Abstract
Welcome
Welcome to our new Junior Editor Nazia Hussain, whose name you should recognise from her work as Guest Editor last year. Nazia works as a locum in South Wales and will be contributing regularly to this column during 2013.
Website of the month
March is Ovarian Cancer Awareness month. The National Cancer Intelligence Network has revealed that mortality rates from ovarian cancer have fallen by over 20% between 2002 and 2010. We should be aware of likely symptoms of ovarian cancer to aid early diagnosis and improve outcomes. The website has a page especially aimed at GPs, with links to a free online module and NICE guidance.
Integrated care pilots
I am probably not the only GP currently feeling overwhelmed by the targets that we now have to meet. Although I think that some targets have raised the lowest common denominator, I feel that some just encourage a tick-box mentality. I do, however, believe that anything that improves communication between the various teams involved in the care of patients with chronic diseases will probably be helpful. A pilot of integrated care services for patients with diabetes and those over 75 has showed a reduction in non-elective medical admissions. Clinicians and managers involved in the pilot have been very honest about describing some of the obstacles: distrust between specialties and between clinicians and management and financial problems. Positive features of the discussion include involvement of patients and descriptions of increasing trust between the members as they got to know one another, allowing changes in long-established ways of working.
At our surgery we have a group of elderly patients who take up a great deal of our time and are seen by a variety of hospital teams. If sharing our experiences with other practices and specialties gives us ideas about how to improve the care of these patients, then I think the extension of the pilot may prove worthwhile.
Vize R. (2012). Integrated care. A story of hard won success. British Medical Journal 344: 24–25. doi: 10.1136/bmj.e3529
Gut feeling about sick children
It was at least five years after completing my GP training that I stopped regularly worrying about whether I would deal with the problems brought in to my surgery that day. Although I still worry about missing serious and rare illness, I am much happier about coping with diagnostic uncertainty. I am reasonably confident I can usually spot the difference between sick and well patients. Over the years I have sometimes admitted patients by saying to the secondary care doctor, ‘I am not quite sure what is wrong, but I know this patient is seriously unwell.’
A recent primary care study showed that a ‘gut feeling’ about something wrong in children substantially increased the risk of serious illness. Specific worrying features were the overall response of the child and parental concern that the illness was different from previous experience. I will go on giving my usual advice of ‘always listen to the parent and always listen to your gut feelings’. Your learning will be improved if you follow up such cases when you see them.
Van de Bruel A, Thompson M, Buninx F & Mant M. (2012). Clinicians’ gut feeling about serious infections in children: observational study. British Medical Journal 345: e6144. doi: 10.1136/bmj.e6144
Supporting drugs and alcohol users
The Royal College of General Practitioners and the Royal College of Psychiatrists have produced a list of competencies for doctors supporting drug and alcohol users. They stress that generalists should be able to diagnose substance use disorders, identify safeguarding issues, provide the person and their family with advice to support and motivate them, prescribe medication in uncomplicated cases and refer on to specialist services as appropriate. Although most generalists will not lead drug and alcohol services, we are expected to participate in governance activities, e.g. audit of uptake of vaccination for blood-borne viruses.
RCGP (2012). Delivering quality care for drug and alcohol users: the roles and competencies of doctors. Retrieved from www.rcpsych.ac.uk/files/pdfversion/CR173.pdf
TARGETing antibiotic prescriptions
Compounded by concerns over growing antibiotic resistance, the question of whether to give antibiotics for common presentations like sore throats and cough is a daily battle for GPs. The Royal College of General Practitioners has launched a toolkit (Treat Antibiotics Responsibly, Guidance and Education Tool) containing new guidance for GPs and their patients on the appropriate prescription of antibiotics. Included are clinical guidance, patient leaflets and audit templates.
RCGP TARGET antibiotics toolkit retrieved from www.rcgp.org.uk/TARGETantibiotics
New rotavirus vaccination
`From September 2013, a new vaccination programme will be introduced against rotavirus. The Department of Health reports rotavirus accounts for around 140 000 diarrhoea cases a year in under-fives, resulting in nearly one in ten needing hospital admission in the UK. Countries already using rotavirus vaccines, such the USA, have shown that rotavirus-related hospital admissions have been reduced by more than two-thirds.
Infants aged less than 4 months will be offered GlaxoSmithKline’s Rotarix vaccine. The vaccine can be incorporated into the childhood vaccination scheme, being administered as two oral doses at two and three months old.
