Abstract
Dementia
A large population-based matched cohort study has provided further evidence of a wide range of risks of antipsychotic use in people with dementia. The article emphasises the need to put the reason for prescribing into context at individual patient level. The balance is complex in people whose carers are struggling to keep them at home or whose care home is saying their behaviour is too difficult for them to manage. Non-drug alternatives are often expensive and/or in short supply. Availability of support varies with geography and income. I wonder how you and your practice make decisions when asked for a sedative for someone who is agitated during the day or wanders at night?
An article on old age psychiatry in the BMJ suggests a variety of steps to take before prescribing sedation in people with dementia. The steps include excluding delirium and trying to consider whether or not the nocturnal activity is a problem.
Mom P, Carr M, Guthrie B, et al. (2024) Multiple adverse outcomes associated with antipsychotic use in people with dementia. BMJ 385(8246): 105–106. DOI: 10.1136/bmj-2023-076268.
Vedavanam K, Warner J and Zaidman S (2024) Ask the consultant: Old age psychiatry. BMJ 385 (8429): 244–246. DOI: 10.1136/bmj.q445.
Care givers
David Kane lives with his brother, who has autism and developmental delay. He describes the many stresses and some of the joys about living in a household where someone needs significant care. I wonder how your practice codes caregivers, and how many in the household receive that code. Finding out what your practice does for carers, and what else it could offer might make an interesting quality improvement project.
Kang D (2024) The ever looming shadow of caregiving. BMJ 385(8426): 115. DOI: 10.1136/bmj.q726.
Falls in care homes
A retrospective study of United States of America (mean age 77.9) residents in nursing homes has investigated the risk of fracture in people who are initiated on or have an addition to their antihypertensive treatment. There was a significant increase in falls and fractures in those receiving new antihypertensive medications. This supports personalised care decisions, taking risks and benefits into account for each patient.
Dave C, Li Y, Steinman M, et al. (2024) Antihypertensive medication and fracture risk in older Veterans Health Administration nursing home residents. Journal American Medical Association Internal Medicine 1;184(6): 661–669. DOI: 10.1001/jamainternmed.2024.0507.
Carbon footprint
Yewmaker has produced a carbon footprint formulary that allows you to look up per dose carbon ratings for large numbers of medicines. You have to register to log in, but access is free of charge.
Migraine
The Heads Up podcast has many episodes, both audio and in transcript form. All episodes centre on headaches with a large variety of focus, for example pregnancy, migraine in men, migraine at university and acupuncture.
www.nationalmigrainecentre.org.uk/understanding-migraine/heads-up-podcast
Death cafes
Death cafes sound morbid but have been set up as a group-led discussion about death in an ‘accessible, respectful and confidential space’. The meetings are held without an agenda and usually involve drinks and a cake. A ‘how to’ pack is included on the website, as well as a search for the nearest cafe.
Mental health
My student attachments for mental health were in large residential mental health institutes. Mental health care has changed dramatically since then.
The latest Kings Fund ‘360 degree’ review of mental health services gives an overview of services in the community and for inpatients, staffing, mental health prevalence and a discussion of inequalities in those likely to develop mental health problems as well as in the care that they receive.
Gilbert H and Mallory S (2024) Mental health 360. Available at: www.kingsfund.org.uk/insight-and-analysis/long-reads/mental-health-360 (accessed 4 June 2024).
Metagnosis
I learned a new word last week. I attended the launch of a new book about general practice that I described in this column in January (fighting for the soul of general practice- the algorithm will see you now) one of the speakers was Danielle Spencer, a leading academic in narrative medicine. I was struck by her use of the word metagnosis- being diagnosed in adulthood with a lifelong condition. This could be colourblindness, often undetected until adulthood, or a condition where diagnostic criteria change, such as autistic spectrum disorder. This made me reflect further about experiences with patients who leave the room after a 10-minute appointment with labels such as diabetes (plus three medications and changed insurance and employment options) or ‘chronic kidney disease’ which is often picked up by a patient seeing on the screen when sharing notes for other reasons. Genetic testing is likely to dramatically increase the number of ‘diagnoses’ that patients can acquire. A simple label can change our view of ourselves.
Spencer D (2020) Metagnosis: Revelatory Narratives of Health and Identity. Oxford: Oxford University Press.
Bumps
I have only just found the Bumps (best use of medicines in pregnancy) website. This draws together current evidence about the use of medicines in pregnant women. There is a searchable list of patient leaflets – search by medication name or category of illness.
