Clinical Practice

Introduction

Across the UK there has been a reduction in the number of children and young people (CYP) presenting acutely to hospital during the COVID-19 pandemic. This was highlighted in a recent survey of consultant paediatricians in the UK and Ireland¹. It showed that not only were fewer children being brought to emergency departments, but there were also delays in acute presentation of critical illness (such as sepsis and diabetic ketoacidosis) and reductions in referrals for cancer treatment and child protection assessments¹.

The reasons for the reduced attendance are thought to be related to the initial government messaging of Stay Home, Protect the NHS, Save Lives². However, as it became clear that not only parents, but other potential patients were not presenting even if warranted, the government adjusted the messaging to make it clear that the NHS was still open for urgent care that was not just COVID-19 related.

In CYP the cause of delayed presentations were likely to be manifold: parents following the initial governmental message; families concerned that hospitals were unsafe; the initial presumption that COVID-19 in CYP would present in the same manner as in adults potentially leading to primary care and NHS 111 pathways channelling them to domestic isolation. It may be that some delays in hospital presentations may be due to reduced referrals from primary care, and that in turn may be influenced by fewer CYP accessing their local General Practice facility. The ‘Take the Temperature’ survey which assessed the views of 1535 respondents (predominantly aged 16-25 years) found, “85% knew that they shouldn’t go to a doctor if they got the virus”³. However, it is possible that CYP and parents may not be able to make the often challenging differentiation between symptoms of COVID-19 and what may be another illness in need of medical attention.

There has been a significant increase in pressure on many aspects of the health service, including on primary care. Automated telephone messages have been used as a tool by General Practice to direct service users to the correct service or point of care for some time. As such, it is unsurprising that automated messages may be used to try to address some questions about the pandemic prior to speaking to a call handler at a practice. In addition to this, significantly limiting face to face contact with patients during the pandemic in Primary Care has been essential to prevent the potential spread of the virus and closure of services. We aimed to review the initial advice that parents and carers may be receiving from their first point of contact when telephoning their local General Practice and whether this considered CYP specifically.

Methods
All General Practices within four Clinical Commissioning Groups (CCGs) in NHS Sheffield CCG, NHS Manchester CCG, NHS Leeds CCG and NHS Birmingham and Solihull CCG were identified using the NHS website. These were chosen as they are large cities, with diverse populations.

Practices were only contacted within their standard opening hours by three of the authors, within a four-day time period (7^th July 2020 to 10^th July 2020). The data collected is shown in table 1. All practices were telephoned and identified as to whether they had the following (see table 1):

Table 1: Questions asked during data collection

Percentages, means, standard deviation, and standard error of the mean were calculated. Proportions were compared using Fisher’s Exact test to calculate statistical significance of some data.

Table 2: Reasons for exclusion from analysis

In total, 549 practices were listed under these four CCGs. 12 practices were excluded (see table 2), leaving 537 practices from which we could obtain results.

Table 3: Analysis of results from 537 GP practices

Table 3 demonstrates that of the 537 practices, 81.9% (n=440) had an automated message. When an automated message was present, the mean length was 54.1 seconds (SD = 26.9).
Of all of the practices with an automated message, 65.9% (n=290) mentioned ‘coronavirus’ or ‘COVID-19’ in their message, 34.8% (n=153) gave specific advice to stay away from the practice if the caller had symptoms of COVID-19, 27.3% (n=120) gave advice about self-isolating with COVID-19 symptoms, and 38.4% (n=169) re-directed callers to telephone NHS 111 or visit the NHS 111 website for advice on worsening symptoms. Only 1.1% (n=5) practices mentioned children specifically. Of these, two said that the advice about self-isolating also applied to children, and the other three said the following:
“…anyone with a new continuous cough or fever of 37.8 degrees centigrade or higher must self-isolate for 7 days. This includes children. Travel history is now irrelevant. Anyone with these symptoms who are well are to stay at home and do not need to ring 111 or be tested. Anyone with these symptoms who are unwell should go to NHS 111 online for advice. You must not come to the surgery…”
“…anyone with a new continuous cough and/or a high temperature should stay at home and self-isolate for the next 7 days. This includes children. All other members of your household will need to self-isolate for 14 days even if they remain asymptomatic. Do not attend the university health service, hospital, pharmacy or other NHS service in person. If you have these symptoms, use the NHS 111 online coronavirus service to find out what to do. Do not call NHS 111 unless you cannot get help online…”

“…anyone with a new continuous cough, a fever of 37.8 degrees or higher, or a loss or change to your sense of smell or taste must self-isolate for 7 days. This includes children. Anyone with these symptoms who are well must stay at home and order a COVID-19 test… Anyone with these symptoms who are unwell should go to 111 online for advice. You must not come to the surgery…”

Sheffield CCG had the fewest number of automated messages compared with all the other CCGs:

• Sheffield CCG (n=75, 70.8%) vs Leeds CCG (n=119, 88.8%) p<0.0005;
• Sheffield CCG (n=75, 70.8%) vs Manchester CCG (n=74, 81.3%) p=0.0974;
• Sheffield CCG (n=75, 70.8%) vs Birmingham and Solihull CCG (n=172, 83.5%) p=0.012.
• Sheffield CCG had the most automated messages with advice to stay away from the practice compared with the other CCGs:
• Sheffield CCG (n=44, 58.7%) vs Leeds CCG (n=34, 28.6%) p<0.0001;
• Sheffield CCG (n=44, 58.7%) vs Manchester CCG (n=26, 35.1%) p=0.0052;
• Sheffield CCG (n=44, 58.7%) vs Birmingham and Solihull CCG (n=49, 28.5%) p<0.0001.
• Manchester CCG had the fewest messages with advice to self-isolate compare with the other CCGs: Manchester CCG (n=9, 12.2%) vs Leeds CCG (n=30, 25.2%) p=0.0415;
• Manchester CCG (n=9, 12.2%) vs Sheffield CCG (n=26, 34.7%) p=0.0018;
• Manchester CCG (n=9, 12.2%) vs Birmingham and Solihull CCG (n=55, 32%) p=0.0009. See Table 4.

Table 4: Breakdown of results for individual CCGs

Automated messages were all in English (although a small number of practices provided a translation in other languages after the message) and orated by a mixture of computerised voices, doctors or staff from the practice. Many automated messages indicated a range of options for the caller to be re-directed to a different line (such as to arrange an urgent appointment or to obtain a repeat prescription) but for the purposes of this study, the key data points listed in table 2 were the only parts of the message which were recorded.

There was no statistically significant difference in mean message length between the four CCGs. Sheffield CCG 51.7 seconds (95% confidence interval 46.5 to 56.8); Leeds CCG 55.7 seconds (95% confidence interval 51.2 to 60.1); Manchester CCG 58.0 seconds (95% confidence interval 52.2 to 63.7); Birmingham and Solihull CCG 52.4 seconds (95% confidence interval 48.7 to 56.0) (p<0.05).

Discussion

This study found that very few practices specifically mentioned children in their automated messaging in relation to the current pandemic. 81.9% of the practices contacted had automated telephone messaging. Of these, 65.9% mentioned COVID-19 in their message but only 1.1% (n=5) specifically mentioned children in their message.

38.4% of practices re-directed callers to either the NHS website or NHS 111 telephone advice line. The website advice states, "Call 111 if you're worried about a baby or child under 5. If your child seems very unwell, is getting worse or you think there's something seriously wrong, call 999”⁴. There is also further advice particularly focussed upon babies and very young children on the website. This is helpful advice for parents or carers of an unwell child and it is important that it is emphasised. However, it relies upon parents and carers to make an assessment as to when something may be getting worse or is ‘seriously wrong’. Whilst this would increase the workload for primary care, it perhaps would be more beneficial for CYP, particularly those under 5 years to be triaged by a call handler at the local practice and have a much lower threshold for a telephone consultation with a clinician at the surgery or advice to attend hospital.

This study provides a timely representation of first point of care health advice which is being provided in England during the current pandemic. It seeks to look specifically at automated advice given to CYP and whether this may contribute the delays in presentation to secondary care for acutely unwell CYP which have been seen.

It is difficult to know for certain how this may be directly attributable to the reported delays in presentation of serious illness.

Practices from within only four CCGs were contacted in this study. However, this covered a sizable number of different practices, 537 in total, all of which were in large cities and towns in England. It is notable that we did not assess any advice that may have been given by those answering the telephone call. Once the automated message had been completed there may have been opportunity to provide targeted advice. Also, for the 18.1% (n=97) practices where there was no automated message, we do not know if any further advice is relayed by those answering the call. It may have been at this point when age specific advice might have been received.

To our knowledge there have been no other studies looking at the spectrum of automated messages in General Practice during the COVID-19 pandemic.

This study highlights the need for tailored and consistent advice for CYP specifically during the COVID-19 pandemic.

There is significant variation in the advice being given by different General Practices. The Royal College of General Practitioners (RCGP) states that ‘as with all patients, children should be triaged prior to any face to face consultation’ and ‘every effort should be made to avoid face to face assessment’⁵. It is very important to note that the pandemic has been an extremely challenging time for General Practice with rapid adaptations to working being made in a very short time period. There have been repeated changes in guidance which highlight the challenges faced by General Practice in providing the most up to date information. Since 18^th February 2020, patients with a travel history or suspected symptoms were advised to call NHS 111 and to not go to their local General Practice, pharmacy or hospital⁶. On 5^th March 2020, General Practitioners (GPs) were advised by NHS England to switch to a telephone-only triage system, to reduce the change of potentially infected patients attending the practice⁷. The latest NHS England Standard operating procedure for General Practice (at the time of writing; 24 June 2020, Version 3.3)⁸ offersspecific advice for GPs regarding children; “Prolonged illness and/or severe symptoms should not be attributed to COVID-19 and should be evaluated as usual”. The rapidly changing advice, coupled with large amounts of uncertainty and anxiety among staff in Primary Care may have contributed to the challenges of providing consistent, standard information for service users such as through automated messaging. For some practices, a telephone triage service was a completely novel way of working, making this large process change over a very limited time frame must have been extremely challenging.

Logistically, the ability to alter automated telephone messaging is often not straightforward and, in many cases, requires outsourcing of this to external companies. This requires an already pressured service to keep up to date with rapidly altering advice whilst arranging for a staff member to formulate a new script and then arrange for this recording to be amended. A process which would have been required to be repeated multiple times over the preceding months, due to regularly changing government messaging.

Although evidence continues to emerge, we know that COVID-19 is less likely to develop into serious illness in healthy children and adolescents compared to adults⁹.

There have been concerns regarding a serious but rare complication of COVID-19 infection in children PIMS-TS (paediatric inflammatory multisystem syndrome temporarily associated with SARS-CoV-2). A recent paper in the Lancet¹⁰ reviewing children admitted to PICUs in the UK between 1^st April 2020 and 10^th May 2020 suggested that incidence of PIMS-TS requiring intensive care was around 1.5%. However, at the time only hospitalised patients were being tested for COVID-19 in the UK, so this does not take into account the number of children who may have had COVID-19 but were not tested. As a result, it is likely to be an overestimation. Whilst this condition can be serious, the likelihood of a child progressing to PIMS-TS after developing Covid-19 remains low. The greater concern is delayed presentation of other serious illness.

As other publications have suggested, there is a greater risk that children may delay in presenting to hospital or be delayed in being referred to secondary care for important investigations due to the widespread ‘stay away’ advice, seen in both the UK¹¹ and in Europe¹².

We suggest that adapting the messaging that parents or carers receive when they first contact their GP to include CYP would be possible and may reduce the number of unwell CYP who have delays in receiving medical care. It would also be important to aim to have consistent messaging across different practices, advice which perhaps should be standardised at a national level. This could greatly assist those working in Primary Care to be able to provide accurate and up to date messaging for their patients. Any adaptations required could be made by individual CCGs to take account of local differences.

Increased amounts of wider public health messaging directed towards encouraging parents and carers to seek medical advice if they are worried about their child, despite the pandemic, are paramount to aid in getting this vital message to those caring for CYP. It is important that additionally where appropriate, this advice is also available in languages other than English.

This study does not prove a direct link between the advice provided at the first point of contact in Primary Care and the delays in CYP presenting to hospital with serious illness. We do not know what influence the advice on automated messages has over CYP and their parents in their decision making about accessing care. Future research should seek to answer this question specifically, perhaps involving directly interviewing CYP and their parents or carers.

Introduction:

Aesophagogastroduodenoscopy (EGD), is a common same-day procedure used for both diagnostic and therapeutic purposes during which a small flexible fibreoptic tubular camera is introduced through the mouth and advanced through the pharynx into the oaesophagus, stomach, and duodenum. EGD procedures are performed under deep sedation, since they can elicit significant pain, discomfort, and anxiety. When pain is not controlled properly, this can lead to an increase use of adjunctive medications such as opioids. This can extend the length of stay and increase adverse outcomes.¹ In a prospective, randomised, double-blinded study, Bedirli et al. found that use of opioid medications such as fentanyl are associated with increased adverse outcomes.²

Since procedural sedation-related complications (such as hypoxia, hypotension, desaturation, and emergent airway intervention) remain one of the biggest challenges in EGD procedures, it is important to select the correct medications to reduce these complications.³ Currently, propofol is the most common and popular main procedural sedation agent used for EGD procedures.^4,5

Propofol is the preferred main intravenous agent in EGD procedures due to its amnestic, sedative, and hypotonic properties.⁶ It has also been favoured due to its ultra-rapid response and duration of effects, usually taking 30-60 seconds for onset of action and lasting up to 4-8 minutes.⁷ However, propofol has been associated with significant adverse effects that include dose-related hypotension, bradycardia, laryngospasms, and apnoea.^8,9 Propofol does not have analgesic properties and will usually be combined with opioids for pain control.¹⁰

Ketamine is classified as a dissociative anaesthetic and is known to provide analgesia and amnesia. Important to note, it causes less respiratory or cardiovascular depression when used alone for children greater than 4 months of age.¹¹ However, ketamine alone can cause such side effects of laryngospasm, increase secretions, and vomiting.^12,13

The mixture of propofol and ketamine in one syringe (coined ketofol) has been shown to be effective in sedation for various procedures, such as spinal anaesthesia,¹⁴ along with orthopaedic¹⁵ and cardiovascular procedures¹⁶ in adults and children. Use of this combination has been favoured in brief but painful emergency room procedures due to the opposing haemodynamic and respiratory effects of both sedative medications.¹⁷ The negative cardiac effects produced by propofol can be attenuated with the use of ketamine, resulting in an increase in mean arterial pressures and cardiac indices.^18,19 The complementary effect of both mediations has enabled the use of lower doses for each medication, thus lowering the toxicity and side effects.^20,21 Although there are studies comparing activities of ketofol sedations,^22-25 there has not been a study published on ketofol compared to propofol use in children during EGD procedures.

