Search

Post-COVID-19 syndrome is a new condition that can have a major impact on the physical and mental well-being of children and young people, affecting their ability to access activities including education. Paediatricians and general practitioners need to be able to assess and manage patients with this condition; making the diagnosis, excluding serious pathology, managing comorbidities and accessing appropriate management are crucial. This 15 minute consultation presents an approach to history taking, examination, investigations, management principles and referrals. [ABSTRACT FROM AUTHOR]

Background Although efforts are underway to address social determinants of health (SDOH), little is known about physicians' SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs. Methods Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a 'proxy' comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams. Results 108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing responding to housing needs increased significantly for intervention teams (15%-41%; p=0.004) but not for the comparison team (21%-29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams. Conclusions Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response. [ABSTRACT FROM AUTHOR]

An extremely preterm infant is one born at less than 27 weeks' gestation. Over time, survival rates in this population have improved. This cohort remains at high risk of mortality and life-long morbidity. The birth of extremely preterm infants is an important public health issue and one which concerns neonatologists, paediatricians, general practitioners and parents alike. This paper aims to provide guidance for the antenatal discussion between clinicians and expectant families and may serve as a template to facilitate open communication. [ABSTRACT FROM AUTHOR]

Background: Current guidelines recommend that patients with obesity hypoventilation syndrome (OHS) are electively admitted for inpatient initiation of home non-invasive ventilation (NIV). We hypothesised that outpatient NIV setup would be more cost-effective.Methods: Patients with stable OHS referred to six participating European centres for home NIV setup were recruited to an open-labelled clinical trial. Patients were randomised via web-based system using stratification to inpatient setup, with standard fixed level NIV and titrated during an attended overnight respiratory study or outpatient setup using an autotitrating NIV device and a set protocol, including home oximetry. The primary outcome was cost-effectiveness at 3 months with daytime carbon dioxide (PaCO2) as a non-inferiority safety outcome; non-inferiority margin 0.5 kPa. Data were analysed on an intention-to-treat basis. Health-related quality of life (HRQL) was measured using EQ-5D-5L (5 level EQ-5D tool) and costs were converted using purchasing power parities to £(GBP).Results: Between May 2015 and March 2018, 82 patients were randomised. Age 59±14 years, body mass index 47±10 kg/m2 and PaCO2 6.8±0.6 kPa. Safety analysis demonstrated no difference in ∆PaCO2 (difference -0.27 kPa, 95% CI -0.70 to 0.17 kPa). Efficacy analysis showed similar total per-patient costs (inpatient £2962±£580, outpatient £3169±£525; difference £188.20, 95% CI -£61.61 to £438.01) and similar improvement in HRQL (EQ-5D-5L difference -0.006, 95% CI -0.05 to 0.04). There were no differences in secondary outcomes.Discussion: There was no difference in medium-term cost-effectiveness, with similar clinical effectiveness, between outpatient and inpatient NIV setup. The home NIV setup strategy can be led by local resource demand and patient and clinician preference.Trial Registration Numbers: NCT02342899 and ISRCTN51420481. [ABSTRACT FROM AUTHOR]

Background Patient-reported outcomes (PROs) can promote patient engagement, shared-decision making and improve the overall experience of care. However, PRO integration in the primary care clinical setting is limited. Exploring the perspectives of primary care physicians (PCPs) on PROs is key to understanding how they are being used in the clinical setting. We sought to elucidate this clinical perspective at one of the largest US health systems that has integrated a wide range of PROs into routine primary care. Methods Mixed methods study with both anonymous online surveys and in-person qualitative semistructured interviews conducted with PCPs to understand their clinical perspectives on the applications of the existing PROs. PCPs from the 19 affiliated clinics were prompted to complete the survey. Interviewed PCPs were selected via a combination of random and purposive selection from the PCP directory. Results Of 172 PCPs, 117 (68%) completed the online survey and 28 completed semistructured interviews. Most PCPs (77%) reviewed PRO responses with their patients. PCPs endorsed that PROs improve clinic efficiency and clinical management. However, PCPs have heterogeneous perspectives on the relevance of PROs in clinical practice, likely due to variations in clinic practice. For specific PRO instruments, PCPs reported anxiety and depression screening PROs to be most helpful. PCPs felt that PROs assisted with completing screening questions that are required by regulatory bodies. Barriers to using PROs include poor user-interface for both clinicians and patients and inadequate training. Conclusions Most PCPs regularly use PRO data though there are mixed opinions about their clinical relevance. An adaptable, user-friendly PRO system has the potential to have meaningful clinical applications in primary care. [ABSTRACT FROM AUTHOR]

