuaded to back a plan to add folate supplement to food after a campaign to reduce the number of babies born in the UK with the neural tube defect (NTD). The Independent adds that the Department of Health and Social Care said the proposal is still being considered.

Two years ago, when the second reading of the above bill was debated, Lord Prior quoted from a report by the UK government’s Scientific Advisory Committee on Nutrition (SACN):

“The fortification of white bread flour with folic acid should be introduced only if it is accompanied by a number of preconditions: for example, action to reduce folic acid intakes from voluntary fortified foods, to ensure that individuals do not substantially exceed their safe maximum daily intake of folic acid . . . It also told us that there is inconclusive evidence on several possible adverse health effects of the mandatory fortification of flour with folic acid. For example, for people aged 65 and over, folate fortification of flour may result in cases of vitamin B12 deficiency not being diagnosed and treated”.

Clinical Education reports that Dr Edward Reynolds from King’s College, London has researched this matter, reviewing the literature from the 1940’s. He maintains that the recommended current upper limit of folate -1 mg – is too high.

In the 2016 debate, however, Lord Prior said the dangers of over-medication are small: “The issue is one of balancing the scientific and medical arguments with issues around choice and whether or not it is right to medicate the entire population for the benefit of a fairly small part of it”.

All women are recommended by the NHS to take a daily supplement of 400 micrograms of folic acid while they’re trying to get pregnant and during the first 12 weeks of pregnancy, when the baby’s spine is developing. The BDA asserts that very few women take this advice and according to research published in a 2015 paper in the British Medical Journal, the prevalence of NTD pregnancies was 1.28 per 1000 total births.

A reader comments on the Independent article: “70 million people to be mass-medicated for the sake of 1000 women… well that makes sense doesn’t it?”

 

 

 

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Mass-medication 2: the prevention element – a potential revenue stream?

23 Sep

As Andrew Miles, senior UK vice-president of GlaxoSmithKline observed cryptically in the Financial Times recently, “As much as people might think that the prevention element may not be a revenue stream for the company, it provides phenomenal insights.”

In July, the journal Science Translational Medicine published a report of the trial at Novartis Institutes for Biomedical Research in Massachusetts into a treatment, administered as two daily pills. A Times article noted that it was found to cut the number of infections in older people. Stephen Evans, the professor of pharmacoepidemiology at the London School of Hygiene and Tropical Medicine, said that the study was only an incremental improvement on the treatments already available and there are unanswered questions about the possible side-effects of the drugs.

Mass medication is an iatrogenic catastrophe

In June, this view was expressed in a BMJ article by James Le Fanu, retired GP and journalist. He wrote that ‘profligate’ prescribing has brought a hidden epidemic of side effects and no benefit to most individuals. There is no drug or procedure with its “chance of good” that may not harm some. The more doctors do, the greater that risk. Over the past 20 years there has been:

  • a dizzying fourfold rise in prescriptions for diabetes treatments,
  • sevenfold for antihypertensives,
  • and 20-fold for the cholesterol lowering statins.
  • Meanwhile the number of people taking five or more different drugs has quadrupled to include almost half of those aged 65 or over.

He continues: “The consequences of this massive upswing in prescribing? A hidden epidemic of immiserating symptoms such as fatigue, muscular aches and pains, insomnia, and general decrepitude, a 75% rise in emergency admissions to hospital for adverse drug reactions (an additional 30 000 a year) …

Proposals have been made in the past for mass or even universal medication by aspirin and statins

The NHS now concludes that the risk of side effects (particularly the risk of bleeding) outweighs the benefit of preventing blood clots. It has long been known that the pills carry a risk of gastro-intestinal bleeding. But a new University of Oxford study, published in The Lancet, suggests that the danger increases far more sharply with age than was thought, according to Professor Peter Rothwell, lead author. A Telegraph artlcle reports on his 2017 findings, adding that taking a daily aspirin is more dangerous than was thought, causing more than 3,000 deaths a year.

Britain is already the “statins capital” of Europe

The UK has the second highest prescribing levels in the Western world, with aggressive prescribing of the medication by GPs, whose pay is linked to take-up of the pills.

In 2014 it was reported that twelve million people (one in four adults) would be told to take statins under controversial new NHS guidelines. Draft proposals from health watchdogs were that the vast majority of men aged over 50 and most women over the age of 60 are likely to be advised to take the drugs to guard against strokes and heart disease. The National Institute for Health and Care Excellence (Nice) had cut the “risk threshold” for such drugs in half and experts said that the number of patients advised to take the drugs is likely to rise from seven million to 12 million.

And current medical guidance says that anyone with a 20% risk of developing cardiovascular disease within 10 years should be offered statins.

Almost all men over 60 and all women over 75 in England qualify for statin prescriptions under guidelines adopted by the National Institute for Health and Care Excellence in 2014, a 2017analysis shows – see BMJ.