You could look into how your practice informs patients about the new vaccine and what implications it has for practice systems and staffing.
Department of Health (2012). New Vaccine to Help Protect Babies from Rotavirus. Retrieved from www.dh.gov.uk/health/2012/11/rotavirus/
Antihypertensives and risk of hip fracture
We are all aware of the increased risk of falls with antihypertensive initiation, especially in the elderly. However, a Canadian study of around 300 000 patients has found that initiating an antihypertensive in elderly patients is associated with a 43% increased risk of hip fracture during the first 45 days of treatment. The results were statistically significant for angiotensin-converting enzyme inhibitors and beta-blockers only. The study highlights the importance of the correct diagnosis of hypertension, being vigilant for orthostatic hypotension and discussing side effects of drug treatments with patients.
Butt D, Mamdani M, Austin P, Tu K, Gomes T & Glazier R. (2012). The risk of hip fracture after initiating antihypertensive drugs in the elderly. Archives of Internal Medicine 172: 1–6. doi: 10.1001/2013.jamainternmed.469
To fast or not to fast?
Personally, I often ask patients to return for fasting cholesterol tests for cardiovascular risk assessment. However, this is often inconvenient for patients and increases pressure on morning appointments. Until recently fasting has been recommended, but the advice is now questioned. A Canadian study of over just over 200 000 patients has concluded that fasting for routine lipid levels is largely unnecessary. Mean cholesterol levels varied by less than 2% for total cholesterol and high-density lipoproteins, less than 10% for low-density lipoproteins and less than 20% for triglycerides.
So for routine cardiovascular risk assessments based on total cholesterol and high-density lipoprotein levels, fasting may be unnecessary.
Sidhu D & Naugler C. (2012). Fasting time and lipid levels in a community-based population. Archives of Internal Medicine 172: 1–4. doi: 10.1001/archinternmed.2012.3708
Drug alert
In October 2012, the Medicines and Healthcare Products Regulatory Agency (MHRA) announced that due to the increased risk of myopathy, the maximum recommended dose of simvastatin co-administered with amlodipine or diltiazem is now 20 mg per day. Consider researching how your practice implements drug alerts.
MHRA (2012). Simvastatin: evidence supporting recent advice on dose limitations with concomitant amlodipine or diltiazem Retrieved from www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON199561
Treating prostate cancer
I find helping men decide whether or not to have prostate screening quite difficult. Sharing the uncertainty of the relevance of a moderately raised prostate specific antigen test and the options of watchful waiting through to radical prostatectomy is complex and time consuming. I am aware that I am at the non-interventionist spectrum of medicine so that I have to be careful not to bias my advice. The results of the PIVOT trial (Prostate Cancer Intervention Versus Observation Trial) help the discussion about the treatment of low risk prostate cancer; suggesting that there is no significant benefit from surgery in men with low risk disease.
Wilt T, Brawer M, Jones K, Barry M, Aronson W, Fox S … Wheeler T. (2012). Radical prostatectomy versus observation for localised prostate cancer. New England Journal of Medicine 367: 203–213. doi: 10.1056/NEJMoa1113162
Expert patients
Patients with rare diseases usually know far more about their illnesses than we do. I am usually totally upfront about my ignorance and pleased when they are able to share knowledge of their condition. Mr Peter Park who has Gitelman syndrome has written some reflections on what it is like to be at the receiving end of doctors’ responses on meeting him. He describes the ‘quadripartite’ relationship between him, his consultant, his GP and his pharmacist. I liked his suggestion that GPs can be ‘guided’ into a ‘fully supportive role’.
Park P & Karet Frankel FE. (2012). A patient’s journey: Gitelman syndrome. British Medical Journal 345: 46–47. doi: 10.1136/bmj.e3590
Mild hypertension
A recent Cochrane review has found no benefit in the treatment of stage 1 (mild) hypertension: systolic blood pressure of 140–159 mm or diastolic of 90–99 mm Hg or both. This reinforces the drive to lifestyle changes and perhaps means that we should spend more time on learning motivational interviewing techniques. If you are not sure how to give lifestyle and dietary advice in a way that may encourage patients to change you could try sitting in with one of your practice nurses. You will find that practising this helps both with treating patients and sitting clinical examinations.
Cochrane (2012). Benefits of antihypertensive drugs for mild hypertension are unclear. Retrieved from: http://summaries.cochrane.org/CD006742/benefits-of-antihypertensive-drugs-for-mild-hypertension-are-unclear