Claire Burton

The association of anxiety and depression with future dementia diagnosis: a case-control study in primary care

Background. Depression is identified as a risk factor for dementia. Little research has been carried out on the importance of anxiety, despite strong evidence of co-morbidity with depression. Objective. To examine the association of anxiety and depression with future dementia diagnosis. Methods. This case-control study was set in the Consultations in Primary Care Archive. Cases (n = 400), were patients aged >65 years old. About 1353 controls were matched to cases by gender, practice, age group and year of case diagnosis. Read codes of risk factors for dementia were searched in patient records. The associations of prior consultations for anxiety and depression, with future diagnosis of dementia were determined using multivariable logistic regression. Results. A past anxiety diagnosis was associated with a future dementia diagnosis [odds ratio 2.76 (95% confidence interval 2.11–3.62)]. The association of depression with dementia was attenuated by the high prevalence of anxiety within those who have depression. Including an interaction of depression and anxiety showed that having only depression was associated with future dementia diagnosis but a diagnosis of depression alongside anxiety did not increase the likelihood of a dementia diagnosis compared to having just an anxiety diagnosis. Conclusion. Prior diagnosis of anxiety was strongly associated with dementia diagnosis after adjustment for other risk factors. The independent effect of depression was weaker compared to anxiety. Given the higher prevalence of anxiety primary care physicians should consider anxiety as well as depression as premorbid risk factors of dementia to improve early recognition and facilitate greater access to services.

Clinical Course and Prognostic Factors in Conservatively Managed Carpal Tunnel Syndrome: A Systematic Review

OBJECTIVEnTo summarize the available evidence regarding the course of symptoms and prognostic factors in patients with diagnosed carpal tunnel syndrome (CTS) who are treated conservatively.nnnDATA SOURCESnComputerized databases, reference checking, and experts in the field were used to identify studies for inclusion in the review.nnnSTUDY SELECTIONnMultiple reviewers were used to identify studies which included adults (aged ≥18y) diagnosed with CTS in either a clinical setting or population setting. The study must have observed the course of CTS over at least a 6-week period in patients receiving no treatment or usual care that included conservative (nonsurgical) treatments. The design was of a longitudinal cohort study with either prospective or retrospective data collection. There were no language restrictions, and none of the research identified was only reported in abstract form.nnnDATA EXTRACTIONnMethodological bias was assessed using the Quality in Prognosis Studies tool. A high risk of bias (predominantly relating to study attrition, confounding, and/or statistical analysis and reporting) was judged to be present in 8 studies. Designs showed wide variability with respect to characteristics of the included population, definition of CTS, assessment of prognostic factors, types of interventions provided, and types of outcome measures applied. This prevented pooled estimates from being produced.nnnDATA SYNTHESISnA negative outcome at 3 years follow-up of conservatively treated participants ranged from 23% to 89%. Four included studies observed the rate of surgical intervention after initial conservative management and found this to be 57% to 66%. Evidence regarding factors predicting the negative outcome of no treatment or conservative treatment was graded, taking into account the number of studies evaluating the factor, the methodological quality of these studies, and the consistency of the available evidence. There was 100% agreement in at least 3 cohorts with a medium or high risk of bias that symptom duration, a positive Phalens test, and thenar wasting were associated with a negative outcome of conservative management; however, not all results were statistically significant, and hence the overall judgment remained inconclusive.nnnCONCLUSIONSnResults of this review should be treated with caution because of the heterogeneity of studies and the risks of bias identified. However, the course of CTS appears variable, and poor prognosis may be predicted by a longer symptom duration, a positive Phalens test, and thenar wasting.

Diagnosing and managing carpal tunnel syndrome in primary care

#### Clinical QuestionnnHow can carpal tunnel syndrome be diagnosed and managed in a primary care setting?nnCarpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve at the level of the wrist; characterised by hand pain, numbness, and tingling in the distribution of the median nerve (thumb, index, middle finger, and the radial side of the ring finger) and a reduction in grip strength and hand function. The severity of symptoms can be clinically categorised into mild, moderate, and severe. A figure of 55–65% of CTS cases present bilaterally1 and the condition can be associated with conditions such as hypothyroidism, diabetes, and rheumatoid arthritis. CTS may present in late pregnancy but is usually transient.nnA study from the UK General Practice Research Database in 2000, calculated the incidence in males to be 88 per 100 000 and in females to be 193 per 100 000, with new presentations being most frequent at ages 45–54 years in females and 75–84 years in males.2 CTS is a recognised work-related musculoskeletal disorder (WMSD) caused by strain and repeated movements (biomechanical overload) and is hence more common in manual workers. Work absence and associated healthcare costs contribute to a significant socioeconomic burden on the UK economy.3nnConsultations …

NICE on rehabilitation. New guidelines on rehabilitation likely to restrict practices and stifle innovation.

