Melvyn Jones

NICE guidelines for chronic obstructive pulmonary disease: implications for primary care

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in the UK with around 30 000 deaths per annum. There are an estimated 3 million people with the disease (900 000 diagnosed and 2.1 million undiagnosed), and COPD is estimated to be the third highest cause of mortality worldwide by the year 2020.1 The National Institute for Health and Clinical Excellence (NICE) 2010 guidelines for the management of COPD in primary and secondary care1 are a partial update of the original guidelines published in 2004.2 The new recommendations are principally concerned with spirometry, assessment of disease severity, and management of stable disease. A diagnosis of COPD is dependent on the presence of characteristic symptoms of cough and breathlessness, examination (principally to rule out other causes of cough/breathlessnes, such as cardiac disease, other lung disease), and the demonstration of airflow obstruction on spirometry. The 2004 guidelines were unclear whether pre- or post-bronchodilator readings of forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) should be used to diagnose COPD. The new guidelines recommend that postbronchodilator readings should be used, which corresponds with requirements of the current UK Quality and Outcomes Framework.3 There has been debate surrounding the merits of using a fixed cut-off point of 0.7 of FEV1/FVC ratio for diagnosing COPD or using the lower limit of normal (LLN) where the …

Recruiting patients to medical research: double blind randomised trial of "opt-in" versus "opt-out" strategies

Abstract ObjectiveTo evaluate the effect of opt-in compared with opt-out recruitment strategies on response rate and selection bias. DesignDouble blind randomised controlled trial. SettingTwo general practices in England. Participants510 patients with angina. InterventionPatients were randomly allocated to an opt-in (asked to actively signal willingness to participate in research) or opt-out (contacted repeatedly unless they signalled unwillingness to participate) approach for recruitment to an observational prognostic study of patients with angina. Main outcome measuresRecruitment rate and clinical characteristics of patients. Results The recruitment rate, defined by clinic attendance, was 38% (96/252) in the opt-in arm and 50% (128/258) in the opt-out arm (P = 0.014). Once an appointment had been made, non-attendance at the clinic was similar (20% opt-in arm v 17% opt-out arm; P = 0.86). Patients in the opt-in arm had fewer risk factors (44% v 60%; P = 0.053), less treatment for angina (69% v 82%; P = 0.010), and less functional impairment (9% v 20%; P = 0.023) than patients in the opt-out arm. Conclusions The opt-in approach to participant recruitment, increasingly required by ethics committees, resulted in lower response rates and a biased sample. We propose that the opt-out approach should be the default recruitment strategy for studies with low risk to participants.

Where students go when they are ill: How medical students access health care

Background  Doctors have high levels of self‐treatment, investigation and referral, but little is known about how medical students seek health care.

Impact of an intercalated BSc on medical student performance and careers: A BEME systematic review: BEME Guide No. 28

Introduction: Intercalated BScs (iBScs) are an optional part of undergraduate (UG) medicine courses in UK, Eire, Australia, New Zealand, the West Indies, Hong Kong, South Africa and Canada, consisting of advanced study into a particular field of medicine, often combined with research. They potentially improve students’ skills and allow exploration of specific areas of interest. They are, however, expensive for institutions and students and delay workforce entry. There is conflicting evidence about their impact. Methods: A mixed-method systematic review (meta-analysis and critical interpretive synthesis) of the biomedical and educational literature, focusing on the impact of iBScs on UG performance, skills, and career choice, and to explore students’ and other stakeholders’ opinions about iBScs. Results: In the meta-analytic part of this review, we identified five studies which met our predetermined quality criteria. For UG performance, two studies using different methodologies report an improvement in UG performance; one study reported an Odds Ratio [OR] of 3.58 [95% CI 1.47–8.83] and the second reported a significant improvement in finals scores (1.27 points advantage 95% CI 0.52–2.02). One study reported a mixed result, while two studies showed no improvement. Regarding skills and attitudes, one paper suggested iBScs lead to the development of deeper learning styles. With regard to subsequent careers, two studies suggested that for those students undertaking an iBSc there is an increased chance following an academic career [ORs of 3.6 (2.3–5.8) to 5.94 (3.6–11.5)]. Seven of eight studies (with broader selection criteria) reported that iBSc students were less likely to pursue GP careers (ORs no effect to 0.17 [0.07–0.36]). Meta-analysis of the data was not possible. In the critical interpretative synthesis analysis, we identified 46 articles, from which three themes emerged; firstly, the decision to undertake an iBSc, with students receiving conflicting advice; secondly, the educational experience, with intellectual growth balanced against financial costs; finally, the ramifications of the iBSc, including some suggestion of improved employment prospects and the potential to nurture qualities that make “better” doctors. Conclusion: Intercalated BScs may improve UG performance and increase the likelihood of pursuing academic careers, and are associated with a reduced likelihood of following a GP career. They help students to develop reflexivity and key skills, such as a better understanding of critical appraisal and research. The decision to undertake an iBSc is contentious; students feel ill-informed about the benefits. These findings could have implications for a variety of international enrichment programmes.

