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Clinical round-up: August

Antibiotic cuts raise complications slightly

GP practices that prescribe fewer antibiotics for respiratory infections have only a slightly increased complication rate compared with other practices.

A new study from King’s College London revealed a slight increase in pneumonia and quinsy, but found no increase in complications for other serious infections.

The authors concluded that GPs can cut back substantially on the amount of antibiotics they prescribe for coughs and sore throats without fear of missing serious complications like meningitis.

The study featured data from more than 600 GP practices in the UK, and found that with each 10% lowering of antibiotic prescribing rates, there was a 13% relative increase in the rate of pneumonia and a 10% higher rate of quinsy.

That equates to around one extra case of pneumonia each year, and an extra case of quinsy every 10 years, for an average practice of 7,000 patients.

The team argued that the small increase in these cases would be offset by the advantages of reduced prescriptions, since both pneumonia and quinsy are treatable conditions.

Lead author Professor Martin Gulliford, professor of public health at King’s College London, said: ‘Our results suggest that, if antibiotics are not taken, this should carry no increased risk of more serious complications.’

BMJ 2016, online 4 Jul

Longer GP slots found to be ‘cost effective’

Offering 30-minute GP appointments to people with multiple health problems helps prevent their health from deteriorating and represents better value for money than many new drugs and devices that are provided on the NHS.

A study conducted at GP practices in Scotland saw GPs give patients with complex health needs appointments that lasted 30 minutes or longer.

Patients who received the longer consultations had better scores for wellbeing and quality of life after one year than similar patients who received usual care from their GP with 10-minute appointments.

Although the approach cost practices more, the benefit to patients meant the longer appointments were of greater value than many drugs and interventions introduced to the NHS under NICE cost- effectiveness thresholds.

The longer appointments cost £929 more per patient than standard GP services, but the cost of £12,224 per quality-adjusted life year was well within the £20,000 used by NICE to decide whether new interventions should be adopted by the NHS.

BMC Medicine 2016, online 22 Jun

200,000 ‘quit statins’ after media outcry

Many patients may have stopped taking statins because of the widespread media coverage of controversy over the drugs’ risks and benefits.

UK researchers have estimated that an extra 200,000 patients stopped statin therapy in the six months after a period of intense media coverage on the topic, which coincided with NICE plans to widen statin use for primary prevention in low-risk people.

Using data from UK GP practice records covering the period January 2011 to March 2015, they found a 19% relative increase in the proportion of people stopping statins for primary prevention – up from a rate of 0.08 to 0.09 per month – in the six months from April to October 2014, following a period of intense media reporting of statin controversies. Discontinuation rates went back to normal after the six-month investigation period.

They claimed this could lead to around 2,000 more heart attacks and strokes within 10 years than would have been expected if the usual discontinuation rates had been maintained.

Co-author Professor Liam Smeeth, part-time GP and professor of epidemiology at the London School of Hygiene and Tropical Medicine, said the study raised concerns that reporting of the debate on statins ‘may have given disproportionate weight to a minority view about possible side-effects, denting public confidence in the drug [sic].’

BMJ 2016, online 28 Jun

Preschools demand ‘needless’ antibiotics

Nursery schools are putting GPs under pressure to prescribe antibiotics to infants with conjunctivitis when they are not needed, according to a new study.

The study found nine out of 10 nursery schools have policies to exclude children with acute conjunctivitis, of which half specified a requirement for antibiotics.

More than two out of five GPs and nurse prescribers said they were influenced by these policies when it came to prescribing topical antibiotics.

Dr Cliodna McNulty, head of the Public Health England primary care unit, said: ‘We would encourage GPs, nurses and pharmacists to do a thorough clinical assessment of the need for antibiotics before advising them. They should try not to be influenced by local nursery policies.’

BJGP 2016, online 6 Jul

CBT alternative ‘could reduce referral times’

An alternative to cognitive behavioural therapy for treating depression in adults could reduce referral waiting times, according to new research.

Behavioural activation has been found to be as effective as CBT and more cost effective, costing £975 per participant, compared with £1,235 for CBT.

The therapy encourages patients to focus on meaningful activities driven by their own personal values.

The trial involved 440 adults with depression at three centres in England. They were randomly assigned to receive either a maximum of 20 sessions of behavioural activation from junior mental health workers or CBT from experienced therapists. No differences were found between groups at six, 12 and 18 months’ follow-up, with both experiencing a 50% reduction in depressive symptoms.

Professor David Richards, lead author and professor of mental health services research at the University of Exeter, said ‘Our findings challenge the dominance of CBT as the leading evidence-based psychological therapy for depression.’

Lancet 2016, online 22 Jul

CPD tip of the  month: Distinguishing migraine from cluster headache

Migraine can occur in bouts, or clusters, but there is a clear difference between such episodes and cluster headache, which is much shorter but more severe. Asking the patient what they do during an attack is a good pointer to the diagnosis. Patients with a migraine will lie quietly whereas cluster headache sufferers will be agitated and pace around restlessly.

Other differences include:

  • Pain location: migraine pain can be anywhere; cluster headache is usually periorbital.
  • Autonomic features: these are usually present in cluster headache, around the eye on the side of the pain. They are rare in migraine.