We are pleased that the National Institute for Health and Care Excellence thought it important to develop guidelines for the management of patients with stroke.1 We are also reassured by the position taken by the Guideline Development Group (GDG)—that the evidence pointed to intervention improving function and mobility, but that there was little evidence to support one type of intervention over another.2nnHowever, despite the GDG’s intentions to facilitate innovations in practice,3 there is a serious risk that …

The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial

Summary Background To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome. Methods We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452. Findings Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference −0·32; 95% CI −0·48 to −0·16; p=0·0001). No adverse events were reported. Interpretation A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care. Funding Arthritis Research UK.

The clinical and cost effectiveness of steroid injection compared with night splints for carpal tunnel syndrome: the INSTINCTS randomised clinical trial study protocol

BackgroundPatients diagnosed with idiopathic mild to moderate carpal tunnel syndrome (CTS) are usually managed in primary care and commonly treated with night splints and/or corticosteroid injection. The comparative effectiveness of these interventions has not been reliably established nor investigated in the medium and long term. The primary objective of this trial is to investigate whether corticosteroid injection is effective in reducing symptoms and improving hand function in mild to moderate CTS over 6xa0weeks when compared with night splints. Secondary objectives are to determine specified comparative clinical outcomes and cost effectiveness of corticosteroid injection over 6 and 24xa0months.Method/DesignA multicentre, randomised, parallel group, clinical pragmatic trial will recruit 240 adults aged ≥18xa0years with mild to moderate CTS from GP Practices and Primary-Secondary Care Musculoskeletal Interface Clinics. Diagnosis will be by standardised clinical assessment. Participants will be randomised on an equal basis to receive either one injection of 20xa0mg Depo-Medrone or a night splint to be worn for 6xa0weeks. The primary outcome is the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6xa0weeks. Secondary outcomes are the BCTQ symptom severity and function status subscales, symptom intensity, interrupted sleep, adherence to splinting, perceived benefit and satisfaction with treatment, work absence and reduction in work performance, EQ-5D-5L, referral to surgery and health utilisation costs. Participants will be assessed at baseline and followed up at 6xa0weeks, 6, 12 and 24xa0months. The primary analysis will use an intention to treat (ITT) approach and multiple imputation for missing data. The sample size was calculated to detect a 15xa0% greater improvement in the BTCQ overall score in the injection group compared to night-splinting at approximately 90xa0% power, 5xa0% two-tailed significance and allows for 15xa0% loss to follow-up.DiscussionThe trial makes an important contribution to the evidence base available to support effective conservative management of CTS in primary care. No previous trials have directly compared these treatments for CTS in primary care populations, reported on clinical effectiveness at more than 6xa0months nor compared cost effectiveness of the interventions.Trial registrationTrial registration: EudraCT 2013-001435-48 (registered 05/06/2013), ClinicalTrials.gov NCT02038452 (registered 16/1/2014), and Current Controlled Trials ISRCTN09392969 (retrospectively registered 01/05/2014).

Addison’s disease: identification and management in primary care

Addison’s disease (AD), also known as primary adrenal insufficiency, is a deficiency of glucocorticosteroids and mineral corticosteroids.1 This can result in an insidious, protracted presentation. Therefore, unsurprisingly, the diagnosis is often delayed2 and 60% of patients have seen two or more clinicians before the diagnosis is considered.3 Around one-half of patients with AD are diagnosed after an acute adrenal crisis,4 which can be rapidly fatal.5 Although tuberculosis is the most common cause of AD worldwide,1 in the developed world, autoimmune disease is the predominant cause.3 In the latter context, AD is often linked to other autoimmune diseases, such as, vitiligo.6nnAddison’s disease is estimated to affect 1 in 10 000 people in the UK,5 and throughout Europe.7 The female:male ratio is 1.8 and adults of all ages are affected.6 Incidence from Norwegian data is 0.44 per 100 000 population per year and there is some evidence of clustering within families.6 Annually, in the UK, 1–2 consultations per 10 000 people are undertaken for adrenal gland disorders, compared to between 80–125 per 10 000 for acquired hypothyroidism.8nnAt the authors’ practice of 11 000 patients, seven are registered …

Predicting surgical intervention in patients presenting with carpal tunnel syndrome in primary care