The primary goal of this study was to determine if there were differences in the outcomes of adverse cardiac and pulmonary events, vital sign parameters including objective pain, and administration of adjunct pain medication (for which fentanyl was used in this study) during EGD procedures between propofol and ketofol groups. A secondary goal was to determine if there was a difference in site performance metrics for EGD procedures (sedation time, stop of sedation to discharge time, and length of stay) between propofol and ketofol groups.

Methods:

This study protocol was approved by the Naval Medical Center Portsmouth Institutional Review Board in compliance with all applicable federal regulations governing the protection of human subjects. Research data was derived from an approved IRB protocol: number NMCP.2018.0021. Written informed consent was not required by the Naval Medical Center Portsmouth IRB, as this data concerned historical dae-identified patients.

Study Design

This was a single centre, retrospective study of a cohort of children (ranging from 2 to 18 years). Data was collected from March 2011 to September 2013 at Naval Medical Center Portsmouth’s Paediatric Sedation Centre. EGD and sedation protocol was not changed during this time period. EGD procedures were performed by the same paediatric gastroenterologists throughout this time period. Sedation was performed by the same paediatric intensivists throughout this time period. All patients used in this study were involved in a same day EGD procedure. Forty-one patients underwent deep sedation via propofol as main sedation agent from March 2011 to May 2012. Forty-nine patients underwent deep sedation via propofol and ketamine combination as main sedation agent from May 2012 to September 2013. Each main sedation agent was given in a similar fashion as an initial intravenous loading dose based on 1 mg/kg propofol followed by an intravenous infusion of 200-250 mcg/kg/minute that was started less than 10 minutes prior to start of the procedure and stopped at the end of the procedure. Ketofol solution used was a 1:5 ratio of ketamine to propofol (40 mg:200 mg). One mcg/kg of fentanyl was given when the sedationist during the EGD perceived the patient experiencing pain. Exclusion criteria included: patients less than 2 years and greater than 18 years, those less than 10 kg, and patients receiving adjunct medications other than fentanyl, ondansetron, or lidocaine.

Data Collection

Fourteen patients were excluded due to weight less than or equal to 10 kg. In addition, 12 patients were excluded due to age less than 2 years or greater than 18 years. Past medical history, ASA class, procedure indications, age, weight, sex, pain scores, vital signs (mean arterial blood pressure [MAP], heart rate [HR], and respiratory rate [RR]), unplanned events (hypoxia defined as SPO2 less than 85% at any time point, and hypotension defined as mean arterial blood pressure with greater than 20% decrease from baseline blood pressure), emergent airway intervention (defined as apnoea needing bag mask ventilation or CPAP use), and unplanned intubation. Vitals and pain scores were obtained from initial presentation in the sedation suite, start of procedure, every 5 minutes during the procedure to stop of sedation, and at time of discharge. Midway procedure vitals used for statistical analysis were obtained by selecting vitals that were at the half-way point of the patient’s EGD procedure. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) was performed every 5 minutes during the EGD procedure by an independent United States Navy Corpsman and used to evaluate patient’s pain prior, during, at stop of sedation, and after procedure for this study.²⁶

Statistics

All statistics performed in this study were calculated using SPSS Statistics programme (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Mann-Whitney U nonparametric test between independent groups was performed to compare age, weight, total EGD procedure time, total time of sedation during EGD procedure, time from stop of sedation to discharge, total length of stay, and total fentanyl use (in mcg/kg) between the two main groups in this study (propofol and ketofol group). The significance level was set to 0.008 after a Bonferroni was corrected, in order to address the probability of making one or more false discoveries when performing multiple hypotheses tests. A repeated measures ANOVA was run to determine the effect of treatments over time for HR, MAP, and RR. Mauchly's test of sphericity was performed for both age groups. The Fisher Exact test was performed to compare propofol to ketofol in unplanned hypotensive events and unplanned apnoea requiring bag valve mask or CPAP. Pearson Correlation statistics were performed to study possible correlations between propofol or fentanyl and sedation time or length of stay. Statistical significance for Pearson Correlation statistics was considered when two-tailed p<0.001.

Results:

Table 1. Demographic divided into 2 age groups. EE= eosinophilic esophagitis. * indicates statistically significant difference.

Figure 1. Propofol amount total per weight (mg/kg). Bars represent standard error of the mean. There was no significant difference between the propofol and ketofol in all age groups.

Figure 2. Fentanyl amount total per weight (mcg/kg). Bars represent standard error of the mean. In all age groups, there was a significant difference between propofol and ketofol. *p<.008.

Figure 3. Vital signs. Mean arterial pressures for ages A) 2-11 years and B) 12-18 years. Main sedative agents’ MAPs were statistically different for ages 2-11 years (p =0.004), but not for ages 12-18 years (p =0.224) for all time periods. Heart rate for ages C) 2-11 years and D) 12-18 years. For Heart Rate, there was a statistically significant interaction between treatment and time for both age group using the Greenhouse-Geisser correction, p =0.002, p =0.014. Main sedative agents’ HRs showed to be statistically different for both age groups, p <0.001 and p =0.004.

Figure 4. Duration of time. A) total sedation time, B) stop of sedation to discharge, and C) total length of stay. In all age groups, there was no significant difference between propofol and ketofol. Bars represent standard error of the mean. *p<0.008.

Figure 5. Pearson Correlation. Propofol versus total sedation time for ages A) 2-11 years (p<0.01*), and B) 12-18 years (p<0.01*). Propofol versus length of stay for ages C) 2-11 years (p<0.01*), and D) 12-18 years (p<0.01*). * Correlation is significant at the 0.01 level (2-tailed).

Figure 6. Pearson Correlation. Fentanyl versus total sedation time for ages A) 2-11 years (p=0.506), and B) 12-18 years (p=0.961). Fentanyl versus length of stay for ages C) 2-11 years (p=0.378), and D) 12-18 years (p=0.352). No significant correlation was not seen for all age groups.

Ninety patients were retrospectively analysed in this study. Baseline demographics were similar between the groups, except for gender proportions (Table 1). Similar amounts of propofol per weight were used in each group (Figure 1). Ketofol significantly reduced fentanyl use in all age groups by ≥.99 mcg/kg compared to propofol alone (p<0.008 for all age groups, Figure 2). In the 2-11 year old age group, the propofol group required a mean fentanyl dose of 1.96 mcg/kg ± 1.24 mcg/kg and the ketofol group required a mean fentanyl dose of 0.44 mcg/kg ± 0.49 mcg/kg; thus ketofol required about 1.52 mcg/kg less fentanyl during EGD procedures. In the 12-18 year old group, the propofol group required a mean fentanyl dose of 1.38 mcg/kg ± 1.05 mcg/kg and the ketofol group required a mean fentanyl dose of 0.39 mcg/kg ± 0.59 mcg/kg; thus ketofol required about 1 mcg/kg less fentanyl during EGD procedures.

Vital signs (HR, RR, and MAP) and CHEOPS pain scores were obtained and analysed for baseline vitals, at the procedure midpoint, at stop of sedation, and at time of discharge. CHEOPS pain scores’ mean was 6 throughout all time periods for both groups, thus there was no statistically significant difference.

A repeated measures ANOVA was run to determine the effect of treatments over time for RR. There was sphericity for the interaction term, as assessed by Mauchly's test of sphericity in both age groups (p =0.070, p =0.762). For RR, there was not a statistically significant interaction between treatment and time for both age groups, p =0.163, p =0.804. The treatments were not found to be statistically different for either age group, p =0.736 and p =0.224.

A repeated measures ANOVA was run to determine the effect of treatments over time for HR. As assessed by Mauchly's test of sphericity, no sphericity was found in either age group (p <0.05). For HR, using the Greenhouse-Geisser correction, a statistically significant interaction was found between treatment and time for both age group, p =0.002, p =0.014. The treatments were found to be statistically different for both age groups, p <0.001 and p =0.004. A repeated measures ANOVA was run to determine the effect of treatments over time for MAP. Sphericity was found in both age groups for the interaction term, as assessed by Mauchly's test of sphericity (p =0.209, p =0.269). For MAP, there was not a statistically significant interaction between treatment and time for either age group, p =0.261, p =0.591. The treatments were statistically different for the 2-11 year old group (p=0.004), but not statistically different for the 12-18 year old group (p=0.224). (Figure 3 A-D)

Unplanned events were analysed for clinically significant hypoxia, hypotension, emergent airway intervention, and unplanned intubations. Ketofol compared to propofol had fewer hypotensive events in the 2-11 year old age group (3.7% versus 15.4%, p=0.192) and in the 12-18 year old age group (0% versus 13.3%, p=0.144). Ketofol compared to propofol had statistically significant fewer apnoea events requiring bag valve mask or CPAP intervention for the 2-11 year old group (3.7% versus 53.8%, p<0.001) and for the 12-18 year old group (0% versus 33.3%, p=0.005). There were no significant hypoxia events. There was one unplanned intubation in the propofol group of a healthy ASA I twelve year old female who had a 20 mL emesis episode after a loading dose of propofol was given on induction. (Table 1)

With propofol leading to significantly more fentanyl usage, more hypotension and emergent airway intervention during EGD procedures, we performed analysis to see if there was an effect on sedation time, time from stop of sedation to discharge, and length of stay (LOS). In all age groups, there was no statistical difference between propofol and ketofol for sedation time (p=0.115 for ages 2-11 years, p=0.124 for ages 12-18 years), time from stop of sedation to discharge (p=0.033 for ages 2-11 years, p=0.511 for ages 12-18 years), and LOS (p=0.026 for ages 2-11 years, p=0.109 for ages 12-18 years) (Figure 4). Based on Pearson correlation test, it was established that propofol was positively correlated with sedation time and LOS (+0.753 for sedation time and +0.611 correlation for length of stay with <0.001 significance) (Figure 5). There was no significant correlation between fentanyl and sedation time or LOS (Figure 6).

Discussion:

This was a retrospective study looking at 90 paediatric patients, ages 2-18 years, undergoing EGD procedures with either propofol or ketofol as the main sedative medication. Patients in this study had similar weights, ages, ASA scores, and EGD indications; however there baseline demographics were not similar with regards to gender proportion (Table 1). Based on the large prospective database on sedation use for procedures outside the operating room obtained by the Paediatric Sedation Research Consortium,²⁷ we separated our patient population into two age risk groups to allow our results to be generalisable. To our knowledge, this study is the first to show that ketofol, when compared to propofol, significantly reduces fentanyl use (≥.99 mcg/kg, Figure 2) and cardiopulmonary adverse outcomes (Table 1) in paediatric EGD procedures.

EGD procedures are known to be invasive and painful. To decrease the pain appreciated by a patient, various adjuncts are often utilised. In our study, we used fentanyl for adjunct pain control. In both main sedation medication groups (propofol and ketofol), there was no statistical significance seen in objective pain based on CHEOPS scores with a mean score of 6 in all age groups (p>0.05). However, the amount of adjunct needed to maintain adequate pain control between both groups statistically and clinically differed (Figure 2). In all age groups, the propofol group compared to the ketofol group required almost 1 mcg/kg more of fentanyl, which leads to the potential for the patient to experience higher incidence of side effects, such as respiratory depression and hypoxia.^28-30

The mechanism that lead to this significant difference in opioid demand between ketofol and propofol is most likely due to ketamine’s ability to stimulate opioid sigma receptors,31 thus leading to opioid sparing effects. It is unclear if propofol and ketamine interaction heightens this opioid sparing effect, because ketamine alone has not been shown to lead to opioid sparing effects in children.³²

In a review of our population’s vital signs, there was a significantly higher MAP in the ketofol group compared to the propofol group for ages 2 to 18 years (Figure 3 A-B). In addition, the ketofol group had statistically higher HR compared to the propofol group for ages 2 to 18 years (Figure 3 C-D). It is our thought that this increase in MAP and HR in the ketofol group mediated by ketamine is a protective factor against major hypotensive changes (31). It is this effect that minimised unplanned hypotensive events in our ketofol group compared to the propofol group by 11.7% in ages 2-11 years and 13.3% in ages 12-18 years (Table 1).

One of the more noticeable differences in our main sedative medication groups was the unplanned apnoea events requiring CPAP or bag mask ventilation intervention. In our 2 to 11 year age group, propofol had 50.1% more apnoea events needing intervention compared to ketofol. In our 12 to 18 year old group, propofol had 33.3% more apnoea events needing respiratory intervention compared to ketofol. This was found to be statistically significant. It is unclear if this is also clinically significant since no emergent airway intubation was needed for these events. However, there was 1 emergent airway intubation in the 12-18 year old propofol group. Based on the review of the medical records, it appears that these apnoea events needing respiratory intervention were mostly associated after the initial loading dose of either propofol or ketofol prior to or at the start of the infusion. Thus, bring into question if not starting with a loading dose bolus would decrease adverse effects.

Despite the propofol group requiring more respiratory intervention, increased fentanyl use, and less haemodynamic stability seen, there was no statistical differences in total sedation time and LOS between the two main sedation medication groups (Figure 4). Yet when we ran correlation statistics, there was a positive correlation to increased propofol dosages, total sedation time, and LOS in ages 2 to 18 years (Figure 5); therefore, if our procedures were longer, there could be a statistically and possibly clinically significant increase in total sedation time and LOS for the propofol only group. Thus, we can infer that propofol compared to ketofol is not the main sedation medication of choice for longer similarly painful procedures in children ages 2 to 18 years, such as EGD procedure followed by a colonoscopy.

A limitation of our study is that it is retrospective. With that, we were not able to blind our sedationists to the main sedation medication that was chosen and could not control the interventions that were performed. Yet, based on strict exclusion criteria, we were able to control the interventions used in our analysis. Also, in our study we did not analyse patients under the age of 2 years. Reviewing the data, we had seven patients, and thus this patient population size was not powered to perform the proper statistical analysis. Another limitation to consider is the time difference in procedure protocols. However, since this study included over 2 years of data, procedure protocols were the same. Additionally, the EGD indications were similar between ketofol and propofol (Table 1). Another consideration of this study is generalisability. This study was conducted at a single centre, but the way we analysed our results makes it easier to perform large scale prospective studies to further investigate our findings. Last limitation is directly correlating fentanyl dose with a significant adverse event. Due to the short length of the EGD procedure, constant sedation medication infusion, and fentanyl dose, it is difficult to directly say that a particular fentanyl dose alone leads to an adverse event. Therefore we can only speculate based on correlation.

Conclusions:

Our study found that ketofol significantly reduced fentanyl use in all age groups by ≥0.99 mcg/kg and cardiopulmonary adverse events compared to propofol alone. In addition, an increase in the amount of propofol was positively correlated to increasing LOS and total sedation time for a child undergoing an EGD procedure. This suggests that increasing amounts of propofol leads to greater LOS. To conclude, our study indicates that ketofol can be a safer alternative to propofol use alone for deep sedation in EGD procedures for children ages 2 to 18 years.

