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Clinical round-up: February

Rotavirus vaccine ‘cuts gastroenteritis’

The number of GP visits for acute gastroenteritis has fallen since the introduction of the infant rotavirus vaccine.

A Public Health England report estimates that 64,457 fewer cases were seen in GP settings among under-fives in 2013/14 than would have been the case without the vaccine.

An estimated 87,000 visits for young children were averted across all NHS settings in 2013/14, saving £12.5m in total.

Infant visits for gastroenteritis showed the largest decrease, dropping by 15% overall in GP practices, and by 41% in months of normally high rotavirus circulation.

Although there was less evidence of a decrease in older children and adults, rates of acute gastroenteritis were reduced by 12-16% in high season.

Lead author Dr Sara Thomas, associate professor in epidemiology at the London School of Hygiene and Tropical Medicine, said: ‘We found the expected seasonal peak of acute gastroenteritis in the months when rates historically have been high completely disappeared. The fact that GP visits in other age groups fell provides evidence that unvaccinated older individuals are also benefitting from the vaccine being introduced.’

Vaccine 2016, online 20 Dec

Diabetes screening ‘too inaccurate’

Leading GP academics have warned that the National Diabetes Prevention Programme in England is unlikely to have ‘a substantial impact’ because the blood glucose tests used to identify people at risk are too inaccurate.

The group said that the ‘screen and treat’ approach being taken under the programme means large numbers of people will be treated unnecessarily, with many others at risk being missed.

The scheme – currently being rolled out in England – requires GPs to screen millions of people for their diabetes risk so at-risk patients can undergo lifestyle change programmes to reduce their likelihood of developing diabetes.

Patients with an HbA1c of 42-47mmol or fasting plasma glucose of 5.5-6.9mmol/l should be referred to the lifestyle change programmes.

But the researchers, led by Professor Trisha Greenhalgh, professor of primary care health sciences at the Nuffield Department of Primary Care, University of Oxford, said their analysis of 49 studies of the screening tests showed low accuracy for picking up pre-diabetes. They claimed fasting glucose was specific but not sensitive, with HbA1c neither sensitive nor specific.

They added: ‘As screening is inaccurate, many people will receive an incorrect diagnosis and be referred on and others will be falsely reassured.’ They suggested supplementing the programme with ‘population-based approaches’.

BMJ 2017, online 5 Jan

Flu vaccine in children ‘protects older people’

Vaccinating children against flu protects low-risk older people as effectively as vaccinating everyone over 65, according to a new report.

The study found vaccinating children early in the flu season could reduce low-risk cases of flu in older people through herd immunity as much as vaccination of older people themselves, if uptake in this group is slower.

The researchers modelled 14 years of surveillance data, from 1995-2009, estimating infections levels with and without the childhood programme, varying levels of coverage and speed of vaccine uptake. They discovered that after the rollout of the child programme, vaccination for the low-risk older cohort would only be borderline cost effective.

But the results supported vaccinating people of all ages at high risk of complications. Dr Katherine Atkins, co-author and assistant professor of infectious disease modelling at the London School of Hygiene and Tropical Medicine, said: ‘Flu programmes are expensive as all eligible people must have the vaccine every year. Developing the most cost-effective strategy is therefore vital.’

Lancet Public Health 2017, online 10 Jan

Pedometers ‘boost activity’ in over-45s

Pedometer usage can boost activity levels in over-45s, even if patients are not directly supported by a GP or a nurse.

A new study has found a pedometer-based walking intervention in inactive 45- to 75-year-olds increased levels of moderately vigorous physical activity by around a third.

A total of 1,023 inactive patients from seven London GP practices were randomised either to usual physical activity or to one of the two intervention groups.

Both intervention groups received a pedometer, a physical activity diary and instructions for a 12-week walking programme to add in 3,000 steps or a three-minute walk on five or more days weekly. But one group received the materials by post, the other through practice nurse consultations.

Lead author Dr Tess Harris, GP and reader in primary care at St George’s University of London, said: ‘Both intervention groups significantly increased their walking from baseline to 12 months compared with controls, with similar effect sizes for nurse and postal groups.’

PLOS Medicine 2017, online 3 Jan

‘Review diagnosis in asthma patients’

Asthma patients may warrant a review of their diagnosis if it was not initially confirmed by an objective test.

Researchers in Canada found that, from a random sample of 613 patients with physician-diagnosed asthma, 33% had a diagnosis of current asthma ruled out. After following the same patients for a further 12 months, 29% were still able to have the diagnosis excluded.

They discovered participants in whom a current diagnosis was ruled out were less likely to have undergone objective testing in the community at diagnosis.

All participants were assessed with objective testing – including spirometry and home peak flow monitoring – and those using daily medications for asthma were weaned off over four sessions.

Lead author Professor Shawn Aaron, senior scientist and respirologist at the University of Ottawa, said: ’It’s impossible to say how many were misdiagnosed, and how many have asthma that is no longer active. We do know they were all able to stop taking medication they didn’t need.’

JAMA 2017, online 17 Jan

CPD Tip of the Month

Distinguishing the cause of syncope

If you have diagnosed a patient as having a syncopal attack, there are certain features to look out for that can help you determine its cause:

  • If the attack occurs during exercise, happens without warning and is associated with chest pain, shortness of breath or palpitations, then a cardiac cause is likely.
  • An attack after exertion, related to a particular activity or occurring in the presence of prodrome, suggests a neurally mediated cause.
  • If excessive use of the upper arm precipitates the syncope, then the attack could have a cerebrovascular cause resulting from occlusive disease of the subclavian or innominate artery.

Syncope (2 CPD hours)