Laurence Leaver

Long-term effects of lithium on renal, thyroid, and parathyroid function: a retrospective analysis of laboratory data.

BACKGROUND Lithium is a widely used and highly effective treatment for mood disorders, but causes poorly characterised adverse effects in kidney and endocrine systems. We aimed to analyse laboratory information system data to determine the incidence of renal, thyroid, and parathyroid dysfunction associated with lithium use. METHODS In a retrospective analysis of laboratory data from Oxford University Hospitals National Health Service Trust (Oxfordshire, UK), we investigated the incidence of renal, thyroid, and parathyroid dysfunction in patients (aged ≥18 years) who had at least two creatinine, thyrotropin, calcium, glycated haemoglobin, or lithium measurements between Oct 1, 1982, and March 31, 2014, compared with controls who had not had lithium measurements taken. We used survival analysis and Cox regression to estimate the hazard ratio (HR) for each event with lithium use, age, sex, and diabetes as covariates. FINDINGS Adjusting for age, sex, and diabetes, presence of lithium in serum was associated with an increased risk of stage three chronic kidney disease (HR 1·93, 95% CI 1·76-2·12; p<0·0001), hypothyroidism (2·31, 2·05-2·60; p<0·0001), and raised total serum calcium concentration (1·43, 1·21-1·69; p<0·0001), but not with hyperthyroidism (1·22, 0·96-1·55; p=0·1010) or raised adjusted calcium concentration (1·08, 0·88-1·34; p=0·4602). Women were at greater risk of development of renal and thyroid disorders than were men, with younger women at higher risk than older women. The adverse effects occurred early in treatment (HR <1 for length of treatment with lithium). Higher than median lithium concentrations were associated with increased risk of all adverse outcomes. INTERPRETATION Lithium treatment is associated with a decline in renal function, hypothyroidism, and hypercalcaemia. Women younger than 60 years and people with lithium concentrations higher than median are at greatest risk. Because lithium remains a treatment of choice for bipolar disorder, patients need baseline measures of renal, thyroid, and parathyroid function and regular long-term monitoring. FUNDING None.

Morality and Markets in the NHS

Since its establishment in 1948, the history of the National Health Service (NHS) has been characterized by organisational turbulence and system reform. At the same time, progress in science, medicine and technology throughout the western world have revolutionized the delivery of healthcare. The NHS has become a much loved, if much critiqued, national treasure. It is against this backdrop that the role of this state-funded health service has been brought into moral question. Certainly, the challenges facing healthcare policy-makers are numerous and complex, but in the wake of the Health and Social Care Act (2012), no issue is more divisive than that of market-based reform. Here we explore the turbulent history of the NHS, from its foundation to the birth of the healthcare marketplace. We explore arguments for and against the healthcare market and resolve that, amid an evolving economic and moral framework, the NHS must ensure that its original tenets of equity and autonomy remain at its core. We propose a values-explicit, systems-based approach to renew focus on both the processes and the outcomes of care.

Situational judgement tests: the role of coaching.

who hold that it isfeasible to construct situationaljudgement tests (SJTs) that are notsusceptible to coaching. With theintroduction of SJTs into UKFoundation Programme (UKFP)selection, candidates and commer-cial organisations are likely to seekways to improve scores. This issueof coaching is likely to be contro-versial in this high-stakes selectionprocess.Questions in SJTs relate to profes-sional behaviour that is under-pinned by values encapsulated inguidelines such as the GeneralMedical Council’s ‘Good MedicalPractice’.

Liberating the NHS or trapping doctors?: The effects of NHS reform on today and tomorrow

The coalition government recently revealed the ambitious task of ‘liberating the NHS’, a goal identified as the widest reforming change that the NHS has seen since its inception in 1948.1 The White Paper2 champions ideological aims to empower doctors while placing patients at the centre of their own management decisions, adopting the maxim ‘no decision about me, without me’.2 While such proposals have been optimistically publicised, on the surface heralding empowerment for both doctors and patients and rightly so, they nevertheless raise a pertinent question: is the motive to actually empower doctors or is it simply a shift of responsibility? At a time when there is financial pressure to cut costs of public services, many might cynically think that this is a way of government conveniently devolving the responsibility for ‘cuts’ which are soon to come; however, Mr Lansley did suggest some of the proposals in the White Paper before the global economic downturn. For GPs especially, the reform entails an increasingly managerial role in addition to their clinical duties. ‘GP consortiums’ will eventually control up to 80% of the NHS budget by 2013 when local primary care trusts (PCTs) are set to be abolished.2,3 The final outcome is intended to be a GP-led, bottom-up system, providing GPs with greater independence arguably improving their ability to provide patient care and optimise use of resources within their assigned communities. Of course, it may be challenging to commission services on unfavourable terms, and whether GPs will better understand the limits of what can be provided is still unanswered. Consortiums that work well to meet targets will be rewarded with lucrative incentives whereas struggling ones are unlikely to be bailed out, nevertheless special measures …

Cancer cases diagnosed as emergencies may be fewer than reported

The news item highlighting survival after elective surgery for colorectal cancer reiterates dismay at the “stubbornly high proportion of patients who present as an emergency” (21% of cancers diagnosed between 1 April 2011 and 31 March 2012).1 2 Using data on cancers diagnosed during 2006-08,3 the current “Be Clear on Lung Cancer” campaign emphasises that “39% of lung cancer …

Containing escalating referrals by bringing optometrists into the NHS

We agree with Clarke that current screening for intraocular pressure (IOP) would fail the Wilson criteria owing to high false positive rates for pneumatic tonometry as much as cost effectiveness.1 In Oxfordshire (2013), 141/182 patients (77%) with raised IOP on pneumatic testing were normal when re-checked by applanation tonometry, and similar data are available from elsewhere.2 3 Before the 2009 National …

Overseas-trained refugee doctors

Editor – I read with interest the paper by Hosking and Albert. This presents an interesting view, and illustrates precisely why the report of the 1993 review group on specialist medical training referred to research being important. Some of the figures given are interesting. For example, only 8% of the sample had had any formal training on how to write papers. The number of publications from all respondents was in fact considerable, and the number of bottom drawer papers much less than might have been expected. It would be interesting to check the control group, which was not done in this publication, of those in academic practice to see how many bottom drawer papers they had. I suspect that it might be of a similar order. The reasons for change are also of interest. In only 10 cases was the paper rejected, much lower than might be suspected from those who regularly submit papers to journals. The alternative conclusion therefore is that there is a significant need for people to develop research interests, to be able to understand the evidence base and how to set out papers for publication. The evidence from this report suggests that this need is still there.

Morality Not Markets: A Manifesto for the NHS; Response to Pollock, Frith, and Cox

We would like to thank Pollock (1), Frith (2) and Cox (3) for their interesting analyses and suggestions on our article “Morality and markets in the NHS.” A number of important themes arise: the lack of either practicality or morality of a healthcare market or privatisation; the need for values to be supported (where possible) by legislation; and the crucial importance of humanity and compassion in healthcare.