- Ann Robinson, NHS GP and health writer and broadcaster
Terminating antiD
Rhesus immunoglobulin (Rho(D), anti-D), has been a game changer for Rh negative pregnant women. Since it’s been routinely given in the third trimester and at delivery, maternal sensitisation rates have fallen from 9-10% at each full term pregnancy to 0.2%. But should we also test and give anti-D after first trimester terminations of pregnancy? New technology that allows detection of low but potentially significant levels of exposure to fetal red blood cells (fRBCs) which might cause maternal sensitisation has provided such much needed clarity.
In this prospective US study, 99.8% (505/506) of women who had a first trimester termination of pregnancy (medical or surgical) fell below the threshold for sensitisation in terms of the numbers of fRBCs in their blood after the procedure, and fRBC levels remained unchanged before and after termination of pregnancy. The threshold is a proxy for what we’re trying to prevent—haemolytic disease of the newborn in subsequent pregnancies—and seems robust. The conclusion that Rh negative pregnant women don’t need Rh testing or treatment is welcome.
JAMA doi:10.1001/jama.2023.16953
We’re in this together
The increased risk of death by suicide among doctors globally is well documented, but less is known about the risks among other healthcare workers (HCWs), who share many of the same work conditions, pressures, and opportunities to self harm. This pre-covid US cohort study found that registered nurses, health technicians, and healthcare support workers were at increased risk of dying by suicide compared with non-HCWs (adjusted hazard ratios 1.64, 1.39, and 1.81). In this study, suicide rates weren’t increased for physicians or social workers (adjusted hazard ratios 1.11, 1.14) compared with non-HCWs. Some 95% of healthcare workers aren’t doctors, and this finding has implications for all of us. Other studies have shown higher rates of mental health problems among HCWs, but the exact work related stressors aren’t clear; burnout, work and home stress, and social isolation are likely to play a role.
JAMA doi:10.1001/jama.2023.15787
Adolescents; catch them if you can
Sweden had compulsory military conscription for men aged 18 years until 2010. Arguably, the greatest gain to humanity was a 40 year treasure trove of data in the form of the Swedish Military Conscription Register (SMCR). This cohort study used the SMCR from 1969 to 1997 to find out what happened to 1.36 million 18 year old conscripts with baseline raised blood pressure (elevated 120-129/<80 mm HG, hypertensive >130/80 mm Hg) over the next 36 years. Overall, 5.8% died or were admitted to hospital with a serious cardiovascular event by the age of 68 years. The cumulative risk for cardiovascular events increased gradually depending on what the blood pressure at age 18 had been (14.7%-24.3%).
This was an observational study of Swedish men who were fit enough for conscription, so it’s hardly universally generalisable, and we have no evidence that intervention might have changed the outcome. But it suggests there may be utility in measuring blood pressure in 18 year olds and offering advice to anyone whose blood pressure is above 120/80 to reduce later cardiovascular events.
Ann Intern Med doi:10.7326/M23-0112
Unequal restraint
Anyone who has spent time in an emergency department will have come across acutely agitated patients. Very occasionally, physical restraint using a mechanical device has to be used to keep staff and patients safe. It carries the risk of aspiration, choking, physical and psychological trauma, and lasting distrust of healthcare services. In the heat of the moment, protocols—if they exist—may not be followed, and unconscious or conscious bias may determine who gets restrained. This US systematic review and meta-analysis including 2.5 million patient encounters and 24 000 episodes of restraint found that Black patients were significantly more likely to be restrained in emergency departments compared with white (risk ratio 1.31) and all non-Black patients (risk ratio 1.27). Hispanic patients were less likely to be restrained than non-Hispanic patients (risk ratio 0.85). Even allowing for confounders, it seems likely that individual, institutional, and systemic racism underlie this disturbing finding.
JAMA Intern Med doi:10.1001/jamainternmed.2023.4832
Wee tests
Screening for albuminuria (albumin:creatinine ratio (ACR) >3 mg/mmol) to detect early stage chronic kidney disease (CKD) is cost effective in populations at high risk of cardiovascular and renal disease. But is it viable to ask everyone to test their urine at home to pick up albuminuria in a similar way to faecal immunochemical tests sent to adults over 60 years old in the UK?
This Dutch study showed that members of the general population were willing to get involved in home based ACR testing, with a participation rate of 59.4%. The researchers thoughtfully didn’t leave all the extra work generated to GPs but invited individuals with confirmed albuminuria to a screening centre to rigorously assess renal and cardiovascular risk factors. Those with newly diagnosed or poorly controlled risk factors were referred on to their GP. That still resulted in 89.5% of those who attended the screening centre being referred to their GP to start or optimise preventive treatment. Just over half went to their GP as instructed, and 66% received treatment as a result.
Lancet doi:10.1016/S0140-6736(23)00876-0