A dermatoscope is a hand-held device for examining the appearance of the skin. Dermoscopy has become an increasingly used and valued tool in the assessment of various skin lesions, and more recently, inflammatory rashes. It is quick, cheap and when used correctly, dermoscopy is an essential tool in helping clinicians detect early stage skin cancer. Various national and international guidelines recommend routine use of dermoscopy in the assessment of pigmented lesions^1,2 because it enhances melanoma detection rates^3,4 and can help confirm the diagnosis of benign lesions such as haemangiomas and seborrhoeic keratoses. As with any skill, competency takes time to develop and a combination of various learning and assessment methods is best. The dermatology specialist training curriculum in the United Kingdom (UK) states that trainees should be competent in using a dermatoscope and interpreting findings, while recognizing the limitations of this tool⁵. Assessment of these clinical skill and behavioural competencies using direct observation of procedural skills (DOPS), case-based discussion (CBD), mini clinical examination (mini-CEX), and/or multisource feedback (MSF) is suggested. There is no specific guidance on what resources a trainee should use to achieve these competencies, nor on what is the minimum expected dermoscopy skillset at completion of specialist training.

The aim of this survey was to explore dermoscopy use amongst dermatology specialist trainee registrars in the UK including frequency of use, how it is being taught and whether trainees feel their dermoscopy training has been adequate.

An online survey was designed and distributed to dermatology trainees in the United Kingdom using an email link and hard copies were distributed at a national dermoscopy course. Respondents who did not identify themselves as dermatology trainees were removed from the analysis. Responses were collected anonymously, then collated and analysed using SurveyMonkey® computer software.

Twenty-five percent (59/238) of dermatology trainees completed the survey. On average, 92% (54/59) use dermoscopy more than once daily. Eighty-five percent (50/59) always use dermoscopy when assessing pigmented lesions while 34% (20/59) always and 59% (35/59) sometimes use it to assess non-pigmented lesions. When asked about specific tools used to learn dermoscopy, 41% (24/59) have been on a previous course, 42% (25/59) reported attendance at a lecture or seminar, 46% (27/59) have used a dermoscopy text book, 14% (8/59) have attended a conference, 19% (11/59) have used online resources. Seventeen percent (10/59) have never used any of the above learning methods. (Figure 1a). Amongst those who have attended a formal dermoscopy course (n=24), 92% (22/24) of these were ≤1 day in duration. When questioned about informal teaching in clinical practice, 12% (7/59) frequently, 56% (33/59) sometimes, 31% (18/59) rarely and 2% (1/59) never receive teaching from their supervising dermatology consultant. (Figure 1b). Fifty-four percent (32/59) feel they have received adequate training in dermoscopy while the remaining 46% (27/59) feel their dermoscopy training is inadequate for their training stage (Figure 1c). Seventy-three percent (43/59) have access to dermoscopic photography within their local dermatology department.

Fig 1a - Have you undertaken any formal study in dermoscopy? 49% of trainees have attended a lecture, 2% a seminar, 14% a conference, 41% a course, 19% have used an online resource, 46% have used a book, 17% have not used any resource.

Fig 1b- Do you receive dermoscopy training from your supervisor in clinic? 56% of trainees sometimes, 31% rarely, 12% frequently, and 2% have never received training from their seniors in clinic.

Fig 1c- Do you believe that you have received adequate training in the use of a dermoscopy for your training grade?

These results of this survey highlight the need for dermoscopy training to be reviewed within the UK national training curriculum for dermatology. Despite daily use by the vast majority, dermoscopy training is largely self-directed and highly variable amongst individual trainees. Of concern, a significant proportion of those who responded feel their dermoscopy skills are inadequate for their training stage. Of note, the 25% response rate means that the results of this survey may not be representative of dermatology trainees in the United Kingdom as a whole.

This is the first time that dermoscopy use has been explored through a national survey of dermatology trainees in the UK, to the best of our knowledge. A survey on dermoscopy use was carried out by The British Association of Dermatologists (BAD) in 2012⁶ but the majority of responses were from dermatology consultants. This confirmed that 98.5% of respondents regularly used dermoscopy, while 81% had received any training. The most frequent source of training was UK based courses, which 62% of respondents reported attending. Of note, 39% of all respondents lacked confidence when making a diagnosis based on their interpretation of dermoscopy findings. It is not clear how many of those lacking in confidence were consultants, trainees or specialty doctors. Although the situation may have improved since 2012, these results do suggest that dermoscopy training needs have not been met for a proportion of doctors across the dermatology community.

Dermoscopy training is an important issue to address for several reasons. The volume of cutaneous lesions being referred to dermatology is increasing, and skin cancer referrals and treatment now account for 50% of a UK dermatologists’ workload⁷. For every melanoma diagnosed, a dermatologist may expect to see 20–40 benign lesions referred from general practitioners (GPs)⁷. These facts highlight the importance of maximising diagnostic skills which frequently include using dermoscopy as part of clinial assessment. Lack of adequate training is a common self-reported reason for dermatologists not using dermoscopy⁸. Both trainees and their supervising bodies have a responsibility to maximize training opportunities and embed the use of dermoscopy in routine practice.

In conclusion, we feel UK dermatology trainees and indeed any clinician who utilizes this tool, would benefit from a more standardized and integrated approach to dermoscopy teaching to ensure safe practice of this skill and deliver high quality evidence-based patient care.

Introduction

Telephone triage has been used by many practices in primary care to manage workload and prioritise patients for same day appointments.^1,2 Telephone triage may have benefits in terms of managing work load,³ but is also associated with certain risks,⁴ which has worried both clinicians and patients.⁵ The analysis of the use of telephone triage has so far focused on the ease of access, demand management, cost effectiveness, quality of consultations, safety and patient satisfaction. However, other effects in terms of patient outcome may exist. One of the main focuses in General Practice is to identify symptoms and signs of cancer for early diagnosis to improve outcome. Our study aims to assess whether telephone triage helps in prioritising early assessment and referral of patients who are subsequently diagnosed with cancer.

Methods

A retrospective analysis of all the patients at our practice who had a diagnosis of cancer made between April 2013 and December 2014 was carried out.

Patients have a choice of 2 different ways to book an appointment in our practice.

1. Telephone triage for same day appointment requests, where a triaging doctor decides about the urgency of a problem and books the appointment, arranges tests or gives advice after speaking to patients over the phone. This group is referred as “Group 1” in this study.
2. Patients book the next available appointment to see a GP through reception without any triage. This group is referred to as “Group 2” in this study.

The date of first contact with the GP practice for the symptoms which later lead to a diagnosis of cancer was noted for both groups. This was the telephone triage date for the first group and the date the appointment was booked by the patients for the second group. The date the patient was first seen in secondary care for further assessment and investigations was also noted. The duration between first contact with GP practice and GP appointment, and the duration between the first contact with practice and first hospital appointment were calculated. This information was gathered from practice computer records.

Patients who were diagnosed with cancer through screening were excluded. Slow growing tumours which do not merit a 2-week rule referral, such as basal cell cancer of skin were excluded. Patients whose appointments were initiated by the GP on reviewing the results of routine tests were not included. Patients diagnosed with cancer in hospital without going through primary care referral were also excluded from this study.

There are two research questions:

1. Is there a significant difference in the time required from the first contact with primary care to the GP Clinic appointment between Group 1 and Group 2 patients?
2. Is there a significant difference in the time required from the first contact with primary care to the date the patient was seen in the secondary care between Group 1 and Group 2 patients?

Descriptive statistics (such as the mean, standard deviation, median, minimum, and maximum) were used to present the time required from the first contact with primary care to the GP Clinic appointment; and the time required from the first contact with primary care to the date patient seen in the hospital, for Group 1 and Group 2 patients. Wilcoxon rank-sum test was used to answer each research question. A p-value less than 0.05 indicated significance at the 0.05 level.

All data analyses were conducted using SAS.

Results

A total number of 39 patients were included in the study. Among them, 13 (33%) used telephone triage to make their appointments and 26 (67%) booked their appointment by themselves.

Figure 1 shows the bar charts of the time required from the first contact to GP practice, to the GP clinic appointment for Group 1 and Group 2 patients. It took 0-3 days for 12 Group 1 patients and 8-11 days for 1 Group 1 patient. The time required from the first contact to GP practice to the GP Clinic appointment for Group 2 patients can be illustrated by the same manner.

Figure 1: Bar charts of the time (days) required from the first contact for surgery to the GP Clinic appointment for Group 1 and Group 2 patients. (Note that the midpoints 2, 6, 10, 14, 18, and 22 represented days within the range of 0-3, 4-7, 8-11, 12-15, 16-19, and 20-23, respectively.)

Table 1 shows the summary statistics for the time (days) required from the first contact with the practice, to the GP Clinic appointment for Group 1 and Group 2 patients. The average time required was 0.77 days for Group 1 patients and the average time required for Group 2 patients was 7.88 days. The results of Wilcoxon rank-sum test indicated that this was a statistically significant difference in time required from the first contact for surgery to the GP Clinic appointment between Group 1 patients (patients using Telephone triage to make their appointments) and Group 2 patients (patients booking their appointment by themselves) (p = 0.0020).

Table 1:Summary statistics for the time (days) required from the first contact for surgery to the GP Clinic appointment for Group 1 and Group 2 patients. SD = standard deviation.

Figure 2 shows the bar charts of the time required from the first contact with the GP practice, to the date patients were seen in the secondary care for Group 1 and Group 2 patients. It took 0-5 days for 4 Group 1 patients, 10-19 days for 5 Group 1 patients, 20-29 days for 1 Group 1 patient, 30-39 days for 2 Group 1 patients, and 90-99 days for 1 Group 1 patient. The time required from the first primary care contact to the date patient seen in the secondary care for Group 2 patients can be illustrated by the same manner.

Figure 2: the bar charts of the time required from the first contact for surgery to the date patient seen in the hospital for Group 1 and Group 2 patients. (Note that the midpoints 5, 15, 25, 35, 45, 55, 65, 75, 85 and 95 represented days within the range of 0-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89 and 90-99, respectively).

Table 2 shows the summary statistics for the time (days) required from first contact with GP practice to the date patients were seen in the hospital for Group 1 and Group 2 patients. The average time required for Group 1 patients was 19.54 days and the average time required for Group 2 patients was 35.69 days. The results of Wilcoxon rank-sum test indicated that this was a statistically significant difference in time required from the first contact to the primary care to the date patient seen in the hospital between Group 1 patients (patients using Telephone triage to make their appointments) and Group 2 patients (patients booking their appointment by themselves) (p = 0.0474).

Table 2: Summary statistics for the time (days) required from the first contact for surgery to the date patient seen in the hospital for Group 1 and Group 2 patients. SD = standard deviation.

Table 3: Number of patients with types of cancer.

Discussion

More than 90% of contacts with healthcare in the UK occur in primary care.⁶ The estimated numbers of consultation for a typical practice in England rose from 21,100 in 1995 to 34,200 in 2008 as per analysis conducted by Hippisley-Cox J et al.⁷ With increasing demands being placed upon General Practice, there is a need to explore innovative ways of working which enable the prioritisation of patients with concerning symptoms. Telephone triage has been considered to reduce the demand for face-to-face consultation with GPs,³ which can potentially free up time for effective use. NHS England report ‘Transforming Urgent and Emergency Care Service in England’ suggests GPs should offer more telephone consultations to reduce pressure on accident and emergency.⁸ However, a cluster-randomised controlled trial (The Esteem Trial) across 42 practices showed that telephone triage increased the number of primary care contacts in the following 28 days, after patients’ request for same day GP consultation.¹

With increasing demands for consultations, it is important to have a system to identify and prioritise patients for early assessment; who may have a suspected cancer diagnosis. Our study demonstrates that telephone triage reduces the time from first primary care contact to face to face assessment in primary and secondary care for patients with suspected cancer. Patient numbers are small and the sample is from one practice, yet the difference seen is statistically significant.

Cancer stage at diagnosis is one of the major reasons for difference in cancer survival in different countries.^9,10 The delay in cancer diagnosis can be due to multiple factors. Telephone triage can provide an opportunity to patients to discuss symptoms early with a GP, and this can reduce delays in the cancer diagnosis pathway. It has been shown that certain alarm symptoms are associated with the likelihood of cancer diagnosis ¹¹ and these can be used to prioritise the patients in triage process. It may also reduce anxiety amongst patients waiting for an appointment, who are concerned about their symptoms.

Telephone triage should not only be seen as a way of managing demands and appointments but also as a system to improve patient outcome. Further research is clearly needed on a larger scale to determine if the results are reproducible in other settings as patients’ knowledge and understanding about cancer warning symptoms and healthcare seeking behaviour may vary among different population sets.

Introduction

Chest pain accounts for 1% of all GP consultations, but in only 8%-18% of cases is it an indicator of underlying ischemic heart disease.¹ Given the potential diagnostic uncertainty associated with chest pain at initial presentation, specialist evaluation of patients in a Rapid Access Chest Pain Clinic (RACPC) is of value and represents an important process in the evaluation of symptoms. These clinics were established with the aim of providing rapid outpatient assessment of patients with suspected cardiac disease in order to permit earlier provision of appropriate treatment and investigations where required.

Stable chest pain typically presents as angina, a triad of dull central chest pain, brought on with exertion and relieved by rest or GTN spray. The aetiology is usually stable atherosclerotic plaque disease which is associated with low mortality and can be treated with oral anti-anginals, as demonstrated by meta-analyses and the landmark COURAGE study. ^{2, 3}

NICE Clinical Guideline 95 (NICE CG95) suggests that choice of initial investigation for stable chest pain should be guided by a patient’s pre-test probability of having CAD. Calculations of the pre-test probability take into consideration a patient’s age, gender, cardiac risk factors and symptoms. Patients are defined as high risk of cardiac disease if they have diabetes, smoke or have hyperlipidaemia (total cholesterol >6.47mmol/litre). Patients with none of the above are considered low risk. Symptoms are defined as “typical angina” if the pain is: 1) constricting discomfort in the front of the chest or in the neck, shoulders, jaw or arms; 2) is precipitated by physical exertion and 3) is relieved by rest or GTN spray within approximately five minutes. Pain is defined as “atypical angina” if only two of the above criteria are met and defined as “non-anginal” if one or none of the above criteria are met.

NICE pre-test probabilities of CAD (Table 1), are based on a version of Diamond and Forrester’s pre-test probabilities published in 1979, modified using data from Duke’s cohort study, published in 1993.^{4, 5, 6} Recent studies suggest that these NICE pre-test probabilities may overestimate the prevalence of CAD in a primary care population and may risk over investigating patients.^{7, 8} In addition to having financial implications, this may cause patients undue anxiety and unnecessarily put them at risk of complications.

