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My first Saga Magazine (16 February 2012)

Dear Reader,

Be kind, because I have just received my first SAGA magazine! I know, it hardly seems possible. But here I am reading about McCarthy and Stone retirement homes and looking at adverts for those sort of trousers that do up just below the nipple and provide an amazing firework display of static when taken off briskly at night. It is all quite a culture shock, but still some interesting reading. Tucked between Dr Roche's useful page on coughing, clotting and post op concerns and a bumper sale of vitamins is an interesting "feature" supported by Pfizer as part of a disease awareness campaign.

The disease in question is Dupuytren's contracture. Jonathan Agnew fronts the piece and describes what life is like with this condition. Despite still having problems and having had seven operations (!) he ends the piece still keen that we should all go to our GP if we think we might have it. It is a frustrating condition and the feature is right to highlight the lack of cure. Bill Nighy is famous for not having touched his dupuytren's and the way priests bless their congregations is thought to be due to St Augustine's dupuytren's contractures.

Anyway, I digress..

Pfizers interest in this condition might have something to do with their recent licensing of Xiapex. This is a collagenase that is injected into the contracture to disrupt it and allow better extension of the finger. It is rather early to know if this will provide benefit but a quick look at you Tube makes you realise its not a simple procedure and certainly not something for GPs. The Drug and Therapeutics Bulletin rather sensibly suggests further research is necessary before it can by recommended. Certainly showing Mr Broadbent's You Tube video to a patient will put many off the idea I suspect.

James Cave

Screening (7 February 2012)
What could possibly be wrong with screening when it saves lives and prevents people having to have more serious operations or treatment? Some sections of society and some countries have been very enthusiastic about it, notably the USA. However, ever since reading Gerd Gigerenzer's book, Reckoning with Risk, I have always realised that life can be more complicated than it seems and this is highlighted this week in JAMA, where Drs Woolf and Harris give a really clear overview of the problems surrounding many of our current screening programmes
They remind us that even a really good test with a sensitivity of 90% and specificity of 96% will still be wrong 88% of the time if used to screen for a condition found in 0.6% of the population.

Recent studies on breast and prostate cancer are now clearly showing that it is possible to over-diagnose. That is, to pick up, and subject to treatment, cancers that would never have made a person ill. This raises the whole philosophy of western medicines approach to diagnosis and treatment.

Currently the USA is reviewing recommendations surrounding prostate cancer screening, and our Cancer Czar, Mike Richards, is undertaking a review of breast cancer screening that should be reporting back shortly.

Meanwhile the early results from the colorectal screening programme are looking good just showing its not the what you do in screening but the how.
James Cave




Putting things inside people's bodies is risky 30 January 2012

Its a bit of a directive-fest this week folks, sorry

The Telegraph caused a little flap on twitter and elswhere on Sunday after headlining that the MHRA is due to give out further information to doctors about metal on metal (MoM) hip implants. Apart from getting the Xray wrong (!) the article was largely correct. The problem lies in DePuy ASR and ASR XL models currently but all patients with MoM should be currently followed up by their orthopaedic consultant as per the MHRA's guidance that came out in 2010 eg annual check ups for the first 5 years. Whilst we wait for the next MHRA guidance, the BMJ produced a useful review of the problem just before Christmas; here are the headlines from it:

  • MoM promised low rate of dislocation, low wear, bone conservation and easier conversion to a total hip replacement later.
  • First 5 year results were good leading to major increase in use after 2005.
  • Now becoming apparent some develop adverse reactions to metal debri. Thought to be particularly cobalt-chrome alloy of some makes.
  • Average time to develop after operation is 17 months.
  • Typical symptoms can be pain, swelling and instability.
  • GPs role
    • to refer back to orthopaedic consultant if not already recalled.
    • Consider differential diagnoses
      • fracture
      • infection (Check FBC, ESR, CRP)
      • loosening or dislocation
      • another source of pain
  • Growing evidence some patients may suffer from circulating cobalt of chromium. (MHRA suggests further investigations warranted if levels >7ug/L).
  • Cobalt and Chromium ion blood tests normally only organised by orthopaedic teams as interpretation difficult. There is no indication to do them onpatientswho have had standard hip replacements. In discussion with your local orthopaedic department.

Meanwhile the CMO produced a 16 page letter yesterday about PIP silicon implants. We think it can be summarised as such:
  1. If you see a patient with breast symptoms that you would usually refer to the local Breast clinic urgently: do that.
  2. If you see a woman who has had a PIP implant and has worries about it, or has symptoms suggestive of rupture and you are confident they are not symptoms that might indicate breast disease, try and ref back to whoever put it in. Failing that ref to the NHS regional breast reconstructive clinic (e.g. plastics).
  3. Advise women that whilst the NHS will remove the implants (if warranted) they will not replace them, but it might be possible to pay the extra to get this done.
  4. GPs should not organise scanning to look for leakage etc as scans can be difficult to interpret; leave it to the specialists.
  5. Those who are happy to keep their PIP implants should be offered an annual review, (by GPs if NHS patients).

