Search

Objectives: We determined trends over time in the prevalence of neonatal drug withdrawal syndrome (NWS) in England compared with that reported in the USA, Western (W) Australia and Ontario, Canada. We also examined variation in prevalence of NWS according to maternal age, birth weight and across the English NHS by hospital trusts., Design and Setting: Retrospective study using national hospital administrative data (Hospital Episode Statistics) for the NHS in England between 1997 and 2011. NWS was identified using international classification of disease codes in hospital admission records. We searched the research literature and contacted researchers to identify studies reporting trends in the prevalence of NWS., Main Outcome Measures: Prevalence of NWS by calendar year per 1000 live births for each country/state. For births in England, prevalence by maternal age group and birth weight group. Prevalence by NHS trust and region at birth, and funnel plot to show outlying English NHS hospital trusts (>3 SD of mean prevalence)., Main Results: Mean prevalence rates of recorded NWS increased in all four countries. Rates stabilised in England and W. Australia from the early 2000s and rose steeply in the USA and Ontario during the late 2000s. The most recent prevalence rates were 2.7/1000 live births in England (2011; 1544 cases); 2.7/1000 in W. Australia (2009); 3.6/1000 in the USA (2009) and 5.1/1000 in Ontario (2011). The highest prevalence in England was among babies born to mothers aged 25-34 years at delivery and among babies born with low birth weight (1500-2500 g). In England in 2011, 8.6% of hospital trusts had a recorded prevalence outside 3 SD of the overall average (7% above, 1% below). The North East region of England had the highest recorded prevalence of NWS., Conclusions: Although recorded NWS is stable in England and W. Australia, rising rates in the USA and Ontario may reflect better recognition and/or increased use of prescribed opiate analgesics and highlight the need for surveillance. The extent to which different prevalence rates by hospital trust reflect variation in occurrence, recognition or recording requires further investigation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To investigate whether there is an increased risk of cardiovascular events in people who exhibit iatrogenic Cushing's syndrome during treatment with glucocorticoids., Design: Cohort study., Setting: 424 UK general practices contributing to The Health Improvement Network database., Participants: People prescribed systemic glucocorticoids and with a diagnosis of iatrogenic Cushing's syndrome (n = 547) and two comparison groups: those prescribed glucocorticoids and with no diagnosis of iatrogenic Cushing's syndrome (n = 3231) and those not prescribed systemic glucocorticoids (n = 3282)., Main Outcome Measures: Incidence of cardiovascular events within a year after diagnosis of iatrogenic Cushing's syndrome or after a randomly selected date, and association between iatrogenic Cushing's syndrome and risk of cardiovascular events., Results: 417 cardiovascular events occurred in 341 patients. Taking into account only the first event by patient (coronary heart disease n = 177, heart failure n = 101, ischaemic stroke n = 63), the incidence rates of cardiovascular events per 100 person years at risk were 15.1 (95% confidence interval 11.8 to 18.4) in those prescribed glucocorticoids and with a diagnosis of iatrogenic Cushing's syndrome, 6.4 (5.5 to 7.3) in those prescribed glucocorticoids without a diagnosis of iatrogenic Cushing's syndrome, and 4.1 (3.4 to 4.8) in those not prescribed glucocorticoids. In multivariate analyses adjusted for sex, age, intensity of glucocorticoid use, underlying disease, smoking status, and use of aspirin, diabetes drugs, antihypertensive drugs, lipid lowering drugs, or oral anticoagulant drugs, the relation between iatrogenic Cushing's syndrome and cardiovascular events was strong (adjusted hazard ratios 2.27 (95% confidence interval 1.48 to 3.47) for coronary heart disease, 3.77 (2.41 to 5.90) for heart failure, and 2.23 (0.96 to 5.17) for ischaemic cerebrovascular events). The adjusted hazard ratio for any cardiovascular event was 4.16 (2.98 to 5.82) when the group prescribed glucocorticoids and with iatrogenic Cushing's syndrome was compared with the group not prescribed glucocorticoids., Conclusion: People who use glucocorticoids and exhibit iatrogenic Cushing's syndrome should be aggressively targeted for early screening and management of cardiovascular risk factors.