Table 1: NICE Clinical Guideline 95 pre-test probabilities table.

Each cell represents the percentage risk of each group of patients having CAD, based on their typicality of symptoms, gender, age and cardiac risk factors (lo, low and hi, high)⁴

ESC guidelines utilise an updated, validated model of the Diamond-Forrester model by Genders et al. to create pre test probabilities of CAD (Table 2), based on patient’s age, gender and typicality of symptoms. ^{9, 10}

Table 2: ESC guidelines clinical pre-test probabilities in patients with stable chest pain symptoms 

Each cell represents likelihood of each group of patients having CAD, based on typicality of symptoms, age and gender.⁹

We hypothesised that strict adherence to NICE guidelines results in over-estimation of the pre-test probability of CAD and therefore over-investigation of patients presenting with stable chest pain. ESC guidelines may offer more accurate pre-test probabilities of CAD and allow a more targeted and cost-effective use of investigations.

Methodology

Clinic records of all patients who attended the RACPC at Tunbridge Wells Hospital between July 2005 and December 2012 were reviewed. This service is run by a cardiology specialist. Patient demographics, cardiac risk factors and information regarding the nature of patient symptoms were collected prospectively and completed at the time of the patient’s RACPC appointment. Results of cardiac investigations were collected from paper and computerised records, and included diagnoses of significant CAD made following invasive coronary angiogram. These results were compared with patients’ pre-test probabilities of CAD calculated using both NICE and the ESC’s calculation methods. Outcome and readmissions were obtained from electronic records from the Maidstone and Tunbridge Wells NHS Trust computer records retrospectively.

Results

Study population

A total of 1968 records were reviewed. 59% (n = 1162) of patients were male and 41% (n = 806) were female. Their mean age was 60 years. At initial assessment, 69.8% patients (n=1373) had non-anginal chest pain, 19.5% (n=383) had atypical angina and 10.8% (n=212) had typical angina, based on the NICE guideline definitions of chest pain.

97.2% (n= 1912) patients underwent further investigation; 15% (n=256) of these were subsequently diagnosed as having significant CAD, accounting for their symptoms. The 2.8% (n=56) of patients who did not undergo investigation either chose not to, were unable to, were lost to follow up, or were diagnosed as having a non-cardiac cause of their symptoms at the initial RACPC appointment.

NICE CG95 pre test probabilities compared against cohort data

Table 3: NICE guidelines 95 pre test probabilities compared against cohort data

Each cell represents the proportion (%) of cohort patients from each group who were diagnosed with CAD. We have colour-coded cells to represent the NICE estimated pre-test probability of CAD in each group. Red cells represent 61-90+% probability, pink cells represents 30-60% probability, blue cells represent 10-29% probability and white cells represents <10% probability of CAD according to NICE Guidelines. “ – “ marks a cell where pre-test probabilities of CAD could not be calculated for cohort patients.

Table 4: A comparison of NICE pre-test probabilities and cohort patient data.

The risk of CAD as predicted by NICE guidelines 95 on the left compared with the actual number of cohort patients in each category and the proportion of those patients diagnosed with significant CAD.

The average discrepancy between the pre-test probability and actual incidence of CAD in cohort patients was 28% (range 20% - 88%). In 48% of cells in the NICE CG95 pre-test probability table (Table 1) the pre-test probability of CAD was overestimated by 30% or more (Table 3). A marked discrepancy between pre-test probability and actual incidence of CAD was found between “high risk” and “very low risk” patients. On average, high risk patients had an overestimated pre-test probability of 34.3 – 40.9% per cell compared with low risk patients whose pre-test probability was only overestimated by 6.5% (Table 3).

The cells highlighted in dark red in table 3 represent high risk patients whose pre-test probability was of 61-90+%, according to NICE CG95. In our cohort, only 31.2% (n=214, 95% CI 27.6-34.5) of high risk patients in this category were diagnosed with CAD. On average, actual incidence of CAD compared with pre-test probability was overestimated by 34.4% – 40.9% in each cell.

The pink cells in table 3 represent medium risk patients with a pre-test probability of CAD of 30-60%, according to NICE CG95. In our cohort, only 4.4% (n=24, 95% CI 3.0 – 6.5) of medium risk patients had a positive angiogram (Table 4). The average overestimate of actual incidence against pre-test probability was 35.9%.

The cells highlighted in blue in table 3 represent low risk patients with a pre-test probability of CAD of 10-29%, according to NICE CG95. In our cohort, only 2.5% (n=7, 95% CI 1.2 – 5.0) of low risk patients were diagnosed with CAD (Table 4). On average, the pre-test probability of CAD exceeded the found incidence of CAD by 18.6% (Table 3).

The white cells in table 3 represent very low risk patients with pre-test probability of CAD <10% according to NICE CG95. In our cohort, only 0.28% (n= 1, 95% CI 0.1 – 1.6) of patients were diagnosed with CAD. Average overestimation in this group was 6.5% in each cell.

ESC guidelines pre test probabilities compared against cohort data

Table 5: A comparison of ESC pre-test probabilities with cohort patient data.

Each cell shows the proportion (%) of cohort patients from each group diagnosed with CAD. Each cell is colour coded to correspond with the ESC estimated pre-test probability. Dark red cells represent >85% probability, pale pink cells represent 66-85% probability, pale blue cells represent 15-65% probability and white cells represent <15% probability.

Table 6: A comparison of ESC pre-test probabilities and cohort patient data

The risk of CAD as predicted by ESC guidelines on the left compared with the actual number of cohort patients in each category and the proportion of those patients diagnosed with significant CAD.

The average discrepancy between pre-test probability of CAD, according to the ESC’s risk stratification table, and actual incidence of CAD in cohort patients was 20.7%. In 28% of cells, the pre-test probability of CAD exceeded the found incidence of CAD by 30% or more (Table 5).

The cells highlighted in dark red in table 5 represent very high risk patients with a pre-test probability of CAD greater than 85%, according to ESC guidelines (Table 5). 73.4% (n= 58, 95% CI 63.7 – 82.7) of cohort patients in this high-risk category were diagnosed with CAD (Table 6). On average, incidence of CAD in each cell has been overestimated by 13% in this category.

The cells highlighted in pale pink in table 5 represent high risk patients, with a pre-test probability of CAD of 66-85%, according to ESC guidelines. 58.5% (n=103, 95% CI 51.1 – 65.5) of cohort patients in this high-medium risk category were diagnosed with CAD (Table 6). On average, the pre-test probability of CAD exceeded the found incidence of CAD in each cell by 17.7% (Table 5).

The cells highlighted in pale blue in table 5 represent medium risk patients with a pre-test probability of CAD of 15-65%, according to ESC guidelines. 6.4% (n=93, CI 5.3 –7.8) of cohort patients in this risk category were diagnosed with CAD (Table 6). On average, the pre-test probability of CAD exceeded the found incidence of CAD by 24.1%in each cell (Table 5).

The cells highlighted in white in table 5 represent patients whose pre-test probability of CAD was less than 15% according to ESC guidelines. Only 0.76% (n=2, 95% CI 0.2 –2.7) of cohort patients in this risk category were diagnosed with CAD (Table 6). On average, pre-test probability of CAD exceeded found incidence of CAD in each cell by 6.2% (Table 5).

Discussion

Only 15% of a total of 1968 patients referred to RACPC were diagnosed with significant CAD. The majority (70%) of referred patients had “non-anginal” chest pain and low pre-test probabilities of CAD, reflecting the importance ascribed by General Practitioners of ruling out ischemic heart disease as the underlying cause for chest pain, even in low risk patients. This may not be surprising given the large media attention to heart disease and sustained campaigns for early warning signs of heart attack in the British media. It is therefore of great public interest for cardiac disease to be identified.

NICE CG95 pre test probabilities compared against cohort data

Comparing cohort data to the pre-test probabilities of CAD outlined in NICE CG95, NICE have overestimated the number of patients likely to have CAD in the majority of groups. Strict adherence to NICE CG95 therefore carries the risk of over-investigating patients. NICE recommend CT calcium scoring as the first line investigation for patients with a low (10-29%) pre-test probability of CAD. 284 patients fall into this category and only 7 patients were shown to have CAD. This means that 40.5 patients need to be treated in order to identify 1 positive patient (NNT= 40.5).

In patients with a medium (30-60%) pre-test probability of CAD, NICE recommends functional imaging as the first line diagnostic investigation. In our cohort 544 patients would undergo functional imaging, but only 24 of these patients would be diagnosed with CAD, NNT=22.7.

Finally, in patient groups with a high (61-90%) pre-test probability of CAD, NICE recommends invasive coronary angiography as the first line diagnostic investigation. In our cohort of 1968 patients, 691 patients had a high pre-test probability of CAD, and 214 had significant coronary artery disease on angiography, NNT= 3.2.

Although invasive coronary angiography is considered the gold standard investigation for diagnosing CAD, and permits simultaneous therapeutic intervention, the procedure is not without risk, particularly in elderly patients and those with renal impairment.¹¹ Furthermore, invasive angiography is expensive and is costed by the East Kent Hospitals University NHS Foundation Trust at £1166.02 per procedure (private correspondence).

NICE CG95 offers no guidance on managing patients who have a <10% pre-test probability of CAD. 347 of our cohort patients fell into this very low risk category and only 1 was diagnosed with CAD. Therefore, NICE CG95, if strictly adhered to, would have missed one diagnosis of CAD in our patient cohort.

ESC pre test probabilities compared against cohort data

ESC guidelines tend to offer more conservative estimates of pre-test probability of CAD compared with NICE guidelines. Using the ESC’s risk stratification table, almost all patients, except those with over 85% pre-test probability and those with less than 15% pre test probability, would be investigated for chest pain. This is due to their claim that non-invasive, image-based diagnostic methods for CAD have typical sensitivities and specificities of around 85%, so that roughly 15% of these investigations could be yielding false results. Hence, due to these inaccuracies, in patients with pre-test probabilities of CAD below 15% or above 85%, ESC state that performing no test at all could provide fewer incorrect diagnoses.⁹

In our patient cohort, 79 patients had very high (>85%) pre-test probability of CAD, but only 58 patients (73%) were diagnosed with CAD. For this patient risk group, ESC guidelines suggest that further investigation may not be necessary and that a diagnosis of CAD may be assumed. Thus, applying ESC guidelines to our cohort could result in 21 patients being incorrectly diagnosed with stable angina, and more serious causes of chest pain, for example pulmonary emboli or gastric ulceration, may be missed. However, in practice, it is likely that many patients in this very high pre-test probability category would have undergone angiography, because patients who have "severe symptoms" or who are clinically thought to have "high risk coronary anatomy" should be offered an invasive angiography with or without pressure wire studies. The vagueness of the guidelines allows interventionists to interpret this in the clinical context.

In ESC guidelines, invasive coronary angiography is not specifically recommended as a first line investigation for stable angina, regardless of the pre-test probability of CAD. In patients with a high (66-85%) pre-test probability of CAD, ESC guidelines recommend non-invasive functional imaging first line. Of the 176 patients who fell into this category, only 102 (58.0%) patients were ultimately diagnosed with CAD.

In patients with medium (15-65%) pre-test probability of CAD, ESC guidelines advise exercise ECG testing (or non-invasive imaging for ischemia if local expertise is available) as first line diagnostic investigations. Of the 1451 patients which fell into this category, only 93 were diagnosed with CAD, NNT= 15.6. Fortunately, exercise ECG testing would not expose the patient to potentially harmful radiation or medication, but their poor diagnostic power may result in the need for further investigations, despite a negative result.

In patients with low risk of CAD (<15%) ESC guidelines suggest making an assumption that the patient does not have CAD and advocates conducting no further investigations. In our cohort, 263 patients fell into this low risk category, two (0.8%) of which were diagnosed with CAD.

The ESC guidelines appear to have higher specificity than the NICE guidelines, and only two patients would have been missed had ESC guidelines been adhered to, compared to one patient missed if NICE guidance was used. Thus, although highly sensitive, ESC guidelines when applied to our cohort have lower sensitivity than NICE guidelines.

Comparison of number of investigations

Following ESC guidance for our cohort of patients would have resulted in fewer diagnostic invasive angiograms being performed than if NICE guidance had been followed. ESC guidance only recommends invasive angiography if first line, non-invasive investigations generate positive results. Overall, however, ESC guidance would result in a greater number of overall investigations being performed.

In total, NICE advises that all 691 of our high risk cohort patients should undergo invasive angiography as a first line investigation. 544 with medium risk should undergo functional testing first and 24 of these patients (assuming an angiogram would follow a positive result) would go on to have invasive angiography. 284 low risk patients should undergo CT calcium scoring first, of which 7 would go on to have functional imaging and angiography if the above logic is followed. This generates a total of 1557 investigations; 722 angiograms, 551 functional imaging investigations and 284 cardiac CT scans.

In comparison, using ESC guidance, 176 of our high risk patients would have functional imaging investigations, 103 patients with positive results would then undergo invasive angiography. 1451 patients would receive exercise ECGs, of which 93 with positive results would undergo functional imaging and invasive angiography. This generates a total of 1916 investigations; 196 angiograms, 269 functional imaging investigations and 1451 exercise ECGs.

If we assume that stress echocardiograms are used as “functional imaging” we can estimate costs for our cohort when applying each set of guidelines. Costs for each investigation are supplied by East Kent Hospitals University NHS Foundation Trust and are as follows: Outpatient elective coronary angiograms are costed at £1,166.02; stress echocardiograms are costed at £132.30; exercise ECGs at £40.26 and CTs of one area at £102.47 (private correspondence). If we were to apply NICE guidelines to our cohort, £841,866.44 would be spent on angiograms, £72,897.30 would be spent on stress echocardiograms and £29,101.48 on CT scans. This is a total of £943,865.22 on investigations.

If we were to apply ESC guidelines to our cohort, £228,539.92 would be spent on coronary angiograms, £35,588.7 would be spent on stress echocardiography and £58,417.26 would be spent on exercise ECGs. A total of £322,545.88 would be spent on investigations. Overall, this is £621,319.34 cheaper than applying NICE guidelines.

Limitations of study

This study is based on data from a single site and may not be nationally representative. The final diagnosis was made clinically by an experienced interventional cardiologist, which introduces subjectivity and the risk of interpreter bias. Not all patients underwent the gold standard of invasive coronary angiography to demonstrate the presence of CAD. However, all patients were seen and fully assessed by a cardiologist and 97% underwent investigations if deemed necessary.This study has all the limitations of a registry study. In addition, costs for investigations may vary throughout the country, and indeed the world, with varying expertise available.