Variation
We are often asked about wearable technology. A study on non-diabetics wearing continuous glucose monitoring devices showed wide intrapersonal variation in fasting glucose readings. Out of over 5000 people who would have been deemed to have normal fasting glucose on their first readings, 40% would have been deemed pre diabetic and 3% diabetic on subsequent readings.
Shilo S, Keshet A, Rossman H, et al. (2024) Continuous glucose monitoring and intrapersonal variability in fasting glucose. Nature Medicine 30 (5): 1424–1431. DOI: 10.1038/s41591-024-02908-9.
Breastfeeding and cancer
Drug trials usually leave out pregnant and breastfeeding women. I am still seeing people who continue to be distressed by the uncertainties that faced pregnant women during COVID.
Another group little highlighted are women who are diagnosed or treated for cancer during their pregnancies and breastfeeding period. Abi Rimmer has written a thought-provoking article about trying to breastfeed through her cancer diagnosis.
She used the Breastfeeding Network for advice and support. She highlights the difficulties she found in getting answers and would have liked to spend time with one of her professionals making a plan about her breastfeeding.
I found a range of useful resources produced by the Academy of Breastfeeding Medicine.
Patient voice
The BMJ recently celebrated 10 years of its patient and partnership strategy. You are most likely to see this when you spot the boxes labelled ‘How patients were involved in the creation of this article.’ The story is highlighted in a recent BMJ article and includes an infographic with suggestions for patient involvement that could apply to primary care as well as to other journals.
We have many opportunities in practice to involve patients for example via our patient participation groups, involving patients in presentations we give, asking about patient involvement at meetings that we attend.
Doble E, Walker S, Price A, et al. (2024) More medical journals must work in partnership with patients and the public. BMJ 386(8435): 25–27. DOI: 10.1136/bmj.q1463.
Lee Silverman
I think that people with Parkinson’s disease are often hidden in our practice populations. There are no specific targets in primary care related to people with Parkinson’s.
Lee Silverman voice treatment (LSVT LOUD) is an intensive therapy for people with voice problems. A large study has recently compared LSVT LOUD with standard NHS speech and language therapy and with no therapy. LSVT loud was more effective than standard or no treatment (although the authors do point out that generic NHS treatment is not clearly defined).
Sackley C, Rick C, Brady M, et al. (2024) Speech therapy for people with Parkinson’s disease. BMJ 386(8435): 17–19.
Multivitamins
Combined data from three large prospective trials on nearly 400,000 healthy adults taking daily multivitamin tablets, followed up for over 20 years, has not shown any improvement in mortality.
Loftfield E, O’Connell C, Abnet C, et al. (2024) Multivitamin use and mortality risk in 3 prospective US cohorts. JAMA Network Open 7(6): e2418729. DOI:10.1001/jamanetworkopen.2024.18729.
Rare diseases
We are unlikely to come across any specific rare disease during our consultations. However, one-in-seventeen people will be affected by a rare disease at some point in their lives, so we can expect to see rare diseases during our careers.
Medics4rarediseases have resources and links on their website. They have a general e-learning module (Rare disease 101) on their Moodle platform.
Substance use
Turning point has free learning modules on substance use and mental health for healthcare professionals (and also resources for people and families who are looking for support).
Janki Foundation
The Janki Foundation is a UK-based charity that focuses on human-centred ethics and practice. They have a resource pack for seven modules on values in healthcare aimed at small groups learning together using tools such as visualisation, listening and appreciation. They also offer day retreats (free for those who cannot afford a donation) for those working in health and social care.
Climate change
Many of our patients’ illnesses are related to the environment in which they live (for example, many patients on lower incomes live nearer to particulate-producing transport networks) As ‘trusted advisors’ we have an opportunity to raise awareness of climate change. A recent BMJ article gives some ‘touch points’ in screening encounters, long term condition management and other consultations.
Kotcher J, Patel L, Wheat S, et al. (2024) How to communicate about climate change with patients. BMJ 385(8428): 199–201. DOI: 10.1136/bmj-2024-079831.
Reasons to promote HPV vaccines
Several studies have shown reduction in cervical cancer rates since the introduction of the human papillomavirus vaccination programme in the UK. Further analysis of English data from 2006 to 2020 showed reduced incidence of cervical cancer and CIN3 (cervical intraepithelial neoplasia) across all levels of deprivation. Although the incidence of disease is still higher in women in the most deprived areas, the downward gradient from high to low deprivation in the non-vaccinated cohort was no longer observed in those offered the vaccine. I think this data reinforces the need for our efforts to reach out to groups that have lower vaccine take up.
