They were stratified into four subgroups: general practitioners (GPs), physicians, surgeons and others and sub-divided again into subspecialties. The top specialties for honours included general practice, paediatrics, psychiatry, public health medicine, pathology, geriatrics, endocrinology and haematology.

GPs head the league table of honours in terms of numbers. Dr Islam says: “This is perhaps not surprising given the fact that GPs collectively constitute the largest single group of the medical workforce. However, when this figure is converted to a percentage of all registered GPs, a relatively small proportion receives honours. Despite ranking fourth overall in absolute numbers, public health medicine comes out top in percentage terms”.

All doctors have to put in at least 30 years of hard graft before they can even expect to be considered for an honour, which the research defined as Knight or Dame, CBE, OBE or MBE. For GPs the mean number of years of clinical practice and subsequent conference of honours is slightly shorter at 31 years, while secondary care clinicians have to work another five years.

Dr Kamran Abbasi, editor of the Journal of the Royal Society of Medicine, said: “The British honours system is one of the oldest in the world and it is extremely competitive. Doctors, like other public sector workers, reach a stage in their careers when they begin to think about being recognised by our honours system. This study has produced two interesting findings. Don’t even think about a gong before you’ve worked for thirty years, and if an honour is your ultimate goal you might want to discard the glamour and scalpels of surgery for a world of hush-puppies and public health”.

References

1 Doctors recognized by the British honours system: A retrospective analysis of the last decade. Islam S, Cole JL, Taylor CJ. JRSM 2011;104:521–4. doi: 10.1258/jrsm.2011.110188.

“Furthermore, consultants are finding themselves less available to teach trainees, often having to do jobs that would have previously been done by junior doctors. This is really worrying as training of future senior doctors is vital to high quality patient care in the NHS,” he added.

Each week, consultants are working 11.5% of their contracted hours extra free, says the census, this figure jumping to 14% for doctors who work part time. Overall, this ‘goodwill’ work accounts for the equivalent of 1,450 fulltime consultants, up by 205 compared to 2009. Despite working longer hours, 51.8% of consultants say that time available to spend with trainees has reduced during the past three years.  This change may result from the fact that consultants are spending more time doing jobs that would previously have been done by a junior doctor.

The European Working Time Directive (EWTD) continues to be seen by many as the main culprit responsible for the disintegration of the clinical team and training. The 2010 census, in addition to showing that the majority of consultants work more than 48 hours a week, also shows that 29.6% of departments do not work EWTD compliant rotas in practice – despite 94.7% being compliant on paper. Significant concerns remain about the impact of the EWTD on training and patient care.

74.9% of consultant said pressure at work had increased. 66.3% of consultant physicians reported their job always, often or sometimes ‘got them down’. The RCP is concerned that this is affecting consultants’ career planning. 51.3% of consultants currently intend to retire at 60 years of age or younger and the main reason given was pressure of work (27.9%).

Overall, consultant expansion slowed in 2010 to 6.7% from 10.2% in 2009. However, the expansion was not evenly spread across the 31 specialties. Large expansions were seen in cardiology and respiratory medicine, accounting for 39% of the new consultants. However, the increases seen in these two specialties were mostly due to improved data collection. If these two specialties are excluded, the expansion was only 4.1%, which is low compared to the last 10 years.

However, the RCP is concerned that six of the 31 specialties saw either no expansion or a reduction in numbers. One of these specialties was geriatric medicine, which is of particular concern since the population in the UK is aging. However, it is likely that some geriatricians have been reclassified as stroke physicians (stroke medicine saw a 48% expansion), and the RCP will be monitoring this specialty carefully in future census surveys to monitor whether the NHS will employ enough geriatricians to treat the increasing numbers of patients who are old and have complex conditions.

References

1 Census of consultant physicians and medical registrars in the UK, 2010. Federation of the Royal Colleges of Physicians. (Available from: http://www.rcplondon.ac.uk/resources/professionalism-and-working-practice/census).

- The prevention of stroke and non-central nervous system (CNS) systemic embolism in adult patients with non-valvular AF and one or more risk factors for stroke including congestive heart failure, hypertension, age over 75 years, diabetes and prior stroke, at a fixed dose of 20 mg once-daily.

- The treatment of deep vein thrombosis (DVT) and prevention of recurrent DVT and pulmonary embolism (PE) following an acute DVT in adults.

“The consequences of blood clots can be overwhelming and their prevention and treatment should rightly be considered a health priority,” said Trudie Lobban MBE, Chief Executive and Founder of Atrial Fibrillation Association. “Thrombosis represents a massive burden on patients and the UK health system. VKA eligible AF patients, especially those with a higher risk profile and with significant co-morbidities, tend to require more frequent INR testing. The additional tests have a significant impact on these patients’ quality of life as well as on NHS resources, so the approval of new therapy alternatives that are easier to manage than traditional treatments are welcome”.