Around the UK, commissioners have different models for delivering NHS 111, General Practice (GP) out-of-hours and urgent care services, focusing on telephony to help deliver urgent and emergency care. During the (early phases of the) COVID-19 pandemic, NHS 111 experienced an unprecedented volume of calls. At any time, 25%-30% of calls relate to children and young people (CYP). In response, the CYP's Transformation and Integrated Urgent Care teams at NHS England and NHS Improvement (NHSE/I) assisted in redeploying volunteer paediatricians into the integrated urgent care NHS 111 Clinical Assessment Services (CAS), taking calls about CYP. From this work, key stakeholders developed a paediatric 111 consultation framework, as well as learning outcomes, key capabilities and illustrations mapped against the Royal College of Paediatrics and Child Health (RCPCH) Progress curriculum domains, to aid paediatricians in training to undertake NHS 111 activities. These learning outcomes and key capabilities have been endorsed by the RCPCH Curriculum Review Group and are recommended to form part of the integrated urgent care service specification and workforce blueprint to improve outcomes for CYP. [ABSTRACT FROM AUTHOR]

Objective To describe social and ethnic group differences in children's use of healthcare services in England, from 2007 to 2017. Design Population-based retrospective cohort study. Setting/Patients We performed individual-level linkage of electronic health records from general practices and hospitals in England by creating an open cohort linking data from the Clinical Practice Research Datalink and Hospital Episode Statistics. 1 484 455 children aged 0-14 years were assigned to five composite ethnic groups and five ordered groups based on postcode mapped to index of multiple deprivation. Main outcome measures Age-standardised annual general practitioner (GP) consultation, outpatient attendance, emergency department (ED) visit and emergency and elective hospital admission rates per 1000 child-years. Results In 2016/2017, children from the most deprived group had fewer GP consultations (1765 vs 1854 per 1000 child-years) and outpatient attendances than children in the least deprived group (705 vs 741 per 1000 child-years). At the end of the study period, children from the most deprived group had more ED visits (447 vs 314 per 1000 child-years) and emergency admissions (100 vs 76 per 1000 child-years) than children from the least deprived group. In 2016/2017, children from black and Asian ethnic groups had more GP consultations than children from white ethnic groups (1961 and 2397 vs 1824 per 1000 child-years, respectively). However, outpatient attendances were lower in children from black ethnic groups than in children from white ethnic groups (732 vs 809 per 1000 child-years). By 2016/2017, there were no differences in outpatient, ED and in-patient activity between children from white and Asian ethnic groups. Conclusions Between 2007 and 2017, children living in more deprived areas of England made greater use of emergency services and received less scheduled care than children from affluent neighbourhoods. Children from Asian and black ethnic groups continued to consult GPs more frequently than children from white ethnic groups, though black children had significantly lower outpatient attendance rates than white children across the study period. Our findings suggest substantial levels of unmet need among children living in socioeconomically disadvantaged areas. Further work is needed to determine if healthcare utilisation among children from Asian and black ethnic groups is proportionate to need. [ABSTRACT FROM AUTHOR]

Objectives Implementation of guidelines into clinical practice is challenging and complex. This study aims to (1) identify the training needs and capacity requirements, and (2) explore the impact on healthcare utilisation and asthma-related quality of life of implementing both spirometry and fraction of exhaled nitric oxide in diagnosis of asthma among children in the UK primary care. Methods Ten UK general practitioner practices and a total of 612 children (5-16 years) with diagnosed or suspected asthma were invited to participate in this prospective observational study. The total times that the trainer and trainee clinical staff spent on developing the training package, providing and receiving, and performing and interpreting the two tests as part of routine child asthma review were collected, and costs were calculated. We compared healthcare utilisation and asthma-related and general health-related quality of life data between the 6 months before and after the asthma review guided by objective tests. Results The average training cost for the 27 primary care clinical members was £1395. The average cost to implement and deliver the test-guided asthma review among the 612 included children was £22. In the 6 months following the tests-guided asthma review, both unplanned primary care attendance, and hospital admissions were reduced, and the asthma-related health status increased significantly. Conclusion This study provides robust cost estimates of the resources needed to implement the National Institute for Health and Care Excellence asthma guideline. It also demonstrates the potential to save healthcare costs and improve health status among asthmatic children by implementing this guideline. [ABSTRACT FROM AUTHOR]