Objectives: To estimate survival after a diagnosis of dementia in primary care, compared with people without dementia, and to determine incidence of dementia., Design: Cohort study using data from The Health Improvement Network (THIN), a primary care database., Setting: 353 general practices in the United Kingdom providing data to THIN., Participants: All adults aged 60 years or over with a first ever code for dementia from 1990 to 2007 (n=22 529); random sample of five participants without dementia for every participant with dementia matched on practice and time period (n=112 645)., Main Outcome Measures: Median survival by age and sex; mortality rates; incidence of dementia by age, sex, and deprivation., Results: The median survival of people with dementia diagnosed at age 60-69 was 6.7 (interquartile range 3.1-10.8) years, falling to 1.9 (0.7-3.6) years for those diagnosed at age 90 or over. Adjusted mortality rates were highest in the first year after diagnosis (relative risk 3.68, 95% confidence interval 3.44 to 3.94). This dropped to 2.49 (2.29 to 2.71) in the second year. The incidence of recorded dementia remained stable over time (3-4/1000 person years at risk). The incidence was higher in women and in younger age groups (60-79 years) living in deprived areas., Conclusions: Median survival was much lower than in screened populations. These clinically relevant estimates can assist patients and carers, clinicians, and policy makers when planning support for this population. The high risk of death in the first year after diagnosis may reflect diagnoses made at times of crisis or late in the disease trajectory. Late recording of diagnoses of dementia in primary care may result in missed opportunities for potential early interventions.

Objective: To assess the cost effectiveness of a self management programme plus education booklet for arthritis in primary care., Design: Cost effectiveness and cost utility analysis from health and social care and societal perspectives alongside a randomised controlled trial., Setting: 74 general practices in the United Kingdom., Participants: 812 patients aged 50 or more with osteoarthritis of the hips or knees, or both, and pain or disability, or both., Interventions: Randomisation to either six sessions of an arthritis self management programme plus an education booklet (intervention group) or the education booklet alone (standard care control group)., Main Outcome Measures: Total health and social care costs and total societal costs at 12 months; cost effectiveness (incremental cost effectiveness ratios and cost effectiveness acceptability curves) on basis of quality of life (SF-36, primary outcome measure), EuroQol visual analogue scale, and quality adjusted life years (QALYs)., Results: At 12 months health and social care costs in the intervention group were pound101 higher (95% confidence interval pound3 to pound176) than those in the control group because the additional costs of the arthritis self management programme did not seem to be fully offset by savings elsewhere. There were no significant differences in societal costs (which were up to 13 times the size of health and social care costs) or any of the outcomes. From the health and social care perspective the intervention was dominated by the control on the basis of QALYs (which were non-significantly lower in the intervention group) and had incremental cost effectiveness ratios between pound279 and pound13 473 for the other outcomes. From the societal perspective the intervention seemed superior to the control owing to non-significantly lower costs and non-significantly better outcomes on all measures except QALYs. Probabilities of the arthritis self management programme's cost effectiveness ranged between 12% and 97% (for thresholds ranging pound0 to pound1000) based on one point improvements in SF-36 outcomes, but the clinical significance of this is debatable. Probabilities of cost effectiveness on the basis of the visual analogue scale and QALYs were low., Conclusions: Cost effectiveness of an arthritis self management programme is not suggested on the basis of current National Institute for Health and Clinical Excellence cost perspectives and QALY thresholds. The probability of cost effectiveness is greater when broader costs and other quality of life outcomes are considered. These results suggest that the cost effectiveness of the Department of Health's expert patients programme cannot be assumed across all clinical conditions and that further rigorous evaluations for other conditions may be needed., Trial Registration: Current Controlled Trials ISRCTN79115352.

Objective: To evaluate clinical effectiveness of a self management programme for arthritis in patients in primary care with osteoarthritis., Design: Randomised controlled trial., Setting: 74 general practices in the United Kingdom., Participants: 812 patients aged 50 and over with osteoarthritis of hips or knees (or both) and pain or disability (or both)., Intervention: Participants were randomised to six sessions of self management of arthritis and an education booklet (intervention group) or the education booklet alone (control group)., Main Outcome Measures: Primary outcome was quality of life, as assessed by the short form health survey (SF-36). Several other physical and psychosocial secondary outcomes were assessed. Data were collected at baseline, four months, and 12 months., Results: Response rates were 80% and 76% at four and 12 months. The two groups showed significant differences at 12 months on the anxiety subscore of the hospital anxiety and depression scale (mean difference -0.62, 95% confidence interval -1.08 to -0.16), arthritis self efficacy scale for pain (0.98, 0.07 to 1.89), and self efficacy for other aspects of management (1.58, 0.25 to 2.90). Results were similar for intention to treat and per protocol analyses. No significant difference was seen in number of visits to the general practitioner at 12 months., Conclusions: The self management of arthritis programme reduced anxiety and improved participants' perceived self efficacy to manage symptoms, but it had no significant effect on pain, physical functioning, or contact with primary care., Trial Registration: Current Controlled Trials ISRCTN79115352 [controlled-trials.com].