Conclusion

In conclusion, strict adherence to NICE CG95 over-estimates the pre-test probability of CAD in our local population group. This is consistent with previous studies conducted in South London where there is a larger Afro-Caribbean population, as well as with studies conducted in the North of England.^8,9 Adherence to ESC guidelines in place of NICE guidelines may enable a more targeted and cost-effective use of investigations. Strict application of the ESC guidelines to the study cohort would have resulted in investigations costing an estimated £322,545.88, compared to £943,865.22 if NICE guidelines were applied. However, conducting fewer investigations carries greater risk of misdiagnosis, and using ESC guidelines in isolation introduces the possibility of assuming CAD in patients without conducting investigations to confirm this.

It is advisable that local cardiology departments audit their stable chest pain guidelines to ensure that the interpretation of pre-test probabilities is in keeping with the local population. Unfortunately there is no ideal policy and local protocols should reflect the local population.

An audit and re-audit on the monitoring of the physical health of patients on antipsychotic medication in the Early Intervention in Psychosis Service of the 5 Boroughs Partnership NHS Foundation Trust

Introduction

A growing number of studies suggest a causal relationship between antipsychotic treatment and metabolic disturbances. The most frequent problems linked to antipsychotic drugs have been abnormalities of glucose metabolism such as insulin resistance, hyperglycaemia or new onset diabetes mellitus and dyslipidemia, including increased levels of total cholesterol, LDL-cholesterol and triglycerides.¹

Developing effective models of identifying and managing physical ill health among mental health service users has increasingly become a concern for psychiatric service providers. Individuals with Serious Mental Illness (SMI) defined as any Diagnostic and Statistical Manual (DSM) mental disorder leading to substantial functional impairment, have higher than expected risks of physical morbidity and mortality in comparison with members of the general population.² People with mental health problems such as Schizophrenia or Bipolar Disorder have been shown to die on average 16 to 25 years sooner than the general population.³ One set of explanations for these vulnerabilities points to the lifestyles of people with serious mental illnesses, which are often associated with poor dietary habits, obesity, high rates of smoking, and the use of alcohol and street drugs.⁴ Illness related factors have also been cited. It has been suggested that individuals with serious mental illness are less likely to spontaneously report physical symptoms.⁵ Poor physical activity has also been shown to be a common occurrence in people with serious mental illness.^{6, 7}

A greater inherent predisposition to develop metabolic abnormalities coupled with metabolic adverse effects of antipsychotic drug treatments may negatively influence physical health.⁸ Many of these problems can be avoided if close attention is paid to the physical health of patients on antipsychotic treatment. A longstanding debate persists concerning who is responsible for the physical care of patients with serious mental illness. Psychiatrists and physicians are advised to play an active role in ensuring that patients with mental illness are not disadvantaged.⁹

The Warrington and Halton Early Intervention in Psychosis Team is based in the 5 Boroughs Partnership (5BP) NHS Foundation Trust in the North West region of the United Kingdom, and in collaboration with Advancing Quality Alliance (AQuA), they embarked on a joint audit between November 2012 and May 2013 with the aim of reviewing the practice regarding the routine monitoring of physical health of service users on antipsychotic treatment. The study set out to reduce the cardio-metabolic effect of antipsychotic medication in service users. The study was also aimed at contributing to a reduction in the mortality rates in people with severe mental illness as well as testing out approaches to improve the physical health of people with serious mental illness who are receiving care from the Early Intervention in Psychosis Teams. The promotion of a more integrated approach to the physical health care of people with a SMI was also targeted.

Method

In November 2012, the Warrington and Halton Early Intervention in Psychosis service (EIP) conducted the initial audit, designed by AQuA as a baseline measure of the current standard of physical health screening amongst the Early Intervention patients in the two boroughs. The recommendations from the National Institute for Health and Care Excellence (NICE) and Maudsley prescribing guidelines were the frameworks for the AQuA design. The Research and Audit Governance Group in the 5 Boroughs Partnership NHS Foundation Trust approved the audit.

A retrospective review of the clinical records of all patients opens to the EIP, who were prescribed antipsychotics, was undertaken. Six physical health parameters were examined and these include; serum lipid profile and blood glucose levels. Others measures were body weight, height, Body Mass Index (BMI) and blood pressure. These parameters were entered into the survey monkey audit tool developed by AQuA.

Other items audited were the frequency of screening, the number of physical health parameters evaluated at each period of recording and the smoking status of the service users. Clinical records were checked for documented history of physical illness in all patients. The number of service users receiving physical health interventions as a result of the screening and the number of service users who were offered physical health interventions at the screening but either refused treatment or did not respond to the referral was also recorded. The results were presented at a Trust-wide forum and recommendations were made, and disseminated shortly afterwards. A re-audit was done in May 2013.

Results

Table 1, summarises the demographic details of patients at baseline and re-audit. 55 patients were involved in the baseline audit and 52 patients were involved in the re-audit. No significant differences were observed in both audits in terms of gender distribution and age. Majority of the patients involved in both audits were of white British ethnicity.

Table 1: Demographic details of patients at baseline audit and re-audit

Baseline audit: November 2012

Screening and monitoring

The table below indicates the number of service users receiving a screening for weight, height, BMI, glucose blood levels, lipid blood levels and blood pressure at the 4 week, 3 month, 12 month and 24 month assessments.

Table 2: Physical health screening of service users at baseline

There was no screening recorded for 19 (34.5%) patients at 4 weeks, 16 (29%) patients at 3 months, 19 (34.5%) patients at 12 months and 17 (30.9%) patients at 24 months.

Smoking status of service users

Based on the analysis of those referred to the smoking cessation service, it was concluded that around 35% of service users within the EIP Service smoke. The findings from this data also indicate high refusal rates to smoking cessation programmes (at over 80% of those service users who confirmed that they smoke).

Documented history of physical illness

The presence or absence of physical illness was documented in the records of 35 patients. Where physical health problems were identified, patients were offered a number of interventions. These include referral to the dietician/exercise programmes, smoking cessation and referral to primary care services for illnesses such as, hypertension, diabetes and hyperlipidemia.

Table 3, summarises the types of interventions available for patients when physical health issues were identified. A number of patients (N/A) required no interventions, as physical problems were not identified.

Number of service users receiving physical health interventions

Table 3: Physical health interventions

Re-audit: May 2013

Screening and monitoring

The table below indicates the number of service users receiving a screening for weight, height, BMI, glucose blood levels, lipid blood levels and blood pressure at the 4 week, 3 month, 12 month and 24 month assessments. The table shows that 29 patients had their screening recorded at 4 weeks, 19 (66%) of which had 6 types of screening. At 24 months, out of the 16 patients who had their screening recorded, 15 (95%) had 6 types of screening. Patients with no screening parameters were omitted.

Table 4: Physical health screening of service users at re-audit

Smoking status of service users

The overall data confirms that 25 patients, who were identified as smokers, were offered smoking cessation, 19 of which refused, thus giving an overall refusal rate of 76%

The table below compares the results of both audits with respect to “6 types of screening” done at 4 weeks, 3 months, 12 months and 24 months. The result shows an overall improvement over the audit period.

Comparing results of both audits with respect to “6 types of screening”

Table 5: Comparison of screening results

Discussion

The first audit revealed a suboptimal screening of the 6 targeted parameters at 4 weeks, 3 months, 12 months and 24 months in the service users audited when compared to the recommendations of the Maudsley guidelines (See Table 3). Some of the issues identified are summarised in the table below;

Table 6: Issues identified following the first audit

Recommendations made following the initial audit are outlined in the table below;

Table 7: Recommendations following the first audit

A Plan, Do, Study, Act (PDSA) model was used which was useful in clarifying issues and actions needed.¹⁰ It helped us to identify issues and actions needed including:

1. Establishing physical health as a priority within the EIP

2. Involvement of primary care and health promotion

3. Establishing a database for physical health monitoring

4. Making physical health monitoring part of care planning

To tackle the identified issues a local project group was constituted. This group was made up of a consultant psychiatrist, business manager, nurse consultant, team manager, an occupational therapist (OT), a support worker (STR), a pharmacist, social services, public health leads, wellbeing nurses, a service user representative, and a locally based General Practitioner. The group had monthly meetings.

Patients in the Warrington and Halton Early Intervention in Psychosis Service were screened using the 5 Boroughs Partnership (5BP) Comprehensive Physical Health Assessment tool. This tool covered the 6 parameters targeted in the audit and other relevant health information such as, smoking, diet, exercise, sexual health, sleep, dental and optical health, ECGs, and other routine bloods checks. An in-house database in which results could be recorded was devised and implemented. A notification list which alerted on computer when a screening is due was developed; a GP DVD and information leaflet for the GP website and the Clinical Commissioning Group (CCG) Newsletter were produced. Wellbeing Nurse-led clinics were held in Halton and a STR-led physical health clinic was initiated in Warrington. Access into the path labs for both localities was established to help facilitate prompt access to blood results. Regular AQuA meetings took place in Salford, Manchester, and links were established with the Medical Director and the Clinical Commissioning Group, who were regularly, provided progress reports.

The re-audit in May 2013 showed an increase in the number of service users being screened and monitoring for the six identified parameters (see Table 8).A robust and comprehensive recording system has been developed, resulting in more service users receiving appropriate screening and physical health monitoring. Better links and working relationships have been established with primary care services and there is increased awareness of the need for physical health monitoring in professionals and service users. Regular and well-equipped physical health clinics with well-trained staff have been established across both localities. Other secondary care agencies within the Trust are now more aware of the requirements for physical health screenings.

Why should we be doing regular physical health monitoring? The benefits of monitoring the physical health of individuals with serious mental illness cannot be overemphasised; it allows early identification and subsequent management of cardiovascular and other risk factors in a timely manner.¹¹ The Maudsley Guidelines recommend monitoring of blood lipids at baseline, at 3 months and yearly. Similar recommendations are made for the weight, which includes BMI and waist size when possible. Plasma glucose measurements are recommended at baseline, at 4 to 6 months and yearly. Blood pressure measurements are recommended at baseline and frequently during dose titration. Full blood count and electrolyte measurements are recommended at baseline and yearly.¹² In the last few years, agencies worldwide have also developed clinical guidelines. In the United States, the American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologist and the North American Association for the Study of Obesity have released joint guidelines.¹³

Even though the side effects of antipsychotics are well established, many mental health services today have yet to adopt a practice of regular blood monitoring as recommended by international guidelines.¹⁴ The issue of responsibility for monitoring metabolic abnormalities remains a much debated topic today.⁹ The primary responsibility for managing the physical health of individuals with severe mental illness has been said to lie with primary care.⁷ Another side of the debate, however, exists, and two consensus conferences have called on mental health care providers to take responsibility for the physical health of their patients.⁸ It is widely recognized that mental health teams have a role to play in the monitoring of the physical health of their service users; however, many psychiatrists still consider psychiatric symptom control as their primary responsibility.^{14 15} Studies have also shown that Individuals with Serious Mental Illness do not readily access primary care.¹⁶ Despite the availability of Clinical Guidelines, screening for and monitoring of metabolic problems in patients with serious mental illness remains suboptimal.¹¹

The usual practice in most centers for monitoring physical health parameters and guidelines used vary and are rarely regulated. Local resource availability is likely to play a significant role in guideline selection. Physical equipment, staffing levels and other resource issues may need to be taken into consideration prior to devising a local guideline. Development of a specialised phlebotomy service, for example, to the outpatient clinics will be a welcome addition, introduction of a key worker system as seen in the Warrington and Halton Early Intervention in Psychosis Team and consideration of the physical health needs of patients as part of the key worker’s duties, a simple one-page monitoring prompt attached to the patient’s medical file, educational intervention and oversight by the senior clinicians may all increase the adherence to routine blood testing guidelines. Regular liaison with General Practitioners regarding a joint approach to physical health monitoring would also help improve adherence to the guidelines.

BACKGROUND

Suicide and deliberate self-harm (DSH) have been recognised as major public health problems in India for some time, but there are significant obstructions to effective intervention including difficulties in following Western models to understand these behaviours.^{1, 2, 3}

The World Health Organisation (WHO) recognises suicide as one of the three leading causes of death in young adults globally.⁴ The greatest burden of suicide is now in low- and middle-income countries like India where annual suicide rates are 10-11 per 100,000.^{5, 6, 7} India is second only to China in the absolute number of annual deaths by suicide.⁵ The number of individuals who die by suicide each year in India alone is more than the total number of suicides in the four top ranked European countries combined.^{3, 5, 8}

DSH, defined as intentional self-poisoning or self-injury, is a closely related public health problem.⁹WHO estimates that for every suicide there are at least 10-20 DSH acts.¹⁰ If this estimated proportion, based on Western research, is also true in India then there are 1-2 million DSH acts in India each year.

Official data for 2005 suggest that 19.6% (n=22,327) of India's 113,914 officially recorded suicides were self-poisonings with pesticides⁷ (predominately organophosphates, which are freely available and widely used in agriculture). The official suicide rate for India, 10.3 per 100,000 in 2005,⁷ is thought to be an under-estimate.^{3, 11} Studies from several regions suggest that India's suicide rates may be as high as 40 per 100,000 and that 30% or more of these deaths are due to pesticide self-poisoning.¹¹ The studies reporting the highest suicide rates within India are from Tamil Nadu (>60 per 100,000 – three times higher than the official figure for the state).^{12, 13, 14, 15} Whilst some of the discrepancies between official statistics and findings in local studies may be due to urban-rural differences in the incidence of suicide, data collated by the Indian police suggest that around 90% of suicides in India occur in non-urban areas.^{7, 11, 15} Extrapolating from these figures, it is conservatively estimated that there may be up to 420,000 suicides per annum in India (126,000 from pesticide self-poisoning).

India's centrally collated self-harm and suicide data are unreliable owing to a number of factors. Death registration processes are below Western standards. Only about 25% of deaths are registered and only about 10% are medically certified.^{16, 17} Attempted suicide is a crime in India.¹⁸ Survivors are interviewed by the police. Fear of legal and social consequences following an act of self-harm probably influence willingness to acknowledge DSH and preparedness to seek medical intervention.

India contributes almost 20% to the world's population, and suicides rates are increasing particularly amongst the young.^{11, 19} Obtaining reliable and nationally representative data on DSH rates in India should be a priority for health-funding agencies over the next decade. In order to reduce fatalities following self-harm, information and investment are needed to improve quality, affordability and accessibility of health care close to the affected communities.²⁰

If, as seems likely, self-harm (especially pesticide poisoning) occurs predominantly in rural areas of India,¹¹ Western models of data collection and intervention aimed at reducing pesticide poisoning (which is predominately accidental in developed economies) are likely to require significant modification to be reliable and effective. The WHO's global suicide prevention strategy is largely based on findings from research and models of suicide prevention developed in the West.²¹ Health care resources in rural areas of India are thinly spread, and are often rudimentary compared to those in the West. There is an urgent need for research in low- and middle-income communities – particularly in rural areas of India – to provide the evidence base to underpin public health strategies for preventing pesticide suicides in these countries.