Objective: Familial hypercholesterolaemia (FH) is characterised by elevated low-density lipoprotein (LDL)-cholesterol and increased risk of cardiovascular disease. However, FH remains substantially underdiagnosed and undertreated. We employed a two-stage pragmatic approach to identify and manage patients with FH in primary healthcare.Methods: Medical records for 232 139 patients who attended 15 general practices at least once in the previous 2 years across five Australian States were first screened for potential risk of FH using an electronic tool (TARB-Ex) and confirmed by general practitioner (GP) clinical assessment based on phenotypic Dutch Lipid Clinic Network Criteria (DLCNC) score. Follow-up GP consultation and management was provided for patients with phenotypic FH.Results: A total of 1843 patients were identified by TARB-Ex as at potential risk of FH (DLCNC score ≥5). After GP medical record review, 900 of these patients (49%) were confirmed with DLCNC score ≥5 and classified as high-risk of FH. From 556 patients subsequently clinically assessed by GPs, 147 (26%) were diagnosed with phenotypic FH (DLCNC score >6). Follow-up GP consultation and management for 77 patients resulted in a significant reduction in LDL-cholesterol (-16%, p<0.01). A higher proportion of these patients attained the treatment target of 50% reduction in LDL-cholesterol (74% vs 62%, p<0.001) and absolute levels of LDL-cholesterol goals compared with baseline (26% vs 12%, p<0.05).Conclusions: A pragmatic approach integrating electronic medical record tools and clinical GP follow-up consultation is a feasible method to identify and better manage patients with FH in the primary healthcare setting.Trial Registration Number: 12616000630415. [ABSTRACT FROM AUTHOR]