Tailoring of corticosteroids in COPD management

This literature review updates the reader on the new studies regarding steroid therapy over the last year in stable COPD and in exacerbations. In stable COPD, we critique the 2011 update and 2013 revision of the GOLD guidelines, discuss why combining inhaled corticosteroids (ICS) with long-acting beta-agonists (LABA) (ICS/LABA) is preferable over LABA alone and review the literature for intraclass differences, finding that the evidence does not clearly support superiority of any particular ICS/LABA. We also address other comparisons against ICS/LABA, including triple therapy. We briefly review which type of inhaler should be chosen. For exacerbations, we report the REDUCE trial findings favouring a 5-day course of systemic steroids, and other trials addressing which steroid and route to use, including in an intensive care setting. Lastly, the future lies in new anti-inflammatories and re-phenotyping the heterogeneous amalgamation of COPD. A Spanish guideline recommends distinguishing steroid-responsive eosinophilic exacerbators from other phenotypes.

Undergraduate research in primary care: is it sustainable?

Aim: To describe the research project component of the BSc in Primary Health Care and to discuss the issues faced by students and faculty in attempting to complete a student-led research project. Background: Medical schools increasingly expect medical students to undertake research as part of intercalated BSc’s or in self-selected study modules. This research has historically been laboratory based, ‘piggybacking’ onto existing projects. Projects initiated by students themselves and studies in primary care or community settings are more unusual. Methods: A qualitative study, based on interviews with students and examiners, triangulated with data from the peer review process and personal observations on the running of the course. Setting: A London medical school, running an intercalated BSc in Primary Health Care. Findings: We interviewed 24 of 26 students and two external examiners during the interview period of the study. Students successfully undertook research, from initial question through to publication. Overall, 90 dissertations were completed since 1997, of which half used a qualitative methodology (45/90). Ten projects have subsequently been published; there were also 16 conference presentations and 6 research letters. Themes from the interview data include: the students’ strong sense of project ownership, the difficulties of being a novice researcher, the difficulties posed by the research governance hurdles, the beneficial and for some students adverse impact (stress and coping with unsuccessful projects) and finally, the impact on their careers. Conclusion: Students gain considerably from this learning process, not only by undertaking their own research, but they also gain in terms of acquisition of transferable skills such as critical appraisal and improved self-directedness. Project completion and publication rates suggest that programmes developing undergraduate initiated research projects can be as successful as those for other novice researchers. The student-led project is a fragile endeavour, but currently is sustainable.

Strategies to screen and reduce vascular risk—putting statins in the tap water is not the answer

Primary prevention of cardiovascular disease in essence refers to the need to prevent the first vascular event be it angina, myocardial infarction or stroke. The importance of prevention is at least twofold—first, that clinical events like these can be disabling to the patient and have a costly impact on society through loss of productivity or need for care and, second, that they require expensive medical care. Finally, as part of our duty of care as health professionals, the fact that the majority of the causes of cardiovascular disease are known and modifiable arguably confers a moral obligation on us to try to prevent the appearance of such diseases. However, screening and prevention are imperfect sciences and are costly, and this is the rationale behind Lawson et al s economic comparison of mass and targeted screening strategies for cardiovascular risk in this months issue of Heart ( see page 208 ) .1 They surmise that determining which members of the general population have a high cardiovascular risk is problematic and though mass screening of the whole population is one option, screening of subgroups of the population known to have higher rates of cardiovascular disease could identify a large proportion of those at risk at relatively low costs. Long ago Geoffrey Rose presented two approaches to prevention of disease—one based on the individual at high risk and the other on a high-risk population2—and a polarised debate between …

Patients' descriptions of angina symptoms: a qualitative study of primary care patients

BACKGROUND Initial diagnosis of angina in primary care is based on the history of symptoms as described by the patient in consultation with their GP. Deciphering and categorising often complex symptom narratives, therefore, represents an ongoing challenge in the early diagnosis of angina in primary care. AIM To explore how patients with a preexisting angina diagnosis describe their symptoms. METHOD Semi-structured interviews were conducted with 64 males and females, identified from general practice records as having received a diagnosis of angina within the previous 5 years. RESULTS While some patients described their angina symptoms in narratives consistent with typical anginal symptoms, others offered more complex descriptions of their angina experiences, which were less easy to classify. The latter was particularly the case for severe coronary artery disease, where some patients tended to downplay chest pain or attribute their experience to other causes. CONCLUSION Patients with a known diagnosis of angina do not always describe their symptoms in a way that is consistent with Diamond and Forresters diagnostic framework for typicality of angina. Early diagnosis of angina in primary care requires that GPs operate with a broad level of awareness of the various ways in which their patients describe their symptoms.

Patient information sheets in emergency care

Can improve measures of mental health outcomes, but clinical benefits are unknown

A systematic review: the role of spirituality in reducing depression in people living with HIV/AIDS

Vermandere et al s1 article highlighted end-of-life care as a particular area where spirituality can play an important role. In a link between spirituality and another chronic disease we looked at spirituality and HIV (R Amuzie, unpublished data, 2009). Vermanderes literature review proposes that spirituality has a key position in the management of HIV sufferers. HIV infection is a major global problem and in 2007 was present in 33?million people around the world.2 Antiretroviral therapy has been successful in …