Objectives: To assess sexual behaviour, prevalence of ICD-10 diagnosed sexual dysfunction, associations between sexual and psychological problems, and help seeking for sexual problems in people attending general practice; to assess predictors of ICD-10 diagnosis of sexual dysfunction., Design: Cross sectional study., Setting: 13 general practices in London., Participants: 1065 women and 447 men attending general practices., Main Outcome Measure: Prevalence and predictors of ICD-10 diagnoses of sexual dysfunction., Results: 97 (22%, 95% confidence interval 18% to 25%) men and 422 (40%, 37% to 43%) women received at least one ICD-10 diagnosis, but only 3-4% had an entry relating to sexual problems in their general practice notes. The most common problems were erectile failure and lack or loss of sexual desire in men and lack or loss of sexual desire and failure of orgasmic response in women. Increasing age and being unemployed predicted sexual problems in women, and bisexual orientation, being non-white, and being unemployed were demographic predictors in men. No practice note factors predicted sexual problems in women, but high consulting rate predicted problems in men. The main clinical predictors were poor physical function and dissatisfaction with current sex life in both sexes and higher psychological morbidity in women. When all factors were considered, increasing age (odds ratio 1.01, 1.00 to 1.02), physical subscale score on the SF-12 (0.98, 0.97 to 0.99), sexual dissatisfaction (1.9, 1.5 to 2.4), and scoring over a 3/4 threshold score on the general health questionnaire (1.5, 1.1 to 1.9) independently predicted an ICD-10 sexual dysfunction diagnosis in women. Being bisexual (4.1, 1.3 to 12.8) was the only independent predictor of an ICD-10 diagnosis in men., Conclusions: Sexual difficulties are common in people attending general practitioners, and many people are prepared to talk about them with their doctors.

Objectives: To determine the accuracy of diagnoses of schizophrenia and non-affective psychosis entered by general practitioners on a computer system. To compare recording of clinical events on computer with written records., Design: Examination of case notes of all patients with a computer diagnosis of psychosis. Search of 8000 randomly selected patient records to identify patients with psychosis not recorded on computer and comparison of 141 computer and written entries for prescribing and consultation in each practice., Setting: 13 London practices on the VAMP research bank., Main Outcome Measures: Accuracy of record of psychosis compared with ICD 9, American Psychiatric Association diagnostic manual, and syndrome checklist criteria., Results: Computer search revealed 102 patients with schizophrenia, 78 with other psychoses, and 71 with non-affective psychosis who had adequate case notes. The sensitivity and positive predictive value of the computer diagnosis of schizophrenia were 88% (95% confidence interval 62% to 98%) and 71% (48% to 88%). For all non-organic psychoses sensitivity was 91% (74% to 97%) and positive predictive value was 91% (74% to 98%). On average 95% of all known prescriptions and 74% of all consultations were recorded on computer compared with 42% and 75% in written records., Conclusions: Recording of psychotic illness on the VAMP computer is accurate and complete. Prescribing was more fully recorded on the computer than on the written records. Computer databases of well motivated general practitioners could be used for research.

Objective: To identify factors influencing decision making by general practitioners in the diagnosis and treatment of lower urinary tract symptoms in women., Setting: Two suburban London general practices., Subjects: Women presenting to their family doctor with lower urinary tract symptoms., Design: After each consultation the doctor completed a questionnaire on presenting symptoms; clinical examination; investigations undertaken; presence of psychological, social, and menstrual problems; patients' requests for antibiotics; antibiotic prescribing; knowledge of the patient; attitude towards the consultation; and any other factors assisting in diagnosis and management. Finally, doctors predicted the presence or absence of clinically important bacteriuria. Each woman completed a demographic questionnaire, the 12 item general health questionnaire, and the modified menstrual distress questionnaire, after which each provided a clean catch midstream urine sample. Case notes were examined for information on previous reports of results of urine analysis., Results: When the general practitioners did not know the patients well they were 4.5 times more likely to assume that there was a clinically important infection. When they knew the patient well, they were four times more likely to make a correct prediction of the test result and 12 times less likely to prescribe antibiotics. Doctors were five times more likely to predict the test result correctly in patients from social classes 1 and 2 and were six times more likely to prescribe antibiotics for the older women in the sample., Conclusions: In women presenting with urinary tract symptoms, these family practitioners seemed to take no particular regard of physical, psychological, or menstrual factors in making their assessments. They were most accurate in their prediction of the result of urine analysis and least likely to prescribe antibiotics when they had a good general knowledge of the patient. Which came first, the diagnosis or prescribing, is difficult to say and probably differed in individual cases. Doctors tended to be more conservative in their management of older women and those whom they knew less well.

Objective: To describe the profile of problem drug users presenting in general practice and to determine whether they can be cared for in general practice., Design: Study of consultations by problem drug users., Setting: Central London general practice., Subjects: 150 problem drug users presenting over two years., Main Outcome Measures: Stopping drug use, alterations in lifestyle, obtaining paid work, and stopping drug related crime., Results: Of the 150 patients, 111 were men and 39 women, and 106 were unemployed. 121 patients used heroin, 112 of whom injected. 145 patients accepted a methadone reduction programme and 81 completed it. A further 25 were stabilised on reducing doses of methadone, until places became available for them as inpatients at drug dependency units or rehabilitation projects., Conclusion: Withdrawal programmes for patients who misuse drugs can be successfully managed in general practice.