Hope that helps!

James Cave




Vitamin D Supplementation 26 January 2012

Vitamin D, Oh Vitamin D. If there is one subject that create more questions than answers its the thorny subject of vitamin D. The BBC has raised the profile further this week after a consultant paediatrician on the BBC breakfast couch said he was seeing a serious case of rickets each month.

Further surveys have raised the embarrassing factoid that most GPs don't know or are unclear what the current guidance is regarding vitamin D supplementation. Whilst it may be embarrassing it is entirely understandable. NICE has changed its mind about vitamin D supplementation several times over the past 5 yrs and experts still cannot agree what a normal level of vitamin D is.

As a result of all this, the Chief Medical Officer will be writing to us all, which will be welcome I am sure.

In the meantime we at GP Update have dusted down the SACN position statement on vitamin D from 2007 and will give you a quick résumé of vitamin D supplementation. The good news is that the Scientific Advisory Committee are reviewing Vitamin D again, the bad news is that they will not report back until June 2014.

We do not propose to cover osteomalacia or rickets treatment in this short piece, just detail those patients most at risk from Vitamin D deficiency and what supplementation should be advised. This is further laid out in a leaflet that can be downloaded from the DoH

So, in short, pregnant women, breast-feeding women, infants, those over 65yrs and adults with little sun exposure to their skin should all be advised to take vitamin D supplementation as detailed below.

Age
Recommended Vit D supplement in µg/day
0-6m
None if formulae fed or breast fed from a well vitamin D stocked mother, otherwise supplement with 7 µg/day from 1 month
7m-5yrs
7
5-65yrs normal sun exposure
-
>65yrs
10
Pregnancy
10
Lactation
10
Adults with poor sun exposure
10


  • 1µg is equivalent to 40IU of vitamin D
  • Standard multivitamins, whilst containing vitamin D are not advised in pregnant women due to their vitamin A content. Stand alone vitamin D supplements are now available and should be used. They cannot be prescribed.
  • Women and children participating in Healthy Start are entitled to free vitamin supplements. Their provision is the responsibility of the PCT.A safe upper limit for vitamin D has not been established but research in health volunteers set the guidance level at 25 µg/d.

James Cave




Polymyalgia and Myeloma 24 January 2012

The BMJ's easily missed series is always thought provoking and worth a look. This week they remind us how easy it is to miss myeloma. Over half of cases take six months to be picked up by GPs and in a third it will be over a year.
The classic presentation is bone pain and a normocytic, normachromic anaemia with a very raised ESR but normal CRP. Of course as we know only too well nothing is classic in general practice.

The article makes a classic specialist error however. "When myeloma is suspected in a patient the baseline investigations should include..." it says, yet for us to consider a disease that effects 1 in 25,000 adults over 40 is not how it works, for if it did we would need encyclopaedic memories and be doing all kinds of rare and needless tests on all kinds of patients. I am sure for the majority of us it is the slightly deranged results of tests that will lead us on to consider this condition: the slightly raised calcium, raised total protein, anaemia, renal impairment for example.

Likewise I also was left thinking the authors are wrong to suggest we should rule out myeloma in every patient we diagnose with polymyalgia rheumatica. Surely we can treat PMR with steroids and if patients fail to respond miraculously as they do, then consider organising a serum protein electrophoresis? What do you all think?

James Cave




CKD diagnosis: does it help? 17 January 2012

Many of you who have been coming to our courses over the last few years will know that we have a problem with chronic kidney disease. Whilst we understand the issues around late diagnosis of end-stage renal failure (how too many people are presenting to nephrologists too late) many of us are yet to be convinced that telling thousands of older people they have older kidneys, and then doing all sorts of medical things to them makes a great deal of difference. Our thoughts have been helped by a review in the Lancet. It is a really thorough appraisal of our current understanding of CKD and worth a read if you are into this. It reiterates throughout, the lack of good research using hard, rather than proxy end points.
It seems the most useful question you can still ask a nephrologist is still, "What is the NNT for CKD to prevent one end stage renal failure?" If you find one that can answer it please let us know!

Meanwhile Archives have published a nice little paper that shows that risk of end stage renal failure in patients with CKD only starts to take off in patients with systolics BP above 150mmHg. Perhaps, the rather unobtainable targets of <130/80 in diabetics and <140/90 in non diabetics will be reviewed in light of this. I hope so.