However, some health experts have questioned the industry forces behind these studies. The first recommendation was put out in 2013 by the American College of Cardiology (ACC) and the American Heart Association (AHA).  CNN reports that a number of experts who worked on the ACC/AHA guidelines had financial links to drug companies, which they disclosed publicly. No conflicts of interests were reported by the authors of the United States Preventive Services Task Force guidelines, but nearly all of the trials they included in their analysis were sponsored by industry, according to Dr Rita Redberg, who stressed this point in a January 2017 editorial in the journal she oversees. “The ACC did not follow its own conflict of interest guidelines“..

Fluoridation – or any practice that uses the public water supply as a vehicle to deliver medicine – violates medical ethics in several important ways:

  • It deprives the individual of his or her right to informed consent to medication.
  • It is approved and delivered by people without medical qualifications.
  • It is delivered to everyone regardless of age, health or nutritional status, without individual oversight by a doctor and without control of dose.
  • The safety of fluoridated water has never been demonstrated by randomized controlled trials–the gold standard study now generally required before a drug can enter the market.

Fluoridating water is a form of mass medication and most western European nations have rejected the practice — because, in their view, the public water supply is not an appropriate place to be adding drugs.

Who profits from all these instances of largescale medication?

 

 

 

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An informative comment on the situation in Ireland

1 Mar

chemStats show immediate world-wide interest in water fluoridation (left) and Chris Price has commented:

“In Ireland, water supplied by local government is required by law to be fluoridated.

“However, water supplied by local community “group schemes”, or from private wells, is nearly always non-fluoridated.

“As a result, less urbanised regions of Ireland have a patchwork of fluoridated and non-fluoridated water supplies serving communities in close proximity”.

We hear about communities developing their own renewable energy schemes, taking over village shops, libraries and pubs  and this is news of another welcome initiative.

A search revealed the existence of the National Federation of Group Water Schemes, the representative and negotiating organisation for community-owned rural water services in Ireland.

 

 

 

 

 

Rising antibiotic resistance in E.coli on UK supermarket meat

9 Sep

tracy-and-pigLast December this site reported that Tracy Worcester is drawing attention to the subject of antibiotic resistance, which is growing – developing not in humans, but in bacteria that can then infect humans. Surgical and cancer chemotherapy patients rely on antibiotics to protect them from potentially life-threatening illnesses and declining efficacy could turn routine procedures into life-threatening ones.

The Organic Research Centre now reports that a new study carried out by scientists at Cambridge University, looked at 189 UK-origin pig and poultry meat samples from the seven largest supermarkets in the UK (ASDA, Aldi, Coop, Morrisons, Sainsbury’s, Tesco and Waitrose). It tested for the presence of E. coli which are resistant to the key antibiotics for treating E. coli urinary-tract and blood-poisoning infections in people. The highly resistant ESBL E. coli was found on meat from all of the supermarkets.

orc-header

The research found rising levels of resistance in chicken meat, with 24% of samples testing positive for ESBL E. coli, a type of E. coli resistant to the ‘critically important’ modern cephalosporin antibiotics. This is four times higher than was found during a similar study in 2015, in which just 6% of chicken tested positive for ESBL E. coli. Modern cephalosporins are widely used for treating life-threatening E.coli blood poisoning in humans.

51% of the E. coli from pork and poultry samples were resistant to the antibiotic trimethoprim, which is used to treat over half of lower urinary-tract infections. In addition, 19% of the E. coli were resistant to gentamicin, a very important human antibiotic used to treat more serious upper urinary-tract infections.

The findings provide further evidence that the overuse of antibiotics used to mass medicate livestock on British farms is likely to be undermining the treatment of E. coli urinary-tract and blood-poisoning infections in humans. Some of the antibiotics tested are used in far greater quantities in livestock farming than in human medicine.

Dr Mark Holmes, from Cambridge University, who led the study said: “I’m concerned that insufficient resources are being put into the surveillance of antibiotic resistance in farm animals and retail meat. We don’t know if these levels are rising or falling in the absence of an effective monitoring system. These results highlight the need for improvements in antibiotic stewardship in veterinary medicine. While some progress has been made we must not be complacent as it may take many years before we see significant reductions in the numbers of antibiotic-resistant bacteria found in farms.”

E-coli is by far the most common cause of urinary-tract infections and of dangerous blood poisoning, and can also cause meningitis. These infections must be treated with antibiotics. Dr Ron Daniels BEM, CEO of the UK Sepsis Trust said: “This study highlights a worrying trend towards rising resistance in E.coli on UK retail meat. E.coli in people is the greatest cause of deaths from sepsis, and poor antimicrobial stewardship in intensive farming is undoubtedly contributing to this trend. It’s of paramount importance that we act decisively to reduce this immediate threat to human life.”

Two recommendations:

 Other proposals:

Tracy points out that we have the choice to buy meat with the high welfare labels RSPCA Assured, Outdoor Bred, Free Range or Organic – eat less meat as Anna advocates – or go meat-free. See the World Health Organisation on the health issues here.

Buy organic/local?

