Abstract
Website of the month
The Royal Marsden Hospital in London specialises in cancer diagnosis and treatment. It has been running a GP Education series since 2009, which includes face-to-face education days and an oncology update email newsletter. The hospital also provides free access to webcasts and presentations on many forms of cancer. If you are struggling for new ways to gain CPD (continuing professional development) time and want to update yourself on cancer diagnosis and management, this resource might be worth a look.
www.royalmarsden.nhs.uk/healthcare-professionals/gp-education-series
Inter-arm blood pressure differences
In a UK-based cohort study over 10 years, inter-arm BP difference was associated with increased cardiovascular mortality in people without cardiovascular disease. This reinforces advice to measure blood pressure in both arms at the initial diagnosis of hypertension. If you wanted a simple quality improvement activity, looking at your practice’s data on this might be interesting.
Clark, C., Taylor, R., Butcher, I., Stewart, M., Price, J., Fowkes, F., … , Campbell, J. (2016). Inter-arm blood pressure difference and mortality: A cohort study in an asymptomatic primary care population at elevated cardiovascular risk. British Journal of General Practice, 66(646), 241–242
Diarrhoea in children
A trial in Toronto compared giving children with mild diarrhoea and vomiting either electrolyte replacement or dilute apple juice. The children preferred the apple juice, and there was no difference in outcomes between the two groups.
Freedman, S., Willan, A., Boutis, K., & Schuh, S. (2016). Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: A randomized clinical trial. Journal of the American Medical Association, 315(18), 1966–1974
Poverty
Family physicians in Ontario are using a clinical tool on poverty that prompts them to ask patient whether they have difficulties making ends meet, encourages them to consider diseases associated with poverty, such as cardiovascular disease and diabetes, and provides guidance on interventions they can make, for example steering towards help with debt management or housing problems
Parry, J. A. (2016). Prescription for poverty. BMJ, 353(8063), 515
Sulfonylureas and hypoglycaemia
A recent research paper published in the BMJ reports that users of sulfonylureas are at a significantly higher risk of hypoglycaemia compare with users of metformin, particularly if the patient’s estimated glomerular filtration rate is less than 30 millilitres/minute/1.73 metres2. The authors suggest caution should be taken when starting this group of drugs in patients who have poor renal function.
Van Dalem, J., Brouwers, M., Stehouwer, C., Krings, A., Leufkens, H., Driesse, J., … , Burden, A. (2016). Risk of hypoglycaemia in users of sulphonylureas compared with metformin in relation to renal function and sulphonylurea metabolite group: Population based cohort study. BMJ, 354. doi: 10.1136/bmj.i3625
Financial incentives for screening
The National Institute for Health and Care Excellence (NICE) has launched a new pilot study in 30 practices to examine the effectiveness of incentivised screening for atrial fibrillation (AF) in those patients at higher risk of stroke. This is despite opposition from groups, including the RCGP’s group on over- diagnosis, who argue that NICE has gone against advice from the National Screening Committee, which in 2014 rejected proposals to screen for AF in over 65 s. The committee plans to review this decision in 2017.
GP training and academia
A team from Imperial has published an interesting article discussing the relationship between GP training and academic primary care. They provide examples of how their own department has worked to provide creative and novel opportunities for trainees and suggest that creating opportunities may allow individuals to design individual, ‘intellectually challenging’ and exciting career paths. Importantly they highlight that if trainers and trainees were more engaged with academic primary care, academia might seem less of an ’ivory tower’. As a trainee, newly qualified GP or trainer, are you aware of links with your local academic primary care department, or whether opportunities to develop an interest in academia could be developed?
One-hour activity
A recent study in the Lancet of over a million individuals demonstrated that the increased risk of death associated with sitting for more than 8 hours was offset by physical activity for 1 hour or more, spread throughout the day (brisk walking and cycling are given as examples of physical activity). The RCGP has responded and suggested that increased activity and exercise levels should continue to be promoted and encouraged. The message to patients is that daily activity is an important part of health, but need not be a chore or high impact, for example including a brisk walk at lunchtime would help to increase activity levels.
The Lancet physical activity series provides articles and viewpoints around how we can try to improve individual and population health. www.thelancet.com/series/physical-activity
Over diagnosis of heart failure
A recently published review of patients with a diagnosis of heart failure in 30 GP practices found that over a third may not have had the condition. After expert review, 17% of the cohort were found not to have heart failure when echocardiography was reviewed, and in 19.2% the diagnosis was uncertain. Considering the burden and costs associated with heart failure medication, the associated risks and monitoring required, it is important to try to reach an accurate diagnosis in all patients. The authors suggest that echocardiography should be more widely available, and that ideally management be initiated by a cardiologist in a heart failure outpatient clinic before transfer of care to primary care once the patient is stable. Practices may wish to consider their own heart failure diagnoses and review their local access to echocardiography.
Valk, M., Mosterd, A., Brockhuizen, B., Zuithoff, N., Landman, M., Hoes, A., & Rutten, F. (2016). Overdiagnosis of heart failure in primary care: A cross-sectional study. British Journal of General Practice. Epub ahead of print 12 September 2016. DOI: 10.3399/bjgp16X685705
InnovAiT 10-minute scenarios
Delivered in partnership with doctors.net.uk, this new RCGP resource highlights difficult areas of practice that GPs struggle with, enabling you to discuss complex clinical, managerial and ethical scenarios with fellow GPs via a secure, online forum. Based on the 10-minute scenarios featured within InnovAiT, the scenarios are released monthly and cover a wide variety of real-life situations. Summaries of previous discussions are also available to view and download. Join the discussion today! (Free to RCGP members and AiTs.)
Raising concerns
The GMC has produced a tool to help you decide what to do if you have a concern about patient safety. It reminds you of sources of help and the importance of keeping records.
Raising and acting on concerns about patient safety. (2016). GMC. www.gmc-uk.org/guidance/ethical_guidance/decision_tool.asp?dm_i=OUY,4EK4Q,7SM344,G75LV,1
Dementia guide
Health Education England Thames Valley has produced a free e-book; a dementia guide for carers and care providers. The book is divided into six sections, including medical detail and practical advice and reference resources, written with the help of a group of people with first-hand experience.
European exchanges
The RCGP is offering 38 funded places for UK AiTs and First5®s within 1 year of Certificate of Completion of Training (CCT) through the European Commission’s Erasmus + grant to undertake a 2-week long placement observing general practice in one of 10 European countries. Exchanges can take place between 1 September 2016 and 31 March 2018. Countries offered include Croatia, France, Germany, Greece, Italy, the Netherlands, Portugal, Romania, Spain and Turkey.
For more information email:
More information on Hippokrates exchanges can be found at http://vdgm.woncaeurope.org/content/about-hippokrates