The establishment of DSH registers is a first step towards the systematic collection of data in relation to self-harm, both for epidemiological purposes and to understand pesticide self-poisoning at an individual level. If DSH registers can be shown to generate reliable information in India, in due course it may be possible to identify the factors that put individuals at risk of behaving in this way, and create relevant evidence-based policies to develop interventions for reducing mortality and morbidity associated with DSH (particularly pesticide poisoning).

This paper explores the feasibility of setting up a DSH register in a resource-poor large State hospital in south India, where rates of suicide and DSH are high.

METHODS

Setting

This study was carried out at Mysore Medical College and Research Institution (MMCRI), a State-run hospital in Mysore, southern India. The hospital serves a catchment area of 1,500,000 population and 135 primary health centres. The hospital has most specialities, with 1050 beds and a 10-bedded intensive care unit. 800-1000 patients attend the hospital outpatient department daily. Daily attendance to the casualty department for the purpose of medico-legal registration (which includes self-harm) is between 110 and 130. All other presentations including emergencies are managed through respective speciality outpatient departments.

Figure 1. Care Pathway for deliberate self-harm (DSH) at Mysore Medical College and Research Institution (MMCRI)

Setting up of the register

The flow diagram (Fig. 1) illustrates the care pathway of those presenting with DSH to MMCRI highlighting that only a few receive psychosocial assessment. A working group of psychiatrists, psychologists, social workers, casualty medical officers, statisticians and hospital managers was formed to arrive at a consensus on the minimum dataset that could be gathered from DSH survivors for the purpose of setting up a register. Literature on establishing self-harm registers was reviewed along with international guidelines in relation to self-harm assessment in the general hospital.^{22, 23} Opinion was sought from senior psychiatrists and public health personnel from the private and public sector in Mysore and from the United Kingdom (UK). The team was visited, supported and advised by the Centre for Mental Health and Society, Bangor, UK.

The items listed in Table 1 were considered as ‘minimal yet essential’ for informing clinical practice, service development and patient engagement in future research. The study was not externally funded and, due to time and resource implications, it was agreed that outcomes of mental health assessments would not be recorded in the register. The method of DSH was coded according to the International Classification of Diseases 10^th Revision (ICD-10) criteria²⁴ and socio-economic indicators were derived from a modified Kuppuswamy’s scale²⁵ that is validated for the south Indian urban population.

Table 1. Contents of the deliberate self-harm (DSH) register.

An electronic DSH register was set up in February 2013 and is currently held in the Department of Psychiatry, MMCRI, and Mysore. Two pre-registration House Officers (junior resident equivalent) visited the casualty department daily and identified those cases registered as self-harm from both the standard patient register and medico-legal case registers. If the individual was discharged from casualty (condition necessitated no further treatment, no intensive care bed available, or patient chose admission in private sector after first aid) the available information is captured from the registers and medical records. If they admitted to the general hospital they were traced and personally contacted. Information (as in Table 1) was collected from DSH survivors and from medical records. The data was verified by a Consultant Psychiatrist before being entered in the register. DSH survivors are asked to provide two contact details (postal address and phone number) for future tracing if they consent to further contact either in person or by phone. Table 2 is a list of the sources of data for the DSH register in Mysore and their limitations.

Table 2. Sources of data for deliberate self harm (DSH) register in Mysore and their limitations.

Feasibility

A DSH register should be representative, complete and accurate. The register should be acceptable to the entrants and only take a minimal time for data collection and registration. For the purpose of this study the following were identified as indicators of feasibility:

· Time between identifying that the patient should be included in the register and completion of data entry in the register. This was recorded for 80 randomly chosen inpatient DSH survivors.

· The proportion of patients presenting with alleged DSH who were correctly identified and, if admitted to the general hospital, traced for the purpose of inclusion to the register (representativeness).

· Proportion of those included in the register for whom a full data set could be captured (completeness).

· Proportion of the DSH survivors who were willing to be included in the register and provided contact details for future follow-up (acceptability).

· Over a period of a week, every month during study period February 2013 to July 2013, a Consultant Psychiatrist independently collected data from casualty registers and checked against the total number registered on the DSH register for the corresponding month (accuracy).

RESULTS

Between February 2013 and July 2013, a total of 19,563 patients attended the casualty department. Of these, 1072 attended in relation to self-harm. 1041 of them were hospitalised for further intervention. All of those who were hospitalised and survived (n=817) were traced and contacted. None objected to their details being entered on the register. However, only 253 of the 817 (30.9%) agreed to be contacted for future follow-up. Of the 817, only 109 (13%) had been formally referred to the psychiatry department for an assessment prior to contact with the research team. None of the 817 had any involvement with Social Services.

Out of the 1023 on the register, complete data was available and/or obtained for 740 (72.3%) individuals and data was incomplete for 283 (27.7%) patients. Either by reviewing the medical records or interviewing the patient, it was confirmed in all 1023 cases that there had been an act of self-harm necessitating medical intervention. The time between identifying that the patient should be included in the register and completion of data entry in the register varied between 30 minutes and 2 hours. When the data collected was cross-verified (n=315) by a Consultant Psychiatrist (author RR), entries of 310 individuals were accurate, with a minor discrepancy in less than 3 items for another 5 individuals.

Various terminologies were used to report a case of DSH in the case records (for example, suicide attempt, failed suicide, self-harm, poisoning, deliberate harm).

DISCUSSION

This is the first description of a method of successfully setting up and maintaining a DSH register in an Indian setting. It was a labour-intensive exercise due of lack of electronic patient data management, administrative support and the absence of an agreed care pathway for DSH in the hospital. Despite these obstructions, we have illustrated that it is feasible to set up a DSH register in a busy tertiary care hospital in India. Results of our study indicate that the register details are accurate and representative of those who seek help from the specialist centre. However, it cannot capture those patients whose DSH was managed successfully within primary health centres, those individuals who failed to seek help and those who died before admission.

Clinical Implications

The experience of establishing a DSH register has lead to changes in local clinical practice. DSH is associated with increased morbidity and increased utilisation of health services.²⁶ DSH survivors who were contacted (n=817) by the psychiatry residents were offered psychosocial assessments. Under normal circumstances, 708 (87%) of this group would not have received any psychosocial assessment. The process of setting up the register has helped to identify DSH cases so that an intervention can be offered before discharge from the general hospital. The register has also played a major role in the identification of people who harmed themselves but were discharged without admission to a ward. This group can also be helped. We have now developed an education and service information leaflet which includes emergency contact details (similar to a crisis card in the UK), which is given to DSH patients on discharge. These are known to decrease the repetition of DSH in the developed world.²⁷ Deaths from suicide are largely preventable if knowledge and understanding of this maladaptive behaviour is used to ensure timely intervention.⁸

By auditing DSH data in a systematic way, clinical decision-making will be based on pooled experience, not just on each clinician’s recall. Comprehensive registers of DSH provide clinicians with the opportunity to review cases of suicide where they have had clinical involvement, using techniques such as psychological autopsy, improving clinical skills and judgements. Overall there is a need for an attitude of vigilance about suicide risk, and of enthusiasm about pursuing initiatives for suicide prevention based on evidence. Better understanding of self-harm will assist in devising means of reaching out to those at risk of dying without having had contact with health care services.

Reporting of DSH in case records was inconsistent. There is a need for uniform recording, medical coding and reporting of DSH. In the DSH register, the method of self-harm is recorded using an international recognised coding system (e.g. ICD-10).

If we continue to offer psychiatric assessment to all cases of DSH, the much higher rate of ascertainment arising from the DSH register will place further strain on an already stretched psychiatric service. Further investment in services specifically targeting self-harm in India is urgently needed.

Service Implications

Use of the register

The register creates an opportunity for a standing DSH audit, allowing for identification of trends over time and comparisons with other services that establish DSH registers using similar methods. Systematic collection of demographic and clinical data will allow calculation of admission rates, repetition rates and other indices of importance in service development. Collaboration with non-governmental organisations in the region who work with those who self-harm will allow development and evaluation of specific culturally appropriate interventions.

Where the register should be held?

In the developed world DSH registers are normally held on electronic systems in the Accident and Emergency department or liaison psychiatric services. In India, it is a mandatory obligation to hold a medico-legal register (which includes DSH) in casualty. Maintaining an additional DSH register risks unnecessary duplication, but modification of a medico-legal register creates an ethical problem and risks under-reporting. There are few liaison psychiatry services in India. On balance, we suggest that our practice of holding the DSH register within the department of adult psychiatry is the optimal arrangement in the Indian setting.

Confidentiality

Confidentiality must be respected. In the UK, when establishing a DSH register, it is necessary to discuss issues of confidentiality and legality with the local Data Protection Officer, and to register under the Data Protection Act. Use of the data for research purposes requires approval from local Research Ethics Committees. In India, there is little regulation of this sort. In order to establish our register it was only necessary to obtain consultant approval and consent through the local medical committee. We suggest that good practice would demand that standards of confidentiality and oversight should, as far as possible, match Western standards.

Manpower and resources

Setting up this register in Mysore required input by a Consultant Psychiatrist, for 2 sessions per week for 6 months, to negotiate with casualty medical officers, consultant physicians and reception staff. The resident from the psychiatry department spent at least 2 hours a day collating and updating the register. The absence of a patient electronic data system and lack of administrative support has placed additional strain on residents and has prolonged the time to identify a case of DSH from the casualty records and trace them on the medical wards. We believe that once the register is established, these tasks could be managed by a trained Social Worker spending 1 session per day collecting the data and 1 session per week editing the register. The work load might vary in other hospitals, depending on the number of daily hospital attendances for DSH.

Integration with other data sources

Linking this register with post mortem records, local civil registration of deaths and police records is desirable but this needs co-ordinated effort from several civil bodies and public health organisations. In the absence of any legislation or national record linkage systems, there are few motivators to drive this change or the allocation of resources. However, a unique person identification number system is presently being rolled out across India. The development of cross-agency electronic databases will facilitate easier record linkage in the future, which creates the opportunity for collection of reliable and representative data at a regional level.

None of those who were contacted during the study period had any formal input from Social Services. Though the models and mode of delivery by Social Services in India is radically different to those in Europe, DSH survivors form a stigmatised vulnerable group who are frequently in need of social assessment and support.

Future investment and development

There are good humanitarian reasons to seek the de-criminalisation of acts of self-harm in India, and there is presently strong lobbying to bring this about. It is reasonable to suppose that this might lead to readier help-seeking and better reporting of self-harm and suspected suicide. However, there are other measures that would be necessary to reduce rates of DSH and completed suicide. Regulating the supply of organophosphate insecticides, so that they are only available in dilutions that make fatal overdose more difficult, would be one such measure. There is also a need to develop liaison psychiatric services, offering psychosocial assessments to a higher proportion of those who present with features indicative of probable self-harm. Other necessary developments include investment in patient electronic records and systematic strategies for destigmatisation of DSH.

The register has provided us with a cohort of individuals who are willing to be contacted for future studies. The register has continued beyond the study period. We presently have 3720 individuals on the register. The unit has established formal links with research centres in the UK. We intend to carry out longitudinal studies to examine the patterns of DSH, rates of repetition, compliance with follow-up and suicide rates. This will help to identify the culture-specific access, adherence and prognostic factors, and will influence the development and validation of brief psychosocial interventions in a social, economic and cultural context that is radically different to the West.

CONCLUSIONS

We have illustrated that it is feasible to set up a DSH register in a busy tertiary care hospital in India where rates of self-harm are high. Results of our study indicate that the register details are accurate and representative of those who seek help from the specialist centre.

Very few were referred for psychosocial assessment following an act of self-harm and none of them had any formal input from Social Services. Though the models and mode of delivery by Social Services in India is radically different to those in Europe, DSH survivors form a stigmatised vulnerable group who are frequently in need of social assessment and support.

Introduction

The discharge summary is an integral part of continuing patient care. Apart from containing vital information regarding current admission, it also conveys key findings and plans to clinicians who will be taking over the care of the patient. This would mean communicating important information about patients to ensure appropriate and safe follow-up management. Studies involving discharge summaries have looked into role of communication from secondary to primary care and have highlighted the importance of accuracy and quality of information,¹ errors² and general practitioner (GP) preference.³ Systematic reviews have found low availability (12-34%) of discharge summary during first visit post-discharge as well as wide variations in content of discharge summaries thereby directly affecting patient management.^4,5 The timing of discharge summary completion and reaching the follow-up physician is therefore of prime importance wherein this has been also found to influence and reduce the risk of rehospitalisation.⁶ The content necessary for a ‘good’ or ‘high-quality’ discharge summary has been studied via surveys. The inclusion of important data such as diagnosis, discharge drugs, complications, laboratory results and follow-up plans have been considered to be important clinical information by hospital physicians and GPs.⁷

Hospital discharge summaries can be hand-written, dictated or in electronic format. These formats have their benefits and downfalls. Hand-written summaries have been found to be well-accepted by primary care physicians although involve the factor of legibility.⁸ A randomised-controlled trial found no difference between electronic and dictated discharge summaries for primary care physician satisfaction.⁹ Although the use of electronic discharge summaries has significantly improved both the content and timing of discharge summaries reaching follow-up physician or healthcare staff,¹⁰ they have been found to contain higher number of errors in patient progress, additional diagnosis and free-text components.¹¹

This audit examined the timing and content of discharge summaries at The Mount and whether they met local Trust standards. A follow-on audit was conducted to study the impact of recommendations that had been put forward at the end of Cycle 1 of the audit.

Aim and Objectives

Aim

Cycle 1: To study the content, accuracy and timing of discharge summaries at The Mount, Old Age Psychiatry hospital.

Cycle 2: To examine changes in clinical practice following recommendations from Cycle 1 of audit involving content and timing of discharge summaries from The Mount.

Objectives

Cycle 1: To ascertain whether Trust guidelines regarding content of discharge summaries are met and also whether the timeline guidance is being maintained.

Cycle 2: To examine adherence to the Trust guidelines as well as to study the changes brought about by recommendations at the end of Cycle 1.

Criteria/ Standards

Trust guidelines state:

• Discharge summaries must be typed and sent in 5 working days post-discharge from hospital.
• They must include the following information (Box 1):

Method

Audit Sample

Patients admitted and discharged from Ward 3 & 4 of The Mount, between 01.04.2011 to 31.10.2011. A total of 103 patient discharge summaries were therefore analysed in Cycle 1 of the study. For cycle 2, the audit sample comprised of patients admitted and discharged from Ward 3 & 4 of The Mount, between 01.04.2012 to 31.10.2012. A total of 97 patient discharge summaries were therefore analysed in this part of the study.