Falcaro M, Soldan K and Ndlela B (2024) Effect of the HPV vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia by socioeconomic deprivation in England. BMJ, 385(8429): 227–228. DOI: 10.1136/bmj-2023-077341.
AmBoree T, Paguio J and Sonawane K (2024) HPV vaccine: The key to eliminating cervical cancer inequities. BMJ 385(8429); 229. DOI: 10.1136/bmj.q996.
Social determinants of health
The BMJ Commission on the Future of the NHS has made a series of recommendations that it believes will reverse widening health equalities, including building an NHs workforce environment that supports action on the social determinants of health, prioritises a good start in life for children and young people and form a cross-party task force on public health. Michael Marmot is one of the authors.
Hiam L, Klaber B, Sowemino A, et al. (2024) NHS and society must act on social determinants of health. BMJ 385(8428): 193–196. DOI: 10.1136/bmj-2024-079389.
New treatment for uterine fibroids
In August a new drug – linzagolix – was approved by NICE for management of moderate-to-severe fibroids. Linzagoliz is a gonadotropin-releasing hormone (GnRH) antagonist which is thought to have a dual mode of action in both reducing bleeding from fibroids ad also reducing the size of the fibroids.
Domestic abuse in the NHS
‘Courage is contagious’: this was the beautiful title of an opinion piece in the BMJ by Seema Haider. Haider briefly mentions her own experiences of domestic abuse, and that ‘it was the acts of kindness and human connection that helped the most’. The piece is both thought-provoking and inspiring, highlighting the need to consider not only process and policies, but also the environments we work in, and the way we look after each other.
Haider S (2024) Courage is contagious: We need to talk about the domestic abuse experienced by female doctors in the NHS. BMJ 386: q1800. DOI: 10.1136/bmj.q1800.
Optimising use of PSA test
Using the prostate-specific antigen (PSA) test as a ‘screening’ investigation for asymptomatic men is an issue the majority of InnovAiT readers will have come across many times. It is certainly a conversation I have had more and more frequently over recent years, and admittedly more often than not end up doing the test. This article is well worth a read, with too much information to succinctly summarise, but key points for me were initiating discussions in men at higher risk of prostate cancer, for example black men aged 45 and over, with a family history of prostate cancer, or certain genetic risk factors.
Harding T, Martin R, Merriel S, et al. (2024) Optimising the use of the prostate-specific antigen blood test in asymptomatic men for early prostate cancer detection in primary care: Report from a UK clinical consensus. British Journal of General Practice 74 (745): e534–e543. DOI: 10.3399/BJGP.2023.0586.
Could hosting medical students doing audits help to combat burnout in primary care?
This was the title of a recent letter, which I hope may have sparked some enthusiasm and optimism to readers of the British Journal of General Practice. The authors describe that ‘four bright, keen medical students’ who undertook an audit in their practice ‘helped renew our enthusiasm’ and ‘may have reduced the risk of burnout’. I appreciate that N = 1, but being based at a medical school I frequently hear similar positive news stories related to out ScotGEM (Graduate Entry Medicine) programme, in which medical students undertake quality improvement projects in primary care from Year 1 as ‘Agents of Change’.
Oakeshott P, Warraich F, Anani L, et al. (2024) Could hosting medical students doing audits help to combat burnout in primary care? British Journal of General Practice 74(745): 347–348. DOI: 10.3399/bjgp24X738861.
Differentiating emotional distress and mental disorder
Mental health consultations are common in general practice and it can be a challenge sometimes to deal with the gray, those situations where there is uncertainty about whether there is an underlying diagnosis. This BJGP article explored the potential role of the ‘Four Dimensional Symptom Questionnaire’, seldom used in the UK, but seeks to help differentiate between emotional distress and mental disorder. The findings of this exploratory were positive, though more research is needed – I’ll be watching this space with interest.
Geraghty AWA, Holt S, Chew-Graham CA, et al. (2024) Distinguishing emotional distress from mental disorder in primary care: A qualitative exploration of the Four-Dimensional Symptom Questionnaire. British Journal of General Practice 74(744): e434–e441. DOI: https://doi.org/10.3399/BJGP.2023.0574
Fifty minutes to save the NHS
Living in Scotland, I try to ensure an annual visit to the Edinburgh Fringe. Last year I saw doctor and comedian Adam Kay, this year I found out unfortunately too late that Professor Claire Gerada and Dr Phil Hammond were at the festival with their show ‘Fifty Minutes to save the NHS’. I do hope some of our readers managed to make it! To find out more about their thoughts behind the show, follow the link below.
