Measles in Africa

Measles mortality in Africa decreased from an estimated 396 000 deaths in 2000 to 36 000 in 2006, a 91% decrease, the Measles Initiative announced on November 29. According to the World Health Organization (WHO), the "spectacular" achievement was made possible by a commitment to immunizing children against measles before their first birthday as part of routine health services as well as by mass vaccination campaigns.

Worldwide, deaths due to measles declined 68%, from an estimated 757 000 deaths in 2000 to 242 000 in 2006. Global routine vaccination coverage reached an estimated 80% in 2006, up from 72% in 2000, with the largest improvements seen in Africa and the Eastern Mediterranean region.

The Measles Initiative, which was founded by the American Red Cross, the US Centers for Disease Control and Prevention, the WHO, and the United Nations Children's Fund, hopes to implement the vaccination strategy in India, Pakistan, and other countries in South Asia, where about 74% of deaths due to measles occur worldwide.

JAMA. 2008;299:279.

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Self management training in refractory angina

Refractory angina pectoris is a major clinical problem characterised by unremitting symptoms of angina (equivalent to severity score class III-IV on the Canadian Cardiovascular Society classification), which are resistant to conventional treatments including nitrates, calcium channel and β adrenoceptor blockade, percutaneous coronary interventions, and coronary artery bypass grafting. Although there are limitations in current surveillance systems worldwide, estimates from data on revascularisation and hospital admission suggest a prevalence of refractory angina somewhere between 600 000 and 1.8 million in the United States and an incidence of 30-50 000/year in continental Europe.

Patients with refractory angina experience persistent anginal pain, poor general health status, psychological distress, restriction of activity, and inability to self manage their symptoms—all of which have a negative effect on health related quality of life.

Self management training that includes cognitive behaviour techniques is showing promise in angina. Indeed, it could be a welcome standard addition to the current technically based effective interventions aimed solely at reducing ischaemia.

Among the most feasible, well established, and widely used therapeutic options at present are neuromodulation techniques such as transcutaneous electrical nerve stimulation and spinal cord stimulation. These techniques can relieve anginal pain secondary to reducing ischaemia. Their anti-ischaemic effect is probably a product of decreased myocardial oxygen consumption.

Self management training is a promising adjunct to the treatment of refractory angina that needs relatively few resources, but few studies have been carried out in this patient population. Self management training interventions are multimodal treatment packages that use learning materials and cognitive behaviour strategies to promote effective self management of disease. In the past decade, a few small self management trials have shown significant reductions in the frequency of angina symptoms, use of nitrates, stress, and aspects of self reported health related quality of life.

A recent and robust trial with 142 participants showed that a self management programme based on cognitive behaviour therapy significantly reduced anxiety, depression, frequency of symptoms, nitrate use, and physical limitations (P<0.05) at six months compared with usual care. This model was designed and tested for patients with newly diagnosed angina, and this research should be adapted and tested for patients with refractory angina.

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Medication errors caused by junior doctors

The effects of medical errors on patient morbidity and mortality have been highlighted in the United Kingdom and the United States. Preventable medication errors account for 10-20% of adverse events in patients admitted to hospital. In the UK, up to 1.5% of hospital prescriptions may contain a medication error, and a quarter of these could result in potentially serious effects. The situation is similar in Australia and the US—medication errors occur in about 1-2% of patients admitted to hospital, resulting in around 7000 deaths a year in the US alone.

The mental health of junior doctors has been studied widely, but no data are available on the possible association between depression and burn-out in prescribers and medication errors. Fahrenkopf and colleagues recently reported levels of depression and burn-out and associated medication errors in junior doctors working in two paediatric hospitals.

The use of a paediatric setting is particularly relevant because prescribing in children is complicated by the use of off label drugs and non-standard doses and formulations. Consequently, the risk of error is high—5-27% for each medication order for children admitted to hospital.

Fahrenkopf and colleagues found that 20% of junior doctors surveyed met set screening criteria for depression and 74% met the criteria for burn-out; these results agree with previous UK and US studies. Only depression, however, was associated with a significant (sixfold) increase in medication errors. As sleep deprivation, stress, and burn-out have all been linked to poor performance, the failure to show an association between burn-out and medication error rate is surprising. In addition, the reported error rate was remarkably low—0.7% per order—half the reported rate for adults and about a 10th of the rate for children.

The report by Fahrenkopf and colleagues is interesting and the suggestion that unrecognised depression may be associated with increased medication errors has face validity, the conclusions that can be drawn from this study are limited. Furthermore, the study cannot determine the direction of any association between depression and medication errors, which is clearly important when designing potential interventions to reduce error rates.

Preventing medication errors and improving patient safety are important goals, which require a better understanding of the complex personal and systems factors involved in generating errors. However, prevention will only be achieved if future studies use standardised methodologies for data collection as well as standardised definitions of medication and prescription errors and a consistent denominator, such as the number of errors for each item prescribed.

Although the suggestion that medication errors may be linked to depression and burn-out seems reasonable, the results reported by Fahrenkopf and colleagues are far from conclusive. Large, prospective, and appropriately designed studies are needed to clarify the roles of individual factors involved in error generation.

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