Two previously well Caucasian teenage girls with no significant travel or family history were admitted with sinusitis refractory to treatment with antibiotics. Both had progressive symptoms despite broad-spectrum antibiotics and developed involvement of other systems, ultimately requiring admission to the paediatric intensive care unit (PICU). They were subsequently diagnosed with the same condition and made an excellent recovery.The first girl, 14 years old, originally presented to her general practitioner with a sore throat, nasal congestion, and fever. Despite multiple courses of antibiotics over the following month she presented again multiple times with progressive symptoms including epistaxis, widespread myalgia and arthralgia, difficulty in breathing, haemoptysis, fatigue, and weight loss. Examination on admission found minimal discharge from her right tympanic membrane, ulcerated inferior turbinates with dried blood and yellow mucus in both nasal cavities, swollen tonsils without exudate, and an isolated aphthous ulcer on the tip of her tongue. She had small bilateral cervical lymph nodes. Examination of the cardiovascular system was unremarkable but on respiratory examination there was reduced air entry on the right side. Her abdomen was generally tender but soft with no organomegaly. A week into her admission she developed an oxygen requirement and increased work of breathing requiring intubation and ventilation.The second girl, 13 years old, presented to her local hospital with a 1-day history of epistaxis, right ear pain, and pain and swelling to the right periorbital tissues. Again, despite multiple courses of antibiotics, she had persistent symptoms and subsequently developed fever, fatigue, haemoptysis, and had a syncopal episode. She was admitted to her local district general hospital and, despite initial treatment, deteriorated over the following 2 weeks with persistent fever, new oxygen requirement, deteriorating renal function, and anaemia. She was transferred to a tertiary centre for respiratory support which escalated from Optiflow, through continuous then biphasic positive airway pressure, intubation and ventilation, and ultimately VV-ECMO.The investigations for both patients prior to admission to PICU at our centre are shown in table 1.edpract;107/2/113/T1T1T1Table 1Investigations Case 1 Case 2 Haematology  Leucocyte peak (×109/L) 18.3 19.0  Neutrophil peak (×109/L) 15.2 13.7  Lymphocyte peak (×109/L) 3.5 2.3  Eosinophil peak (×109/L) 0.9 2.5  Platelets Normal Normal  Haemoglobin nadir (g/L) 79 74  ESR (mm/hour) 104 44 Biochemistry  Creatinine peak (umol/L) Normal 153  CRP peak (mg/l) 321 280  ALT (IU/L) 122 Normal Microbiology Nasal swab: Moraxella catarrhalis Ear swab: Pseudomonas aeruginosa Sputum negative for acid-fast bacilli, PCR negative ASOT 1600 IU/ml No growth on blood or urine culture Negative viral throat swab and MCS throat swab No positive microbiology including Monospot, Mantoux and TSpot Urine dipstick On day of admission: 1+pro, 4+Hb, 2+leu, 2+ket One week into admission: 3+pro, 4+Hb, 2+leu, 2+ket Three days prior to admission: 2+Hb, otherwise normal Radiology Echocardiogram: normal CXR at admission: normal CXR after 1 week: see figure 1 CT head: pansinusitis Abdominal USS: mild hepatomegaly, diffusely echogenic kidneys Echocardiogram: normal CT chest at local hospital: see figure 2 CXR on admission to PICU: bilateral consolidation with rounded lucency in right lower zone suggestive of cavity formation ALT, alanine aminotransferase; ASOT, anti-streptolysin O titre; CRP, C-reactive protein; CT, computed tomography; CXR, chest X-ray; ESR, erythrocyte sedimentation rate; Hb, haemoglobin; leu, leucocytes; ket, ketones; MCS, microscopy, culture, and sensitivity; PICU, paediatric intensive care unit; pro, protein; TSpot, measures T lymphocytes primed to Mycobacterium tuberculosis antigens; USS, ultrasound scan. QUESTIONS: Describe findings in figures 1 and 2.Which causes of sinusitis could explain the presentation of both cases?Acute sinusitis following viral upper respiratory tract infection.Bacterial infection.Allergic sinusitis secondary to mould.Underlying diagnosis of cystic fibrosis.Sarcoidosis.Tuberculosis.Granulomatosis with polyangiitis.Samter's triad.Ciliary dysfunction.Immunodeficiency.What investigations should be performed in a child presenting with symptoms of sinusitis?edpract;107/2/113/F1F1F1Figure 1The chest X-ray for case 1, 1 week into her hospital admission.edpract;107/2/113/F2F2F2Figure 2The chest CT for case 2 at her local hospital, prior to transfer. Answers can be found on page XX. [ABSTRACT FROM AUTHOR]

Objective: We aimed to investigate the number and distribution of general practitioners (GPs) in China, and to predict the number of GPs needed in the future. Methods: From China Health Statistics Yearbook 2014, China Health Statistics Yearbook 2016 and China Statistical Yearbook 2016, we obtained the number of GPs and the populations in China and each of its regions from 2012 to 2015. IBM SPSS Statistics version 22.0 was used to conduct descriptive statistical analysis. Grey model GM(1, 1) and the manpower-to-population ratio method were used to predict the number of GPs needed in China from 2016 to 2020. Results: The total number of GPs in China was 109,794 in 2012, 145,511 in 2013, 172,597 in 2014, and 188,649 in 2015. The number increased by 78,855 from 2012 to 2015, and the average annual growth rate was 19.77%. By the end of 2015, of the GPs in all of China and in eastern, central, and western China, those who had achieved a GP qualification certificate following training accounted for 63.76% (120,285/188,649), 60.06% (62,474/104,015), 65.20% (29,565/45,344), and 71.89% (28,246/39,290), respectively, of the total. The number of GPs per 10,000 population in all of China and in eastern, central, and western China was 1.37, 1.83, 1.05, and 1.06, respectively, and the number of GPs needed for all of China and the eastern, central, and western parts would be 86,275, 9787, 40,764, and 34,976, respectively, calculated on the basis of the standard of two GPs per 10,000 population. Grey model GM(1, 1) predicted that, in accordance with the natural growth trend of GPs, the number of GPs in China would be 220,314 in 2016, 253,728 in 2017, 293,101 in 2018, 339,928 in 2019, and 396,228 in 2020. Moreover, the number of GPs in China in 2020 would be 277,000–415,500 if the calculated number of GPs to the population ratio is based on the standard of two to three GPs per 10,000 population. Conclusion: In recent years, although the number of GPs has increased rapidly, GPs are still greatly needed in all of China and in eastern, central, and western China. Moreover, the distribution of GPs is not balanced, and the number of qualified GPs is far from enough. Therefore, team building for GPs should be strengthened, and the training system for GPs should be improved.