Just one thing
Over the summer, many readers will have been aware of the devastating news of the death of Dr Michael Mosely. Dr Mosely’s books and his podcast, ‘Just One Thing’ have helped millions of people to improve their lifestyle and their health, I for one can think of several changes I have made. His manner with others, his balanced approach, positivity and humour were all attributes I really warmed to when listening to him. If you haven’t tried the podcast, I would strongly recommend you do.
Walking and back pain
Don’t Stop Moving – catchy song title from the noughties, important message for those with low back pain! This Lancet article highlighted the importance of walking regularly in preventing patients from experiencing flares of their low back pain. This is in line with current recommendations, but I always find it helpful to be able to inform, and even show patients, the most up-to-date evidence that supports lifestyle advice in managing medical problems.
Denneny D and Walumbe J (2024) Physical activity to prevent recurrences of low back pain. The Lancet 404; 10448: 98–100. DOI: 10.1016/S0140-6736(24)01247-9.
Run talk run
I recently came across an Instagram post by Dr Callum Leese, a GP based in Aberfeldy who is a passionate advocate of promoting physical activity to improve health. His post was about the ‘Run, Talk, Run’ event he hosts –a weekly 5k run that is open to all, aiming to provide a space in which people feel they can talk, alongside some exercise. Well worth exploring whether you have a local group to recommend to patients, join yourself if interested, or even become a group leader! There is also a ‘Run, Walk, Run’ option.
Caring for dying patients in the community
Palliative care is an aspect of primary care which may seem daunting, particularly at first and for those trainees who may well not have had any experience in palliative care. A recent BMJ article provided some helpful points and strategies. I particularly appreciated Box 4 ‘example of how to explain dying’, adapted from Kathryn Mannix, whose book ‘Listen: How to find the Words for Tender Conversation’ is on my reading list ….
Holdsworth R, Rowley G and Farrington E. (2024) Caring for dying patients in the community. British Medical Journal 386: e071661. DOI: 10.1136/bmj-2022-071661.
Becoming a GP supervisor
Here is an interesting article for those readers who may have aspirations to be a GP supervisor/trainer (or indeed already are GP trainers!). This Australian study examined factors that appear to be important in supporting those in the role of GP supervisor. Some of the key messages were around building a relationship with the trainee, having a supportive practice, and making connections with other trainers. All are key issues to consider for those in such a role.
Garth B, Kirby C, Nestel D, et al. (2024) Becoming a general practice supervisor: A longitudinal multi-case study exploring key supportive factors. Clinical Teacher 21(4): e13738. DOI: 10.1111/tct.13738.
Monkeypox
Over the summer, urgent guidance was issued around the detection and management of Monkeypox, due to the outbreak of strain Clade I MPXV, declared as a global emergency by the World Health Organization. The risk to the UK at the time of writing is thought to be low. There are several review articles available; this one from the Journal of the Royal Society of Medicine is specific to primary care.
Rallapalli S, Razai MS, Majeed A, et al. (2022) Diagnosis and management of monkeypox in primary care. Journal of the Royal Society of Medicine 115(10): 384–389. DOI:10.1177/01410768221131914.
Teen sleep problems
A recent article in BMJ Paediatrics Open reviewed sleeping problems in adolescence, based around three clinical case scenarios. While some of the information is quite specialised, the article is really informative and provides some helpful strategies to discuss with patients and their families.
Delahoyde M, Tyack C, Kugarajah S, et al. (2024) Insomnia and other sleep disorders in adolescence. BMJ Paediatrics Open 8: e001229. DOI: 10.1136/bmjpo-2021-001229.
Patient decision aid for actinic keratosis
Patient decision aids (PDA) can be so helpful in consultations, and I read with interest about the development of a PDA for treatment of actinic keratosis by Brent et al. While the tool developed requires further investigation in a primary care setting, as a clinician I found reading the information in the decision aid helpful in being able to discuss the different treatment options with patient – I look forward to hopefully hearing more about the tool’s utility in a primary care setting.
Brent G, Beardmore C, Mayers K, et al. (2024) The development and validation of a decision aid to enhance shared decision-making for the management of actinic keratosis. Skin Health and Disease. 4(3): e388. DOI: 10.1002/ski2.388.