James Cave




Evidence into practice 11 January 2012

We spend a great deal of our time at GP Update squirrelling around find the evidence that will make a difference to your work as a GP, and as a consequence your patients. We take considerable pride in ensuring we check all the relevant journals and some of the less relevant ones too. Its about a 2" pile of evidence a month (CI=1.8-2.5)!
Yet what we learnt from the BMJ this week is that even 4 years after completion a third of studies publicly funded in the USA have not been published. Now this is after the FDA made it mandatory for trials to be published within 12 months. And its not that this is all some sort of cover up by Pharma to hide bad news. The BMJ also publishes research that shows that when unpublished data was incorporated into 41 meta-analyses on nine different drugs, in 19 studies the drug benefits were improved (in 19 it was lowered and in 3 it stayed the same).

Whilst this is really important stuff and we applaud the BMJ and Richard Lehman in particular for banging this drum, it still remains a major challenge to get the evidence that is published into everyday practice. Well that's where we come in!

James Cave




A New Years Resolution? How about 10 commandments? 1 January 2012

Richard Lehman is one of those rare beasts. He can mix it with the most academic of researchers, yet he remains grounded as a GP. His ability to take a research paper and work out what it really means for the patient he will see tomorrow morning is seemingly effortless. We know at GP Update that this is far from the case!

One of Richard's bugbears in research are surrogate end-points - where a reduction in something like HbA1c is taken to be a good thing for diabetics for example, before anybody has proven that it is.

The BMJ looked at this in a great article published on line over the holiday period. Richard says John Yudkin was going to include 10 commandments of therapeutics in his article but felt he couldn't because of sensitivities in the USA to the term.
Well, they look really useful to me, so here they are:

The New Therapeutics: Ten Commandments
  • Thou shalt treat according to level of risk rather than level of risk factor
  • Thou shalt exercise caution when adding drugs to existing polypharmacy
  • Thou shalt consider benefits of drugs as proven only by hard endpoint studies
  • Thou shalt not bow down to surrogate endpoints, for these are but graven images
  • Thou shalt not worship Treatment Targets, for these are but the creations of Committees
  • Thou shalt apply a pinch of salt to Relative Risk Reductions, regardless of P values, for the population of their provenance may bear little relationship to thy daily clientele
  • Thou shalt honour the Numbers Needed to Treat, for therein rest the clues to patient-relevant information and to treatment costs.
  • Thou shalt not see detailmen, nor covet an Educational Symposium in a luxury setting
  • Thou shalt share decisions on treatment options with the patient in the light of estimates of the individual's likely risks and benefits.
  • Honour the elderly patient, for although this is where the greatest levels of risk reside, so do the greatest hazards of many treatments.
Something to think on over the coming year.

With all the distractions we now face as GPs we at GP Update trust you keep your medicine safe and your patients safer.

Happy New Year.

James Cave




24,000 premature deaths from diabetes 21 December 2011

This was the startling figure being discussed in the media this week after the publication of this year's national diabetic audit run by the NHS Information Centre. This audit now covers over 2/3rd of all diabetics in the UK and provides some staggering data if that's your thing. Dr Rowan Hillson challenges us to manage diabetics better and asks why only about a half of type 2 and only a 1/3 of type 1 diabetics have had their 9 care processes carried out in the past year.

Oh yes you say, I know what the 9 care processes are! I didn't. And there lies the rub. Our diabetes template at work is now so large its hard to see the wood for the trees, and if I'm struggling it is no wonder our patients are too.

So my new year resolution is to do some culling and see if I can simplify and reduce all the boxes we tick down to the important 9.

What are they?

Measure these six: Weight, BP, HbA1c, Urine albumin-creatinine ratio, serum creatinine, cholesterol.

And check these three: eyes, feet and smoking habit.

Less is more.

Have a great Christmas.

James Cave




Knee Pain 13 December 2012
Knee pain is on the up according to a review in Annals of Internal Medicine this week. This looked at one of those enormous surveys undertaken by the Americans between 1971 and 2004. Independent of obesity and age knee pain is increasing, yet X-ray evidence of osteo-arthritis in knees is not. The authors suggest this might be related to our increasingly sedentary lives. This chimes with my own experience: middle aged people with knee pain yet normal knee X-rays seem to be a common conundrum for me. What to do?

Well I find the following hand-out from the Arthritis Research Campaign still really helpful even though it was originally written in 2005. What I love about it is the no holds barred approach Mike Hurley takes when it comes to his advice. In short, not to advise our patients about the importance of exercising and increasing level of activity amounts to professional negligence!

Where's the evidence you all cry! Well its, all there, in the handout. So, next time you are met with a knee pain with little to find on examination or X-ray, try Mike Hurley's handout.