Data Collection

Data was collected using an anonymous data collection tool (Appendix 1) which was designed according to Trust guidelines. Administrative staff provided the clinical audit leads with list of patients discharged during the study dates. The electronic patient record system of the Trust (PARIS: Patient Record Information System) was used to study the discharge summary letters. Data collection was performed under the supervision of consultant responsible for the audit, between November 2011 and January 2012 for cycle 1 and for cycle 2 data collection was performed between October 2013 and November 2013. Patient confidentiality and anonymity was maintained.

Data Analysis

Qualitative data was gathered, coded and collated on to a Microsoft Excel spread sheet. The data collected was reviewed by the authors to ensure each aspect of data collection tool was filled. The data was analysed by the Clinical Audits Facilitator at the Trust Clinical Audit Support Team and placed into a report format for dissemination.

Results

The number of discharge summaries analysed in Cycle 1 and 2 of this study was 103 and 97 respectively.

Data were collected using the data collection tool (appendix 1). Dates of discharge, dictation and typing were recorded. Date of typing was used as a proxy of date sent to GP since there was no record of this. Seven days were permitted for discharges to be sent (equivalent to 5 working days). Discharge summaries were read and it was recorded if each stipulated heading from the Trust guidelines was present. No comment was made on quality of information; only consideration was whether information was present or absent.

Compliance with each point from the above categories is shown in the following series of tables and comparison is made between the studies in Cycles 1 and 2 (Table 1-4). The statistical significance of the differences found in the two audit cycles was evaluated using chi-square tests.

Table 1: The presence of information mentioned in the Trust guidelines is analysed. The percentage adherence in cycle 1 is compared with findings from cycle 2. Significant increase in inclusion of family history, social history, follow-up arrangements and date of dictation is observed. A healthy increase is also observed in inclusion of premorbid history and progression and treatment during admission. A significant reduction in spelling/typing errors is also seen. The decrease in inclusion of name of key worker, discharge medications, mental health examination and results of investigation amongst others is also noted. GP, general practitioner.

The comparison of findings from Cycle 1 and 2 establish a significant increase in adherence to family history (p<0.001), social history (p<0.001), premorbid history (p=0.036) as well as progress and treatment during hospital stay (p=0.049) components of the discharge summary. There was also a significant increase in inclusion of date of dictation of discharge summaries (p<0.001). Increase in adherence to most of the components of discharge summaries was observed. However, there was significant decrease in inclusion of follow-up arrangements (p=0.007) as well as a decrease in inclusion of name of key-worker assigned to patient (from 64% in cycle 1 to 56% in cycle 2; p=0.0225). A significant decrease in spelling/typing errors in diagnosis or medical jargon was observed (p<0.001).

Timing of Discharge Summaries

Table 2: The time taken between discharge of patient and dictation of letter is analysed. A significant increase is observed in the dictation of letter as per Trust guidelines (within 5 working days).

Table 3: The time taken between dictation of letter and typing of discharge letter is analysed. A significant decrease is observed in the time taken for typing of letter within 5 days of dictation of letter.

Table 4: The time taken between discharge of patient and typing of discharge letter is analysed. A significant increase is observed in the early typing of discharge letter from the date of discharge of patient.

The number of discharge summaries being dictated and typed within 7 days of discharge was significantly increased (p<0.001) and a significant decrease in discharge letters being dictated more than 2 weeks (p=0.004) or 3 weeks (p<0.001) of patient being discharged was observed. The time taken between dictation of letter and it being typed up was also found to have dropped, with 73% being done within 7 days, significant decrease (p<0.001) being observed since the first cycle. Furthermore, a significant increase is observed in early (less than 7 days) typing of discharge letter since patient being discharged (p<0.001).

Discussion:

The discharge summary is a very important means to communicate medical (both physical and psychiatric) and nursing interventions to the GP or community mental health team. This in turn helps in making invaluable decisions to patient care in the community. Hence, it is worth spending time on doing a good discharge letter which includes relevant information. A timely discharge letter can also be very useful in this regard.

At the end of Cycle 1 of the audit, recommendations that were made included (Appendix 2):

• Disseminating information amongst all junior doctors, consultants and administrative staff on each ward to include the above mentioned headings in accordance with Trust guidelines.
• Information was also provided regarding finding out Name of Keyworker in PARIS system.
• A specific note was also placed regarding to spell out medical terminologies that would assist in the typing of discharge summaries by administrative staff.

From the results, it is evident that the content of the discharge summary has largely been maintained. In other words, good practice was maintained and recommendations from previous audit were implemented in most spheres of discharge letters. However, despite the recommendation of finding out name of key-worker from PARIS system, there was a decrease (from 64% in first cycle to 56% in second cycle) in its inclusion (p=0.225). Thus, training in usage of information technology system is essential. Providing appropriate instruction and training to junior doctors has been found to be useful in improving the quality of discharge summaries.¹² Therefore, it might be beneficial to include instructions or guidelines for appropriate discharge summaries at local Trust or departmental inductions. This will help junior doctors in ensuring completion of accurate and succinct discharge summaries that will aid in patient management.

There was a reduction in documentation of discharge medication, follow up arrangement, mental state examination and physical health investigation carried out as an in-patient. This certainly needs improving as these are the relevant areas to facilitate smooth transition of care in the community and follow-up arrangement. With regard to the timing of the discharge summary, this was found to have significantly improved from the previous audit cycle. For example, the timing between discharge and dictation (within 7 days) has increased from 30% to 73% and almost all discharge summaries are dictated no later than 3 weeks. The possible reasons for delays in dictation could be ongoing workload, availability of medical staff and of the medical notes, as these are sometimes requested by the Intermediate Community Service (ICS) team. There was a slight drop in the time between dictation and typing (from 84% to 73%), which could possibly due to availability of administrative staff, dictation tapes or medical notes and proof reading by medical staff. Significant increase was observed in inclusion of date of dictation of discharge summaries which will be a useful component for future audits. A significant decrease in spelling/typing errors in diagnosis or medical terminologies was observed. Furthermore, there was significant increase in inclusion of family history, social history, premorbid history as well as information on progress and treatment during hospital in the discharge summary. Therefore, timely audit and feedback can be very useful in improvement of discharge summaries and patient care.

Recommendations & Actions:

1. Raise awareness amongst senior house officers (SHO’s) and other doctors in the Trust regarding recording of pre-morbid history, occupational history, name of keyworker as this was only done in 52%, 62%, 56% cases respectively. This could be done by disseminating findings from this audit amongst SHO’s and other doctors of Trust through hand-outs to wards as well as through local teaching session.
2. Remove number of pages from the list of sub-headings needed in discharge summary as this is dependent on typing and not necessarily possible to estimate while dictating discharge summary. However, it is an important part of discharge summary. Therefore, send information with audit findings to medical secretaries informing the need to keep number of pages in the discharge summary.
3. Consider adding a section on documentation of risk assessment should be included in the discharge summary as well as ‘early relapse signature’ which would enable early intervention in the community to avoid inpatient admission. This could be included in the discharge summary. This would involve liaising with consultants and the responsible person for making/printing discharge summaries for Trust.

Introduction and Epidemiology

Irritable bowel syndrome (IBS) is a chronic and often debilitating condition with a complex aetiology¹. It is the most common diagnosis made by gastroenterologists worldwide². The incidence and prevalence of IBS vary depending on the diagnostic criteria used but it is estimated that the prevalence in the UK is 17% overall, with a prevalence of 11% among men and 23% among women^3-4. IBS can have a significant negative impact on quality of life and social functioning, although it is not known to be associated with the development of serious disease or excess mortality. However, patients with IBS are more likely to undergo specific surgical operations such as hysterectomy and cholecystectomy. IBS further represents an economic burden on society due to the high consumption of healthcare resources and the non-productivity of IBS patients⁵. It appears that 33–90% of patients do not consult a physician, and that a proportion of patients who meet the IBS criteria are not diagnosed with IBS. The frequency of IBS symptoms peaks in the third and fourth decades, and there is a female predominance of about 2:1 in the 20s and 30s, although this discrepancy is less apparent in older patients⁶. The female predominance is less apparent in the general population, which suggests that women with IBS are more likely to seek healthcare for their symptoms⁷. IBS symptoms which persist beyond middle life continue to be reported by a substantial proportion of individuals in their seventh and eighth decades.

Pathogenesis

The pathogenesis of IBS appears to be multifactorial. The following factors play a central role in the pathogenesis: heritability and genetics, dietary and intestinal microbiota, low-grade inflammation and disturbances in the neuroendocrine system of the gut².

IBS is known to aggregate in families and to affect multiple generations but not in a manner consistent with a major Mendelian effect. Relatives of an individual with IBS are two to three times as likely to have IBS⁸.

Psychological distress is not only a common co-morbidity in IBS patients, but also a factor which is likely to play a direct role in the pathogenesis⁴. Interestingly, parental modelling and the reinforcement of illness behaviour can also contribute to IBS. Having a mother with IBS has been shown to account for as much variance as having an identical set of genes as a co-twin who has IBS. This insinuates that the contribution of social learning to IBS is at least as great as the contribution of heredityFurthermore, the role of childhood events such as nasogastric tube placement, poor nutrition, abuse, and other stressors have been clearly associated with IBS⁸.

A substantial proportion of patients with IBS report onset of their symptoms after acute gastroenteritis⁹. Post-infectious (PI)-IBS has been reported after viral, bacterial, protozoa and nematode infections, with the incidence of PI-IBS varying between 7% and 31%. In this subset of IBS patients GI symptoms appear following gastroenteritis, with approximately 10% developing persistent symptomsRecent studies suggest that some individuals are genetically predisposed to developing PI-IBS, with some people demonstrating a specific cytokine response to infection⁴.

It is important to note that women appear to have more frequent and severe IBS symptoms during menses compared to other phases of the menstrual cycle and that female gender is a significant independent risk factor for the development of IBS⁷.

Diagnosis and Investigations

Adult patients who present to their general practitioner (GP) with lower gastrointestinal tract disorders account for one in 20 of all general practice consultations. The possibility of sinister conditions such as colorectal cancer or inflammatory bowel disease may create diagnostic uncertainty and reluctance for the doctor to attribute the symptoms to IBS. In the United Kingdom up to 29% of patients with IBS are referred to a specialist but the majority of these will return to their GP for long term management⁶.

Primary care differs from specialist care because the GP’s greater familiarity with the patient, and their previous consultations, enable presenting problems to be seen in context rather than in isolation. Furthermore, it involves the first contact for care of problems at a stage when they are likely to be poorly defined. Lastly, primary care is characterised by a biopsychosocial model of care that takes into account the context of the person’s problem. These characteristics are especially important when managing chronic disorders, such as IBS, where there is a high priority on continuity of care⁶.

There is currently no biochemical, histopathological or radiological diagnostic test for IBS. The diagnosis is based principally on symptom assessment. The Rome III criteria (Figure 1) is the most recent, updated and universal diagnostic criteria for IBS. However, although the Rome III criteria are widely used in clinical studies, it is not used by most cliniciansIn fact, most primary care physicians are not aware of diagnostic criteria for IBS and about one third of secondary care doctors do not use them in practice⁶.

IBS patients are grouped on the basis of the most predominant bowel symptom as diarrhoea- predominant, constipation-predominant, a mixture of both diarrhoea and constipation, and un-subtyped IBS in patients with an insufficient abnormality of stool consistency to meet the criteria for the other sub-groups. Approximately one third of patients have diarrhoea- predominant, one third have constipation-predominant, and the remainder have a mixture of both diarrhoea and constipation. The classification of IBS patients into sub-groups is useful for clinical practice, but it is common for IBS patients to switch from one subtype to another over time. More than 75% of IBS patients change to either of the other 2 subtypes at least once over a 1-year period^2,10.

Figure 1 - Rome III diagnostic criteria* for IBS ⁶

According to the National Institute for Health and Clinical Excellence (NICE), healthcare professionals should consider assessment for IBS if a patient presents with any of the following symptoms for at least six months¹¹:

• abdominal pain/discomfort
• bloating
• or a change in bowel habit

NICE has also given the following guideline pertaining to “red flag” indicators. All people presenting with possible IBS symptoms should be asked if they have any of the following indicators. Referral to secondary care should be made if any are present¹¹:

• unintentional and unexplained weight loss
• rectal bleeding
• family history of bowel or ovarian cancer
• change in bowel habit to looser and/or more frequent stools persisting for more than 6 weeks in a person aged over 60 years.

Furthermore, all patients presenting with IBS symptoms should be appropriately assessed and clinically examined for the following 'red flag' indicators. A referral should be made to secondary care if any are present¹¹:

• Anaemia
• Abdominal masses
• Rectal masses
• Inflammatory markers for inflammatory bowel disease
• Serum CA125 should be measured in women with symptoms that suggest ovarian cancer

In addition, NICE have stated that IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defecation or associated with altered bowel frequency or stool form. This should be accompanied by at least two of the following four symptoms¹¹:

• altered stool passage (straining, urgency, incomplete evacuation)
• abdominal bloating (more common in women), distension, tension or hardness
• symptoms made worse by eating
• passage of mucus

Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis.

According to NICE, patients who meet the IBS diagnostic criteria should have the following tests to exclude other diagnoses (Figure 2):

Figure 2 ¹¹ - Tests to exclude other diagnoses

The value of serological tests for coeliac disease (EMA or TTG antibodies) in patients with IBS diarrhoea-predominant depends on the population and is generally considered cost-effective if the incidence of coeliac disease is above 1%. It is therefore likely to be beneficial in the United Kingdom, where up to 3% of cases of IBS diarrhoea-predominant in primary care have coeliac disease⁶.

The following tests are not necessary to confirm diagnosis in people who meet the IBS diagnostic criteria¹¹:

• Ultrasound
• Rigid/flexible sigmoidoscopy
• Colonoscopy/barium enema
• Thyroid function test
• Faecal ova and parasite test
• Faecal occult blood
• Hydrogen breath test (for lactose intolerance and bacterial overgrowth)

It is important to note that IBS is associated with several other conditions. At least half of IBS patients can be described as depressed, anxious, or hypochondriacal. In addition, between 20% and 50% of IBS patients have fibromyalgia. Furthermore, IBS is common in several chronic pain disorders, being present in 51% of patients with chronic fatigue syndrome, in 64% with temporomandibular joint disorder, and in 50% with chronic pelvic pain. The lifetime rates of IBS in patients with these syndromes are even higher. Patients with such co-morbidities generally have more severe IBS. A careful history to identify such associated disorders is helpful in identifying patients who are likely to have severe IBS and associated psychiatric disorder⁶.

Management

The treatment of IBS is determined by the patient’s most troublesome symptoms. Although there is overlap in the therapies offered to the different IBS sub-groups, treatment decisions are primarily based on the frequency and severity of symptomsThe management discussed in this section is largely based on the NICE guidelines¹¹.

