Helen F Ashdown

Identification of children at risk of influenza-related complications in primary and ambulatory care: a systematic review and meta-analysis

BACKGROUND Interventions to prevent influenza-related complications are recommended for individuals at the greatest risk of serious clinical deterioration. However, guidelines are based on consensus opinion rather than evidence, and do not specify risk factors in children. We aimed to provide an evidence-based definition of children who are most at risk of such complications. METHODS In this systematic review, we searched the Medline and Medline In Process, Embase, Science Citation Index, and CINAHL databases for studies published between inception and April 3, 2013. We included studies that reported data for underlying disorders and complications in children presenting in primary or ambulatory care with influenza or influenza-like illness. We requested unpublished data from investigators of studies that had obtained, but not published, relevant data. We analysed data with univariable meta-analysis and individual patient data multivariable meta-analysis methods. The primary outcome was admission to hospital as a proxy for complications of influenza or influenza-like illness. FINDINGS We included 28 articles that reported data from 27 studies (14 086 children). Strong risk factors for hospital admission were neurological disorders (univariable odds ratio [OR] 4· 62, 95% CI 2·82-7·55), prematurity (4·33, 2·47-7·58), sickle cell disease (3·46, 1·63-7·37), immunosuppression (2·39, 1·24-4·61), diabetes (2·34, 1·20-4·58), and age younger than 2 years (2·51, 1·71-3·69). However, reactive airways disease including asthma (1·36, 0·82-2·26) and obesity (0·99, 0·61-1·62) were not found to be risk factors. On the basis of individual patient data multivariable analysis (1612 children, four studies), the risk of hospital admission was higher in children with more than one risk factor than in children with just one risk factor, when age younger than 2 years was included as a risk factor (92 [74%] of 124 vs 428 [52%] of 817; difference 22%, 95% CI 13-30%, p<0·0001). INTERPRETATION We identified prematurity as a new strong risk factor for influenza-related complications in children. Our findings also support the inclusion of neurological disorders, sickle cell disease, immunosuppression, diabetes, and age younger than 2 years as risk factors in existing guidelines. Interventions to prevent influenza-related complications should be prioritised in these groups, but should also be considered for other children, especially those with more than one risk factor or severe underlying comorbidities. FUNDING UK National Institute for Health Research.

Pain over speed bumps in diagnosis of acute appendicitis: Diagnostic accuracy study

Objective To assess the diagnostic accuracy of pain on travelling over speed bumps for the diagnosis of acute appendicitis. Design Prospective questionnaire based diagnostic accuracy study. Setting Secondary care surgical assessment unit at a district general hospital in the UK. Participants 101 patients aged 17-76 years referred to the on-call surgical team for assessment of possible appendicitis. Main outcome measures Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios for pain over speed bumps in diagnosing appendicitis, with histological diagnosis of appendicitis as the reference standard. Results The analysis included 64 participants who had travelled over speed bumps on their journey to hospital. Of these, 34 had a confirmed histological diagnosis of appendicitis, 33 of whom reported increased pain over speed bumps. The sensitivity was 97% (95% confidence interval 85% to 100%), and the specificity was 30% (15% to 49%). The positive predictive value was 61% (47% to 74%), and the negative predictive value was 90% (56% to 100%). The likelihood ratios were 1.4 (1.1 to 1.8) for a positive test result and 0.1 (0.0 to 0.7) for a negative result. Speed bumps had a better sensitivity and negative likelihood ratio than did other clinical features assessed, including migration of pain and rebound tenderness. Conclusions Presence of pain while travelling over speed bumps was associated with an increased likelihood of acute appendicitis. As a diagnostic variable, it compared favourably with other features commonly used in clinical assessment. Asking about speed bumps may contribute to clinical assessment and could be useful in telephone assessment of patients.

GP views on strategies to cope with increasing workload: a qualitative interview study

BACKGROUND The existence of a crisis in primary care in the UK is in little doubt. GP morale and job satisfaction are low, and workload is increasing. In this challenging context, finding ways for GPs to manage that workload is imperative. AIM To explore what existing or potential strategies are described by GPs for dealing with their workload, and their views on the relative merits of each. DESIGN AND SETTING Semi-structured, qualitative interviews with GPs working within NHS England. METHOD All GPs working within NHS England were eligible. Of those who responded to advertisements, a maximum-variation sample was selected and interviewed until data saturation was reached. Data were analysed thematically. RESULTS Responses were received from 171 GPs, and, from these, 34 were included in the study. Four main themes emerged for workload management: patient-level, GP-level, practice-level, and systems-level strategies. A need for patients to take greater responsibility for self-management was clear, but many felt that GPs should not be responsible for this education. Increased delegation of tasks was felt to be key to managing workload, with innovative use of allied healthcare professionals and extended roles for non-clinical staff suggested. Telephone triage was a commonly used tool for managing workload, although not all participants found this helpful. CONCLUSION This in-depth qualitative study demonstrates an encouraging resilience among GPs. They are proactively trying to manage workload, often using innovative local strategies. GPs do not feel that they can do this alone, however, and called repeatedly for increased recruitment and more investment in primary care.