James Cave




What are the four most dangerous classes of drugs you prescribe in the elderly? 29 November 2011
Warfarin, Yes I think we would all get that. Anti-platlet drugs? Yes they would be in my top four. But then what? You might be surprised to hear, in this special report in NEJM. that in the US the other two drugs were oral hypoglycaemics such as sulphonylureas and the insulin group.

These four drug groups were responsible for about 1% of all hospitalisations, in most cases through unintentional overdoses, and whilst the study looked at the over 65 year olds over half of the cases were in over 80 year olds. Digoxin and opioids also came in the top ten but quite a way behind.
Interesting reading, particularly warfarin given that NICE will be making a decision about dabigatran in the next few weeks.

James Cave



Domestic Violence 22 November 2011

A study in this week's Lancet should get us all thinking. The IRIS study showed that practices that were given some simple training and had prompts from their computer systems about abuse referred 21 times more women on to agencies than the control practices. These were urban practices in Bristol and Hackney and the average practice (of about 7000 patients) in this study picked up 25 disclosures of domestic violence in the year. Twenty five. How many has you practice picked up this year? I looked at ours and it was none.

Domestic violence damages health, the evidence is clear. This study simply got clinicians to have a low threshold for asking about domestic violence and their computers would prompt enquiry in patients with depression, anxiety, irritable bowel syndrome, pelvic pain and assault. Something to think about, something to act on?

James Cave
Economical with the truth 15 November 2011

Last year in our courses we included some useful papers on palliative care. These are still available online. They demonstrated that being able to communicate to dieing patients could improve patient mood scores and quality of life and even longevity. But for many of us, GP and patient alike, talking about death is difficult. I was really taken by Evan Davis' interview of Dr George, a palliative care consultant, on radio four. It is currently still available and is a brief 15 minutes of ethical clarity I would heartily recommend.
Concerns about prolonged Q-T interval in high doses of citalopram have been raised by the FDA. Time for a search of all our patients on 60mg or more perhaps. Interestingly evidence for using more than 40mg of citalopram is weak.

James Cave




Is your mobile phone killing you? 9 November 2011

Well, probably not if you are an adult. Unless you are reading this off your smart phone in the car, in which case you are 6 times more likely to have an accident than if you just put the thing down and concentrated on your driving.

A big nationwide cohort study from Denmark published in the BMJ has recently compared the risk of brain tumours in adults over 30 with a mobile phone subscription against those without. This study found that even those with the longest subscriptions had no higher risk of brain tumours that non-subscribers. For those that like the numbers the incidence rate was 1.03 (95% confidence limits of 0.83-1.27).

Some of you might be thinking, 'didn't I read somewhere that mobile phones might cause gliomas?' The INTERPHONE study did show a small increase in gliomas in a very select group of people who had over 1640 hours of mobile phone use.

James Cave

Prostate and Supplements 5 November 2011

Am I the only one who remembers the time when vitamin E was the answer to all ills? The vitamin that all nutritional intelligentsia were taking? The ATBC trial confirmed its power in preventing prostate cancer: a 35% reduction in incidence men taking 50mg/d. Not surprising then that a recent survey suggested that 50% of men in the USA over 60 years old have taken it at some time.

However like so many things in medicine the pendulum swings and the evidence now suggests that vitamin E might actually increase the risk of prostate cancer.

In 2009 the SELECT study reported on the impact of vitamin E and selenium on prostate cancer and found no benefit after 5 years, JAMA it has recently reported back again after a 7-12 year follow up. Now it looks like taking vitamin E at 400IU/day increased the risk by 17%. Selenium alone or selenium and vitamin E seemed to have no effect either way.

And before you think, never mind, there is always Saw Palmetto for prostate health, that's been found to be ineffective in helping with lower urinary tract symptoms in JAMA too. One of my partners thinks all nutritional supplements are rubbish..perhaps he's right!

My DEN this week: what's Roo's test?

James Cave


Does arcus senilis increase your risk of heart disease? 20 Oct 2011

Welcome to GP Update and our first blog! We know only too well as practicing GPs ourselves that yet another source of information can be yet another thing you feel must be read. We will therefore keep this brief, informative and helpful.

We are now almost through our autumn set of courses: Exeter, Cardiff and London completed last week. Feedback has been fantastic and it is great to hear so many GPs find the day helpful and encouraging. Our stand on avoiding pharmaceutical sponsorship is clearly important to the vast majority of you; though we did receive one comment from a GP you said he missed the pens! (Our GP update pen and marker not enough it seems). Dates for next year are now posted on the website. If you are anything like our practice we start to organise leave for next year now so why not include a day with us next year?

Does arcus senilis, or arcus cornea as it is now called, increase your risk of heart disease? This is a thorny question, that has now been answered by the Copenhagen City Heart Study published in the BMJ. A big cohort study of 12,745 people followed up for an average of 22 years says no.

James Cave