Organic farming is perceived as providing a better quality of life for farmed animals and an earlier article reports that a new financial report on organic farming in England and Wales for 2014/15, undertaken by the Organic Research Centre for the Welsh Government, shows organic farm profits increasing, with organic dairy farming outperforming conventional dairy farming in England and Wales. In particular, the organic dairy industry is now generating higher profits than conventional farms despite producing lower yields.

Animal welfare has been a key motivator to consumers who are increasingly choosing organic products with quality assurance standards, because they want to know the origins of their food, and are willing to pay more for products which are ‘friendly’ to wildlife and the environment.

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Professor Nic Lampkin from the Organic Research Centre in Newbury, was one of the co-authors of the report and the Cambridge study was commissioned by the Alliance to Save our Antibiotics, of which the Organic Research Centre is a member.

 

 

 

Why aren’t people in London and the South receiving compulsory medication?

6 Jun

The Nuffield Council on Bioethics, funded jointly by the  Wellcome Trust and the Medical Research Council, advises policy makers and stimulates debate in bioethics.

nuffield fluoridation logoIts 21 page chapter on the fluoridation of water has drawn on expert assessments, in particular the fifteen year old York review, the most recent major review in this area. It points out that water fluoridation is an example of an intervention that directly affects whole populations, noting that the case of fluoridation raises issues about ‘the nature and strength of evidence required in arguments about the acceptability of an intervention, and about ways in which evidence is, and should be, communicated’.

BFS, BDA & NAEDH: overstated potential benefits, understated potential harms

Soon after the York Review’s publication in 2000, its authors drew attention to their view that the report had been “widely misinterpreted” and sought to correct the record, expressing concern over statements by groups including the British Fluoridation Society, British Dental Association and the National Alliance for Equity in Dental Health which “mislead the public about the review’s findings”. The reported problems included overstating the potential benefits of fluoridation, understating the potential harms, and the inaccurate claim that the review concluded water fluoridation to be “safe”.

A rose by any other name? BFS: fluoride is not a waste product – it is a industrial byproduct or a co-product

nuffield fluoridation coverThe Nuffield report points out that in its ‘Technical Aspects of Fluoridation’, the British Fluoridation Society, confirms that the source of fluoride used in the UK: hexafluorosilicic acid or its sodium salt, disodium hexafluorosilicate, are chemicals are produced from co-products of the manufacture of phosphate fertilisers:

“The chemicals are important co-products of the manufacture of phosphate fertilisers.  Part of the manufacturing process involves `capturing’ gases using product recovery units.  These units are technically similar to pollution scrubbers.  However the important difference is that, in the process of the manufacture of fluoride chemicals, the end result is a valuable and useful resource, not a waste product.”

Reducing inequalities: quality of evidence, low

The York Review of 2000 found that “The research evidence is of insufficient quality to allow confident statements about … whether there is an impact on social inequalities”. It concluded that “[although] the available evidence… appears to suggest a benefit in reducing the differences in the severity of tooth decay, … the quality of evidence is low and based on a small number of studies”. For now, we note that based on the best available evidence it is not straightforward to conclude that water fluoridation reduces dental health inequalities as measured by outcomes. Of the 30 studies assessed, twelve had not detected a statistically significant difference between the populations receiving fluoridated and non-fluoridated water . . .

‘Inconclusive’ association with bone problems, cancers, Alzheimer’s disease, malformations and mental retardation

Alarms voiced in reports in the Mail (Dec. 2015) and the Telegraph (Feb 2015, thyroid problems) were not echoed by the York review study group which concluded that on the basis of the best available evidence no clear association could be established between either bone problems or cancers and fluoridation and studies on other health risks, including Alzheimer’s disease, malformations and mental retardation, were inconclusive.

bedford council fluoridation hearing

The Nuffield Report concludes that the most appropriate way of deciding whether fluoride should be added to water supplies is to rely on democratic decision-making procedures (above Bedford’s Overview and Scrutiny Committee which unanimously recommended (April 2016) that fluoride should NOT be added to Bedford’s water, following a protracted two-year debate).

Conclusion: there should be comprehensive, well-funded and designed research into the impact of fluoridation of the public water supply on human health

Authors of the York Review, McDonagh M, Whiting P, Bradley M et al. (2000) in A Systematic Review of Public Water Fluoridation (York: NHS Centre for Reviews and Dissemination) declare that:

fluoride UK map“Given the level of interest surrounding the issue of public water fluoridation, it is surprising to find that little high quality research has been undertaken”. This is particularly surprising as fluoridation has been implemented as an intervention in some areas of the country, and has been considered as a policy option in others, over several decades”.

The Nuffield Council Report adds (7.42):

“We noted that the evidence base for fluoridation is not strong, and that as such ongoing monitoring and further research, particularly on risks, are recommended. Policy makers and the public need to have access to clear and accurate information, and uncertainties and the strength or weakness of the evidence should be explicitly recognised. Therefore, the UK health departments should monitor the effects of water fluoridation, including the incidence and severity of fluorosis and other possible harms.

“Water fluoridation policy should be objectively reviewed by the UK health departments on a regular basis in light of the findings of ongoing monitoring and further research studies. Furthermore, the conclusions and their basis should routinely be published”.