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Top five clinical papers from 2016

Difficult patients ‘increase risk of GP misdiagnosis’

Patients who display ‘difficult’ behaviour during consultations increase the risk of misdiagnosis.

Doctors were shown to be 42% more likely to misdiagnose a ‘difficult’ patient – one displaying distressing or disruptive behaviours – than a ‘neutral’ patient.

The authors, from the Institute of Medical Education Research in Rotterdam, said the impaired decision making was a result of GPs devoting excessive mental resources to these patients.

GPs in their last year of training were asked to evaluate six vignettes. The cases consisted of three diagnostically simple presentations, and three complex presentations. The behaviours displayed were a mix of ‘neutral’ and ‘difficult’.

The GPC said that the study showed the need to work on reducing stress for GPs. Prescribing spokesperson Dr Andrew Green said: ‘One of the hardest skills GPs need to learn is the ability to put aside our personal feelings about patients and provide them all with the same level of service. This is not an easy thing to do, and we don’t always succeed, but it remains at the heart of our professionalism.’

BMJ Qual Saf 2016; online Mar 2016

E-cigarettes ‘help thousands to quit’

E-cigarettes may have helped around 18,000 people quit smoking in 2015, according to research from University College London.

Data from more than 170,000 smokers aged 16 and over and taking part in the Smoking Toolkit study were analysed to look at the relationship between changes in e-cigarette use and the prevalence and success of quit attempts.

E-cigarette use among people trying to quit was found to be negatively associated with nicotine replacement therapy on prescription.

The research came shortly after Public Health England backed the use of licensed e-cigarettes to help people quit as an alternative to other NRT.

But Cancer Research UK said that while the findings were welcome, prescription medications and stop-smoking support services were the most effective way to quit smoking.

The charity’s director of prevention Alison Cox said: ‘It’s important to remember that getting support from stop smoking services is still the most effective way to quit.’

BMJ 2016, online Sep 2016

Social prescribing ‘does not cut workload’

Referring patients for social activities such as gardening or cooking did not cut subsequent GP consultations or improve patients’ health outcomes, an evaluation of a pilot scheme at east London practices has found.

Patients referred to social prescribing programmes involving gardening or cooking continued to consult their GP more than eight times a year on average, twice as often as controls. They also used more prescription medication than controls both before and after referral.

The study looked at a social prescribing scheme at practices in NHS City and Hackney CCG, where GPs and other practice staff direct referrals to a ‘link worker’ based in the practice, who then puts together a care plan with the patient and refers them on to one or more local services that offer programmes for activities such as gardening or cooking.

Lead author Dr Sally Hull, a GP and reader in primary care development at Queen Mary University London, told Pulse ‘there was no demonstrable impact on GP consultation rates’ and that ‘we were not able to show a change in outcomes such as levels of depression, anxiety or confidence in self-management’.

However, Dr Hull said a randomised controlled trial would ideally be needed to test the approach properly.

SAPC 2016, abstract 1D.4

Bilateral BP differences ‘identify risk’

GPs should routinely measure blood pressure in both arms as it could identify those at high risk of cardiovascular disease.

A team from the UK found a difference of 5mmHg or more between left and right arms was associated with an increase in risk of cardiovascular disease and all-cause mortality of 91% and 44% respectively over 10 years, compared with patients who had no inter-arm difference.

For patients with an existing diagnosis of hypertension, differences of 5mmHg and 10mmHg increased the risk of death from all causes by 67% and 63%, respectively.

The participants in the trial all had an ankle brachial pressure index of ≤0.95, but no pre-existing vascular disease.

Dr Chris Clark, lead author and a GP in Exeter, said: ‘Current guidelines state that blood pressure should be measured in both arms when assessing patients for hypertension, but often this advice is not followed due to time constraints or lack of awareness among clinicians.

‘Suitable lifestyle advice, can be targeted at individuals identified in this way.’

BJGP 2016, online April 2016

High-dose vitamin D ‘harms older patients’

Prescribing vitamin D supplements at high doses offers no benefit for older patients and could increase risk of falls in these patients.

Patients over 70 prescribed 60,000IU vitamin D3, or 24,000IU vitamin D3 combined with 300µg calcifediol, a more potent form of the vitamin – did not experience any improvements in lower extremity function after 12 months, compared with patients on a lower dose of 24,000IU vitamin D.

There were also higher rates of falls in the high-dose groups – two-thirds of whom fell, compared with less than half of those on the lower dose.

Dr Tony Brzezicki, GP and clinical chair at NHS Croydon CCG, told Pulse it was unlikely that many elderly patients would be on this high a dose of vitamin D, but that ‘it should not be difficult to identify these patients from GP systems’.

JAMA Int Med 2016, online Jan 2016

CPD Tip of the month

Milk allergy in children with GORD

You should consider milk allergy in children with previously suspected GORD if infants have not responded to treatment, and:

  • It is not a physiological feeding variation
  • You are sure there has been 100% compliance with past treatments for the suspected GORD
  • You have a reliable history from the parent

A family history of allergic disease is suggestive, but be aware that presence doesn’t confirm allergy, nor does absence exclude it.

If milk allergy is confirmed, do not use soya-based feeds in children under one year of age.

Management of GORD in children





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