China faces a huge task in managing the large numbers of people with diabetes. Primary care is at the forefront of this challenge, and needs to begin to adopt some of the management and organizational approaches that have been shown to be successful in tackling diabetes and similar chronic diseases.

Objective: To determine the diagnostic accuracy of calprotectin to diagnose inflammatory bowel disease (IBD) in children in whom general practitioners (GPs) suspected IBD.Design: Prospective observational cohort study of a new calprotectin-based primary care referral pathway.Setting: 48 GP practices and gastroenterology secondary care services at the Royal Devon and Exeter NHS Foundation Trust in the South-West of England, UK.Patients: 195 children aged between 4 and 18 years referred on the pathway between January 2014 and August 2017 for investigation of gastrointestinal symptoms were included.Interventions: Primary-care-driven faecal calprotectin testing. Primary and secondary care records over 12 months from the point of calprotectin testing were used as the reference standard.Main Outcome Measures: Diagnostic accuracy of calprotectin testing to detect IBD.Results: 7% (13/195) tested patients were diagnosed with IBD. Using our prespecified cut-off of 100 µg/g, calprotectin had a diagnostic accuracy of 91% (95% CI 86% to 95%) with a sensitivity for distinguishing IBD from non-IBD of 100% (95% CI 75% to 100%), a specificity of 91% (95% CI 85% to 94%), a positive predictive value of 43% (95% CI 25% to 63%) and a negative predictive value of 100% (95% CI 98% to 100%). Calprotectin testing had no effect on the time to diagnosis, but a negative test contributed to saved referrals and was associated with fewer diagnostic tests in secondary care.Conclusions: Calprotectin testing of children with suspected IBD in primary care accurately distinguishes IBD from a functional gut disorder, reduces secondary care referrals and associated diagnostic healthcare utilisation. [ABSTRACT FROM AUTHOR]

Objective: To examine temporal trends in incidence of Rolandic epilepsy (RE), prevalence of comorbidities and antiepileptic drug (AED) prescribing patterns.Design: Retrospective cohort study.Setting: The UK.Patients: Children aged 0-16 years born 1994-2012 were followed from birth until September 2017, transfer to another general practitioner practice or death or practice withdrawal from The Health Improvement Network (THIN), whichever occurred first.Main Outcome Measures: Incidence of RE, prevalence of comorbidity and AED prescribing patterns. Read codes for comorbidities and AEDs were adapted from other UK population-based epilepsy studies.Results: There were 379 children with first RE event recorded between 2000 and 2014 from active THIN practices with available mid-year population counts. Crude annual incidence across all years was 5.31/100 000 (95% CI 4.81 to 5.88). There was no significant time trend in adjusted incidence rate ratios (aIRR) (0.99/year, 95% CI 0.96 to 1.02). Males had higher aIRR (1.48, 95% CI 1.20 to 1.82) as did children aged 6-8 and 9-11 years compared with 4-5 years (aIRR 2.43, 95% CI 1.73 to 3.40; aIRR 2.77, 95% CI 1.97 to 3.90, respectively). There was recorded comorbidity in 12% with 6% with a recorded diagnosis of pervasive developmental disorder. Half of children with RE had a record of being prescribed AEDs.Conclusions: UK incidence of RE has remained stable with crude incidence of 5/100 000/year. Carers and clinicians need to be aware that comorbidities may exist, particularly pervasive developmental disorders. Carbamazepine is consistently the most commonly prescribed AED for RE in the UK. [ABSTRACT FROM AUTHOR]