Purpose Carpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve. This study investigated the value of candidate prognostic factors (PFs) in predicting carpal tunnel release surgery. Patients and methods This is a retrospective cohort study set in the Clinical Practice Research Datalink. Patients ≥18 years presenting with an incident episode of CTS were identified between 1989 and 2013. Candidate PF’s defined in coded electronic patient records were identified following literature review and consultation with clinicians. Time to first carpal tunnel release surgery was the primary end point. A manual backward stepwise selection procedure was used to obtain an optimal prediction model, which included all the significant PFs. Results In total, 91,412 patients were included in the cohort. The following PFs were included in an optimal model (C-statistic: 0.588 [95% CI 0.584–0.592]) for predicting surgical intervention: geographical region; deprivation status; age hazard ratio (HR 1.02 per year, 95% CI 1.01–1.02); obesity (HR 1.23, 95% CI 1.19–1.27); alcohol drinker (HR 1.05, 95% CI 1.00–1.10); smoker (HR 1.06, 95% 1.03–1.10); inflammatory condition (HR 1.13, 95% CI 0.98–1.29); neck condition (HR 1.13, 95% CI 1.03–1.23); and multisite pain (HR 1.10, 95% CI 1.05–1.15). Although not included in the multivariable model, pregnancy (if gender female) within 1 year of the index consultation, reduced the risk of surgery (HR 0.24, 95% CI 0.21–0.28). Conclusion This study shows that patients who are older and who have comorbidities including other pain conditions are more likely to have surgery, whereas patients presenting with CTS during or within a year of pregnancy are less likely to have surgery. This information can help to inform clinicians and patients about the likely outcome of treatment and to be aware of which patients may be less responsive to primary care interventions.

Trends in the prevalence, incidence and surgical management of carpal tunnel syndrome between 1993 and 2013: an observational analysis of UK primary care records

Objectives To describe the prevalence, incidence and surgical management of carpal tunnel syndrome (CTS), between 1993 and 2013, as recorded in the Clinical Practice Research Datalink (CPRD). Design We completed a series of cross-sectional epidemiological analyses to observe trends over time. Setting Primary care data collected between 1993 and 2013, stored in the CPRD. Population Individuals aged ≥18 years were selected. Prevalent and incident episodes of CTS and episodes of surgical intervention were identified using a list of preidentified Read codes. Analysis We defined incident episodes as those with no preceding diagnostic code for CTS in the past 2 years of data. Episodes of surgery were expressed as a percentage of the prevalent population during the same calendar year. Joinpoint regression was used to determine significant changes in the underlying trend. Results The prevalence of CTS increased over the study period, with a particular incline between 2000 and 2004 (annual percentage change 7.81). The female-to-male prevalence ratio reduced over time from 2.74 in 1993 to 1.93 in 2013. The median age of females and males with CTS were noted to increase from 49 and 53 years, respectively in 1993 to 54 and 59 years, respectively in 2013. Incidence was also noted to increase over time. After an initial increase between 1993 and 2007, the percentage of prevalent patients with a coded surgical episode began to decrease after 2007 to 27.41% in 2013 (annual percentage change −1.7). Conclusion This study has demonstrated that the prevalence and incidence of CTS increased over the study period between 1993 and 2013. Rates of surgery for CTS also increased over the study period; however after 2007, the per cent of patients receiving surgery showed a statistically significant decline back to the rate seen in 2004.

A painful tingling hand

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.nn#### What you need to knownnA 48 year old woman presents with pain and tingling in the thumb, index, and middle finger of her left hand. Her symptoms are worse at night and wake her from sleep. Shaking her hands relieves the discomfort.nnPain, numbness, and tingling in the hands are common, with a population prevalence of 14.4%.1 The most common entrapment neuropathy and most likely diagnosis is carpal tunnel syndrome.2 The incidence of carpal tunnel syndrome is 192.8 per 100u2009000 in women and 87.8 per 100u2009000 in men.3nnConsider the patient’s symptoms anatomically. Figure 1⇓ shows the sensory innervation of the hand.nnnnFig 1 xa0Sensory innervation of the handnn©Keele University 2013nn### Causes of pain and numbness in the handnn#### Median nerve compressionnnCompression of the median nerve in the carpal tunnel gives rise to sensory dysfunction. Patients might describe numbness, tingling, pain, or aching of the thumb, index, middle finger, and radial half of the ring finger. Aching often extends to the elbow. Motor deficit includes weakness in flexion of the index and middle finger and weakness in thumb abduction and opposition.4 5 Carpal tunnel syndrome affects women more than men at a ratio of …