“Antithrombotic medicine is a fast-evolving area in which we are continually improving our understanding of how to combat blood clots,” said Professor Keith Fox, Professor of Cardiology at the University of Edinburgh. “Treatments which act at a key point in the blood-clotting process are now emerging as an important therapy option in both short and long-term clinical settings, and have the potential to help re-shape clinical practice”.

About one in 3,300 women in England will die between the ages of 15 to 34; but this risk increases nine-fold among women with type 1 diabetes to one in 360, and six-fold among women with type 2 diabetes to one in 520.  A similar picture is true for young men with diabetes; men aged 15 to 34 in the English population are much more likely to die than women, at one in every 1,530; but this risk rises four-fold for men with type 1 diabetes to one in 360, and by just under four-fold among those with type 2 diabetes to one in 430.

The findings echo conclusions made earlier this year by the National Diabetes Audit, which found nearly 450,000 children and younger adults (aged up to 54) with diabetes have high risk blood sugar levels that could lead to severe complications. The audit, which is managed by the NHS Information Centre and commissioned by the Healthcare Quality Improvement Partnership (HQIP), also found this age group was the least likely to receive all the basic care checks required to monitor their condition.

The report also found:

• There is a strong link between deprivation and increased mortality rates. Among under-65s with diabetes the number of deaths among people from the most deprived backgrounds is double that of those from the least deprived backgrounds.

• Death rates among people with diabetes vary according to where they live. London has the lowest rates for both type 1 and type 2 diabetes, at 1.8% and 1.2% respectively, while the highest rate for both type 1 and type 2 diabetes was in the North East, at 2.4% and 1.7% respectively.

Audit lead clinician Dr Bob Young, consultant diabetologist and clinical lead for the National Diabetes Information Service, said: “For the first time we have a reliable measure of the huge impact of diabetes on early death. Many of these early deaths could be prevented. The rate of new diabetes is increasing every year. So, if there are no changes, the impact of diabetes on national mortality will increase. Doctors, nurses and the NHS working in partnership with people who have diabetes should be able to improve these grim statistics”.

References

1 NHS The Information Centre. National Diabetes Audit 2007/8 Mortality Analysis.  The Health and Social Care Information Centre, 2011.

The report highlights a persistent trend of higher rates of premature mortality not just in men as compared to women, but when comparing men from different socio-economic and cultural backgrounds.

In terms of the differences between men and women:

• Life expectancy for the EU27 stands at 76.07 for men and 82.21 for women, ranging from 80 years in Iceland and Lichtenstein to 66.3 years in Lithuania (a gap of 13.7 years)

• A clear gap exists between the Eastern European Countries as compared to Western Europe

• It is key to note that there are big differences within each member state so no country can be complacent

In 2007, there were over 630,000 male deaths between the ages of 15 and 64 years of age as compared to 300,000 female deaths. Across EU27, deaths in this 15-64 age group account for 26% of total male deaths compared to 13% of female deaths.  However, these proportions vary considerably between countries: ranging from nearly 44% of total male deaths occurring in this age group in Lithuania to 18% in Sweden.  For every country, this has significant implications for family and community life, and for the economy.

When the causes of these deaths were analysed they extended across the majority of conditions that should be seen to affect men and women equally.  Although men’s increased susceptibility to cardiovascular disease and deaths as a result of accidents in their earlier years is quite well known, their vulnerability to such a wide range of conditions is less well recognised.

The higher rates of deaths in both communicable and non-communicable disease are, in part, a result of men’s riskier lifestyles but are also underpinned by the social determinants of men’s health, the report says. In all Member States, men who live in poorer material and social conditions are likely to eat less healthily, take less exercise, be overweight/obese, consume more alcohol, be more likely to smoke, engage in substance misuse, and to engage in more risky sexual behaviours.  All of these have significant impacts on length and quality of life.

The report provides the first complete picture of the breadth of issues affecting men’s health. It shows clearly that right across Europe, men are more likely to die prematurely than women, and that men in lower socio-economic groups have significantly poorer health than those in higher groups. This applies to every country within the EU27.

References

1 White A, de Sousa B, de Visser R, et al.  The state of men’s health in Europe: extended report. European Union 2011.  (Available at: http://ec.europa.eu/health/population_groups/docs/men_health_extended_en.pdf)

After the enrollment of 3,236 patients, the study was stopped for safety reasons. The first coprimary outcome occurred in 43 patients receiving dronedarone

and 19 receiving placebo (p=0.002).  There were 21 deaths from cardiovascular causes in the dronedarone group and 10 in the placebo group, including death from arrhythmia in 13 patients and 4 patients, respectively.  The increase in the rate of death from cardiovascular causes was mostly due to a substantial increase in the rate of death associated with arrhythmia.