Diagnostic accuracy study of three alcohol breathalysers marketed for sale to the public

Objectives To assess the diagnostic accuracy of three personal breathalyser devices available for sale to the public marketed to test safety to drive after drinking alcohol. Design Prospective comparative diagnostic accuracy study comparing two single-use breathalysers and one digital multiuse breathalyser (index tests) to a police breathalyser (reference test). Setting Establishments licensed to serve alcohol in a UK city. Participants Of 222 participants recruited, 208 were included in the main analysis. Participants were eligible if they were 18 years old or over, had consumed alcohol and were not intending to drive within the following 6 h. Outcome measures Sensitivity and specificity of the breathalysers for the detection of being at or over the UK legal driving limit (35 µg/100 mL breath alcohol concentration). Results 18% of participants (38/208) were at or over the UK driving limit according to the police breathalyser. The digital multiuse breathalyser had a sensitivity of 89.5% (95% CI 75.9% to 95.8%) and a specificity of 64.1% (95% CI 56.6% to 71.0%). The single-use breathalysers had a sensitivity of 94.7% (95% CI 75.4% to 99.1%) and 26.3% (95% CI 11.8% to 48.8%), and a specificity of 50.6% (95% CI 40.4% to 60.7%) and 97.5% (95% CI 91.4% to 99.3%), respectively. Self-reported alcohol consumption threshold of 5 UK units or fewer had a higher sensitivity than all personal breathalysers. Conclusions One alcohol breathalyser had sensitivity of 26%, corresponding to false reassurance for approximately one person in four who is over the limit by the reference standard, at least on the evening of drinking alcohol. The other devices tested had 90% sensitivity or higher. All estimates were subject to uncertainty. There is no clearly defined minimum sensitivity for this safety-critical application. We conclude that current regulatory frameworks do not ensure high sensitivity for these devices marketed to consumers for a decision with potentially catastrophic consequences.

Prescribing antibiotics to 'at-risk' children with influenza-like illness in primary care: qualitative study.

Objectives National Institute for Health and Care Excellence guidelines recommend immediate antibiotic treatment of respiratory tract infections in ‘at-risk’ individuals with comorbidities. Observational evidence suggests that influenza particularly predisposes children to bacterial complications. This study investigates general practitioners’ (GPs’) accounts of factors influencing their decision-making about antibiotic prescribing in the management of at-risk children with influenza-like illness (ILI). Design Qualitative interview study using a maximum variation sample with thematic analysis through constant comparison. Setting Semistructured telephone interviews with UK GPs using a case vignette of a child with comorbidities presenting with ILI. Participants There were 41 GPs (41.5% men; 40 from England, 1 from Northern Ireland) with a range of characteristics including length of time in practice, paediatrics experience, practice setting and deprivation. Results There was considerable uncertainty and variation in the way GPs responded to the case and difference of opinion about how long-term comorbidities should affect their antibiotic prescribing pattern. Factors influencing their decision included the childs case history and clinical examination; the GPs view of the parents ability to self-manage; the GPs own confidence and experiences of managing sick children and assessment of individual versus abstract risk. GPs rarely mentioned potential influenza infection or asked about immunisation status. All said that they would want to see the child; views about delayed prescribing varied in relation to local health service provision including options for follow-up and paediatric services. Conclusions The study demonstrates diagnostic uncertainty and wide variation in GP decision-making about prescribing antibiotics to children with comorbidity. Future guidelines might encourage consideration of a specific diagnosis such as influenza, and risk assessment tools could be developed to allow clinicians to quantify the levels of risk associated with different types of comorbidity. However, the wide range of clinical and non-clinical factors involved in decision-making during these consultations should also be considered in future guidelines.

Clinical characteristics of pertussis-associated cough in adults and children: a diagnostic systematic review and meta-analysis

Background Pertussis (whooping cough) is a highly infective cause of cough that causes significant morbidity and mortality. Existing case definitions include paroxysmal cough, whooping, and posttussive vomiting, but diagnosis can be difficult. We determined the diagnostic accuracy of clinical characteristics of pertussis‐associated cough. Methods We systematically searched CINAHL, Embase, Medline, and SCI‐EXPANDED/CPCI‐S up to June 2016. Eligible studies compared clinical characteristics in those positive and negative for Bordetella pertussis infection, confirmed by laboratory investigations. Two authors independently completed screening, data extraction, and quality and bias assessments. For each characteristic, RevMan was used to produce descriptive forest plots. The bivariate meta‐analysis method was used to generate pooled estimates of sensitivity and specificity. Results Of 1,969 identified papers, 53 were included. Forty‐one clinical characteristics were assessed for diagnostic accuracy. In adult patients, paroxysmal cough and absence of fever have a high sensitivity (93.2% [CI, 83.2‐97.4] and 81.8% [CI, 72.2‐88.7], respectively) and low specificity (20.6% [CI, 14.7‐28.1] and 18.8% [CI, 8.1‐37.9]), whereas posttussive vomiting and whooping have low sensitivity (32.5% [CI, 24.5‐41.6] and 29.8% [CI, 8.0‐45.2]) and high specificity (77.7% [CI, 73.1‐81.7] and 79.5% [CI, 69.4‐86.9]). Posttussive vomiting in children is moderately sensitive (60.0% [CI, 40.3‐77.0]) and specific (66.0% [CI, 52.5‐77.3]). Conclusions In adult patients, the presence of whooping or posttussive vomiting should rule in a possible diagnosis of pertussis, whereas the lack of a paroxysmal cough or the presence of fever should rule it out. In children, posttussive vomiting is much less helpful as a clinical diagnostic test.