Stroke occurred in 23 patients in the dronedarone group and 10 in the placebo group, while hospitalisation for heart failure occurred in 43 patients in the dronedarone group and 24 in the placebo group.

Contrary to the authors’ hypothesis that dronedarone would reduce major vascular events in the patients, they found that it increased rates of heart failure, stroke, and death from cardiovascular causes in patients with permanent AF who were at risk for major vascular events. The authors recommend that “dronedarone should be avoided in patients with heart failure and other advanced cardiovascular disease, particularly when they also have permanent AF”.

To explain the trial’s results, they hypothesise that “for high-risk patients with permanent AF, direct and indirect toxic effects of dronedarone are not offset by the benefit of maintaining sinus rhythm, and any benefits that might occur from heart-rate slowing, blood-pressure reduction, antiadrenergic action, and suppression of ventricular arrhythmia were either small or nonexistent”.

References

1 Connolly SJ, Camm J, Halperin JL, et al.  Dronedarone in high-risk permanent atrial fibrillation. N Engl J Med 2011. doi:10.1056/nejmoa1109867.

The authors assert that “AECG monitoring is necessary when asymptomatic AF is suspected (as in patients presenting with cryptogenic stroke) or when an ECG diagnosis of unexplained arrhythmic symptoms is warranted”.

In addition, they say that “AECG plays an important role in patients with known AF to guide ventricular rate control and anticoagulation therapy, and assess the efficacy of antiarrhythmic drug therapy and/or ablation procedures”.  Finally, they outline areas of uncertainty and provide recommendations for use of available AECG monitors in clinical practice.

References

1 Mittal S, Movsowitz C, Steinberg JS. Ambulatory external electrocardiographic monitoring: focus on atrial fibrillation.  JACC 2011;58:1741–9. doi:10.1016/j.jacc.2011.07.026.

It does not focus on the therapeutic management of the various channelopathies and cardiomyopathies. Treatment/management issues are only discussed for those diseases (i.e., LQTS, HCM, DCM + CCD, RCM) in which the genetic test result could potentially influence treatment considerations.

The recommendations seek to define the criteria used to rank the strength of recommendation for genetic diseases.  The most obvious difference is that randomised and/or blinded studies do not exist. Instead, most of the available data are derived from registries that have followed patients and recorded outcome information.

The authors of this statement have therefore defined specific criteria for Class I, Class IIa or b, and Class III recommendations and have used the conventional language adopted by AHA/ACC/ESC Guidelines to express each class. All recommendations are level of evidence (LOE) C (i.e., based on experts’ opinions).

A Class I recommendation (“is recommended”) was applied for genetic testing in index cases with a sound clinical suspicion for the presence of a channelopathy or a cardiomyopathy when the positive predictive value of a genetic test is high, AND/OR when the genetic test result provides either diagnostic or prognostic information, or when the genetic test result influences therapeutic choices.

In all the remaining situations, the authors have used either “can be useful” to articulate either a Class IIa recommendation or “may be considered” to signify a Class IIb recommendation. A Class III (“should not” or “is not recommended”) recommendation was applied in cases in which it was agreed that the genetic test result failed to provide any additional benefit or could be harmful in the diagnostic evaluation of patients with possible inherited heart disease.

Screening of family members for the mutation identified in the proband of the family is recommended as a Class I when genetic testing leads to the adoption of therapy/protective measures/lifestyle adaptations. Conversely, the authors have assigned a Class IIa recommendation when results of genetic testing are not associated with the use of therapeutic or protective measures but the results may be useful for reproductive counseling or instances in which genetic testing is requested by the patient who wants to know his/her mutation status.

When using or considering the guidance from this document, it is important to remember that there are no absolutes governing many clinical situations. The final judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all relevant circumstances. Recommendations are based on consensus of the writing group following the Heart Rhythm Society’s established consensus process. It is recognised that consensus does not mean unanimous agreement among all writing group members. We identified those aspects of genetic testing for which a true consensus could be found.

Surveys of the entire writing group were used. The authors received an agreement that was equal to or greater than 84% on all recommendations; most recommendations received agreement of 94% or higher. This statement is directed to all healthcare professionals who are involved with genetic testing for the channelopathies and cardiomyopathies. All members of this document-writing group provided disclosure statements of all relationships that might present real or perceptible conflicts of interest. Disclosures for the members of the task force are published in the Appendix section.

References

1 Ackerman MJ, Priori SG, Willems S, et al. HRS/EHRA expert consensus statement on the state of genetic testing for the channelopathies and cardiomyopathies.  Developed as a partnership between the Heart Rhythm Society (HRS) and the European Heart Rhythm Association (EHRA). Europace 2011;13:1077-109. doi: 10.1093/europace/eur245.