Ask the expert: Electronic cigarettes

2. How much do they cost and where can they be purchased? A single, disposable EC costs around £6, whereas a starter kit that also contains a charger, battery and replacement cartridges, can retail from between £15 and £90. These are widely available online, as well as on the UK high street in supermarkets, newsagents and some pharmacies. In comparison, smoking 20 cigarettes per day can cost the user around £250 per month. It is difficult to estimate the savings associated with switching to ECs, however, Professor Robert West, Director of Tobacco Studies at University College London, has estimated it to be around 20% (NHS Choices, 2015).

Pertussis has low prevalence in adults with acute cough and is difficult to distinguish clinically from other causes

Commentary on: Teepe J, Broekhuizen BD, Ieven M, et al. Prevalence, diagnosis, and disease course of pertussis in adults with acute cough: a prospective, observational study in primary care. Br J Gen Pract 2015;65:e662–7.[OpenUrl][1][Abstract/FREE Full Text][2] Pertussis (whooping cough) is an important cause of persistent cough, even in fully vaccinated individuals, where risk of pertussis increases with time since vaccination.1 ,2 In adults, symptoms may be milder and without the classical paroxysms, whoop and vomiting traditionally associated with pertussis, but nonetheless can be associated with considerable morbidity.1 Several previous studies have investigated incidence and clinical characteristics of pertussis in adults with persistent cough, including a recent study in New Zealand (2 weeks cough duration or greater, n=156 adults) in which 7% adults had laboratory-confirmed pertussis.3 The present study aimed to investigate the prevalence and clinical features of pertussis in adults presenting … [1]: {openurl}?query=rft.jtitle%253DBritish%2BJournal%2Bof%2BGeneral%2BPractise%26rft.stitle%253Dbjgp%26rft.aulast%253DTeepe%26rft.auinit1%253DJ.%26rft.volume%253D65%26rft.issue%253D639%26rft.spage%253De662%26rft.epage%253De667%26rft.atitle%253DPrevalence%252C%2Bdiagnosis%252C%2Band%2Bdisease%2Bcourse%2Bof%2Bpertussis%2Bin%2Badults%2Bwith%2Bacute%2Bcough%253A%2Ba%2Bprospective%252C%2Bobservational%2Bstudy%2Bin%2Bprimary%2Bcare%26rft_id%253Dinfo%253Adoi%252F10.3399%252Fbjgp15X686917%26rft_id%253Dinfo%253Apmid%252F26412843%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=bjgp&resid=65/639/e662&atom=%2Febmed%2F21%2F3%2F116.atom

Backgrounds and aspirations of primary care academic clinical fellows.

Dear Editor,Twenty-first century primary care has led the way in evidence-based medicine and emerged at the forefront of a new era of medical research in the United Kingdom. Despite this, only a sm...

Lumps, bumps and diagnostic stumps

Numquam ponenda est pluralitas sine necessitate (plurality ought never be posed without necessity), proposed William of Ockham (Occam) in the early 14th century. Commonly known as ‘Occam’s razor’, this principle asserts that a single unifying diagnosis is more likely to explain multiple simultaneous presenting symptoms than several different diagnoses.1 In primary care, patients frequently present with multiple symptoms. This case report follows a patient who presented to different GPs within our practice with various symptoms, that were subsequently explained by one unifying diagnosis. A previously well 52-year-old university academic, of Asian descent, presented initially with blurred vision. An ophthalmologist diagnosed bilateral anterior uveitis, which responded well to dexamethasone eye drops. Around the same time, he consulted a different GP for a right groin lump. In addition to a reducible hernia there was also bulky inguinal lymphadenopathy which was felt clinically to be lymphoma. A full blood count was normal. A fine needle aspiration showed no evidence of malignancy, but a probable reactive lymphadenopathy. Following excision biopsy, histology of the lymph node was reported as numerous epithelioid granulomas, with Ziehl-Nielson staining showing aggregates of acid-fast bacilli, consistent with mycobacterial infection. Meanwhile, he had presented to a third GP with an enlarging painless breast lump that was considered to be potentially malignant, and he was referred via the 2-week-wait bureau to a breast surgeon. …