Dietary and lifestyle advice

People with IBS should be given information about the importance of self-help in effectively managing their IBS. This should include information on general lifestyle, physical activity, diet and symptom-targeted medication. Healthcare professionals should assess the physical activity levels of people with IBS (ideally using the General Practice Physical Activity Questionnaire). People with low activity levels should be given advice to encourage them to increase their activity levels. Healthcare professionals should also encourage people with IBS to make the most of their available leisure time and to create time for relaxation¹¹.

Figure 3 summarises the general advice that should be given to patients regarding their diet and nutrition. If diet continues to be considered a major factor in a person's symptoms and they are following general lifestyle/dietary advice, they should be referred to a dietician for further advice and treatment, including single food avoidance and exclusion diets. Such advice should only be given by a dietician¹¹.

Probiotics are live microorganisms which when taken in sufficient quantities, confer a health benefitPeople with IBS who try probiotics should be advised to take the product for at least 4 weeks while monitoring the effect. Probiotics should be taken at the dose recommended by the manufacturer¹¹.

Figure 3 - Diet and nutrition should be assessed and the following general advice given ¹¹

Pharmacological therapy

Healthcare professionals should consider prescribing antispasmodics for patients. These should be taken as required, alongside dietary and lifestyle advice. Laxatives should be considered for the treatment of constipation, but patients should avoid taking lactulose. Patients should be advised how to adjust their doses of laxative or antimotility agent according to the clinical response. The dose should be titrated according to stool consistency, with the aim of achieving a soft, well-formed stool (corresponding to Bristol Stool Form Scale type 4). Loperamide should be the first choice of antimotility agent for diarrhoeaOne advantage of loperamide is its peripheral site of action with little penetration of the blood brain barrier and thus, little potential for CNS side effects or habituation⁴.

Psychotropics possess a variety of peripheral and central effects which make them attractive treatments for IBS. These effects include modulation of pain perception, mood stabilisation, treatment of associated psychiatric conditions, and possible direct effects on GI motility and secretionHealthcare professionals should consider tricyclic antidepressants (TCAs) as second-line treatment for patients if laxatives, loperamide or antispasmodics have not helped. Treatment should be started at a low dose (5–10 mg equivalent of amitriptyline), which should be taken once at night and reviewed regularly. The dose may be increased, but does not usually need to exceed 30 mg¹¹.

Selective serotonin reuptake inhibitors (SSRIs) should be considered only if TCAs have been ineffective. The anticholinergic effects of TCAs and their ability to prolong intestinal transit times are the reasons they are particularly preferred over SSRIs in IBS diarrhoea-predominant. Furthermore, given the propensity of SSRIs to commonly cause GI adverse events of nausea, vomiting, and diarrhoea, indicate that TCAs may have more utility in IBS diarrhoea-predominant than SSRIs¹². Healthcare professionals should take into account the possible side effects when prescribing TCAs or SSRIs. After prescribing either of these drugs for the first time at low doses, the patient should be followed up after 4 weeks and then at 6–12 monthly intervals¹¹.

Psychological interventions

Anxiety and depression are common in IBS and patients report a correlation between stress and their symptoms, providing a rationale for psychological therapyReferral for psychological interventions (cognitive behavioural therapy, hypnotherapy and/or psychological therapy) should be considered for people with IBS who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS).¹¹ Hypnotherapy reduces patient anxiety and improves symptom control in the majority of patients with refractory IBS. The benefits extend well beyond symptom control and include improvements in quality of life and reduction in emotional distress¹³. Data from general practice shows that hypnotherapy is effective during the first three months, although the effect is less marked after that⁶.

Prognosis of IBS depends on the length of the history, those with a long history being less likely to improveFollow-up should be agreed between the healthcare professional and the patient based on the response of the person's symptoms to interventions. The emergence of any 'red flag' symptoms during management and follow-up should prompt further investigation and/or referral to secondary care¹¹.

Introduction

Grapefruit (Citrus paradise) is thought to have originated as a cross between the Jamaican sweet orange (Citrus sinensis) and the Indonesian pomelo (Citrus maxima) fruit. It was first bred in Barbados and brought to Florida in 1820s. Subsequently, different mutant and hybrid varieties were developed. Although the white and pink varieties were being popularly consumed, the ruby red variety has become very popular and commercially successful.

The taste is a mixture of the sweetness and tanginess of an orange and the sourness of a citrus fruit. It is a rich source of vitamins C and potassium. It is found to have antioxidant properties due to the presence of lycopene¹and an ability to inhibit atherosclerosis due to the presence of pectin^2,3. The seed extract is thought to have antimicrobial and antifungal properties.

With good publicity, marketing and coverage by health magazines, grapefruit juice has gained widespread use and in most Western Europe and America it is one of the common fruit juices consumed at breakfast. In the United Kingdom, in terms of fruit juice sales, it ranks second among citrus fruits and the fourth overall.⁴

Pharmacokinetic effects

The interaction of grapefruit juice with medication was first reported by Bailey et al in 1991 after their accidental discovery of up to four fold increase in the blood levels of filodipine when taken with grapefruit juice⁵. Further studies have identified similar interactions with more than 85 drugs⁶. The half life of the effects of grapefruit juice is estimated to be around 12 hours⁷, but these effects may last from 4 hours to 24 hours⁸. The effects are more pronounced with regular consumption of grapefruit juice prior to ingestion of the drug and there can be a cumulative increase in drug concentrations with continued grapefruit juice intake^7,9.

As little as 200-250ml may be sufficient to induce its effects^7,10. Some of the interactions involve medication that have narrow therapeutic window and can therefore cause potent adverse effects such as torsade de pointes, rhabdomyolysis, myelotoxicity, respiratory depression gastrointestinal bleeding, nephrotoxicity and sudden cardiac death.⁶ There is a lack of awareness among both doctors and patients about its effects and interaction with various medications.

Mechanism of action

These pharmacokinetic interactions with grapefruit juice are more observable in drugs with high first pass metabolism and in those with an innate low oral bioavailability. The oral bioavailability of affected drugs is increased but their half life usually remains unaltered^11,12. Grapefruit juice is associated with the inhibition of Cytochrome P450 enzyme system, particularly the CYP3A4 enzyme⁷. The CYP3A4 enzyme is present both in the liver and intestinal mucosa. Once the drug is taken up by the mucosa, the susceptible drug may be metabolised by the CYP3A4 or pumped back into the intestine lumen by P-glycoprotein. The observed effects of grapefruit juice are thought to be mainly due to the inhibition of intestinal CYP3A4 activity, which leads to decreased first pass metabolism and hence increased bioavailability. This inhibitory action is fairly quick and may be due to the rapid degradation of the enzyme or any decrease in its production from the mRNA. The production of mRNA itself from DNA is not thought to be affected¹³. The susceptibility varies between individuals depending upon their genetic expression of CYP3A4, the effects being more prominent in those with high small intestinal CYP3A4 content^{7, 14}.

The effect of grapefruit juice on the P-glycoprotein is unclear. The activation of P-glycoprotein pumps the drug back into the intestinal lumen which should reduce bioavailability and similarly the inhibition of P-glycoprotein increases the bioavailability. Some studies suggest that the inhibition of P-glycoprotein is the mechanism responsible for the increased bioavailability of certain drugs like cyclosporine^15,16.

The active ingredients responsible for interactions of grapefruit juice with medication are not clearly identified. The compounds exerting this action are thought to be either the flavanoids such as naringin and naringinen^17,18,19,20 or the furanocoumarins such as bergamottin and its derivatives^21,22,23,24, but there is no clear consensus.

Drug interactions

Table 1 below lists some of the commonly used drugs whose bioavailability is affected by grapefruit juice. Although the best known interactions have been mentioned in the table, there are many other drugs like carvedilol, estrogens, itraconazole, losartan and methyl prednisolone whose bioavailibility is increased by grapefruit juice and the adverse effects are not yet clear.

Table 1: Potential risk of drug interactions with grapefruit juice^{6, 7,13,25,26,27}

Implications on clinical practice

Clinicians should make themselves aware and educate their patients of these potential interactions, keeping in mind the individual variations in susceptibility. This may be particularly important for medications that have a very narrow therapeutic window, medication that have an innate low oral bioavailability and a high first pass metabolism mainly via CYP3A4.

A patient may develop exceptional beneficial effects or equally, significant adverse effects should he start consuming grapefruit juice mid- treatment. Conversely, a drop in efficacy of a drug is also possible, should a patient using grapefruit juice on a regular basis, stops it suddenly.

To achieve steady concentration of the medication and avoid such potential effects, it may be best to advise patients to avoid consuming grapefruit juice if there is a potential of interaction. The half life of the effect of grapefruit juice appears to be around 12 hours and therefore, it is advisable to discontinue grapefruit juice 72 hours prior to starting any drug with potential interactions. ^8,9

Due to the prolonged effect of CYP3A4 inhibition which may last up to 24 hours, it is not possible to avoid these interactions by separating the times of drug and grapefruit juice consumption.^8,9

There is more research needed to clarify the mechanism of action and to determine the active ingredients. The identification of the active ingredient can allow oral administration of drugs that undergo CYP3A4 mediated high first pass metabolism because of which currently, they can only be given systemically.

In light of the possible increase in bioavailability of specific drugs, although it might be possible for patients to use this to their advantage in reducing the dose of their medication under medical supervision, it is perhaps too early to recommend the use of grapefruit juice as an adjunctive or augmentation strategy.

Introduction:

Total knee replacement (TKR) is an effective and cost-effective intervention for advanced osteoarthritis (OA). Pain is the main indication for the procedure, and the majority of patients undergoing a TKR gain significant pain relief ^1-3.

However, an important minority of those who undergo a TKR have persistent pain in the operated knee ⁴. Baker showed that 19.8% of patients with data in the National Joint Registry had persistent knee pain, and 18.2% were dissatisfied with the procedure ⁵. Anderson, in a study of 98 patients, found that 8.1% claimed that the operated knee was worse at follow-up (2-3 years after surgery) than prior to surgery and 9.2% were dissatisfied Wylde et al reviewed the available literature in 2009, and found that 10-20% of patients report significant pain in the operated knee, and that the patient centred outcomes of TKR appear to be considerably worse than those of total hip replacement, where as implant survivorship figures are fairly similar ⁷.

There are numerous possible causes of pain after a TKR, including anterior knee pain arising from the patello-femoral joint and extensor apparatus, prosthesis loosening, or infection. Other likely causes include soft-tissue periarticular problems, referred pain, pain sensitisation, or neuropathic painBecause of the risk of infection, and the possible need for further surgery, orthopaedic surgeons are generally keen to investigate these patients thoroughly and exclude surgical causes of the problem. However, there seems to be background pain vulnerability in the knee causing this high incidence of post-operative pain. The pain itself clearly needs appropriate management but patients also need surgical evaluation to exclude important reversible causes.⁹

In spite of this being a sizeable and worrying problem in orthopaedics, very little has been written about the assessment or management of these patients. No protocols or guidelines are available and the costs of management have not been explored.

In this paper we describe the first case series of patients with chronic knee pain after a TKR, and document the investigations and treatment undertaken, and the direct financial costs of their care to the NHS Trust in which they were seen.

RD&E provides an Arthroplasty tertiary referral service for a large area but is a large District General Hospital and as such the costs and results we report should be representative of most trusts within the UK

Methods:

A specialist service for revision knee surgery is available at the Royal Devon and Exeter Hospital, resulting in the referral of patients with problems in a knee after a TKR. A registry of such patients has been established at the hospital. The data presented here is based on examination of the records of 41 of these patients. These were patients with a painful TKR who had been referred to one of the authors from Orthopaedic specialists in various institutions including the resident hospital.

The notes of these patients were analysed to ascertain the number of appointments patients’ had attended to address the TKR problem, and what investigations and treatments had been undertaken for that problem both by the originating surgeon and by the revision knee specialist.

In addition data was obtained from the Trust on the current costs of the clinic appointments, investigations and any treatment or interventions undertaken.

Results:

The 41 patients studied included 27 women and 14 men, with a mean age of 63.9 years (range 49-81) at time of initial TKR. In the year 2009, 536 TKR’s were performed in the trust with an average age of 70.5 years (range 37-94) with 298 females and 238 males.

Investigations were commenced for abnormal pain post total knee replacement on average 15 months (range 1-84) after their knee replacement. Appointments and investigations were undertaken over a mean time of 20 months from initial investigation (range 7-45).

Neuropathic pain was diagnosed in 6 patients and instability was identified as a cause in 5 patients. 4 patients suffered aseptic loosening and no diagnosis was made in 26 patients (63%).

Table 1 shows the average number of appointments attended and investigations undertaken on these 41 patients.

Data on the costs of these appointments, investigations and treatments to the local NHS Trust are presented in Table 2.

Table 1- Number of appointments and investigations per patient with a painful TKR

Table 2 – Costs of appointments, investigations and treatments per patient

*= X-ray radiographs costs were insignificant and not charged to the NHS Trust

The outcomes of these 41 patients included medical management alone in 19 (14 of whom reported significant improvement) and further surgical interventions in 22 (14 of whom reported improvement). The calculated direct costs of investigation and management of those treated solely medically (i.e. non-surgically) was £190/patient, while the cost of those treated surgically was £5,051/patient. This is shown in table 3.

Table 3 – Comparison of operative versus non-operative costs

Discussion:

We have analysed the management of a case series of patients with persistent pain in the knee after TKR. The results show that most of the 41 people studied attended numerous appointments with different specialists, and had the same investigations (serology and x-rays) repeated on many occasions over a relatively short period of time (less than 2 years), often before referral to a surgeon with a specific revision knee interest. We have also shown that the investigations and treatment undertaken were costly to the NHS, particularly if specialist imaging investigations (CT or MRI) or further surgical procedures (including aspiration or arthroscopy) were undertaken. The costs to the patients of the numerous appointments and repeated investigations have not been included, but are likely to have been considerable.

The fact that many different appointments were offered, and many investigations repeated, along with the wide range of different approaches to the different patients, are indicative of the absence of clear patient pathways or of a co-ordinated clinical service for these patients. Patients were seen by orthopaedic surgeons, pain specialists and physiotherapists, but definitive diagnoses or management plans did not often result from these appointments, and investigations were often repeated unnecessarily. We do not believe that this situation is unique to our area, as there are no clear guidelines or protocols to help us know how best to investigate or manage these patients before referral and the natural history of the condition is unknown.

The investigations carried out most frequently were serological tests (ESR and CRP) to try to exclude infection, and x-rays to look for prosthesis loosening or other bony problems. Previous work has shown that a single test of ESR greater than 22.5 or CRP greater than 13.5, in this situation, has a sensitivity of 0.77 and a specificity of 0.93 for the diagnosis of infection Repeating these tests offers little help, and if these were positive it would seem more appropriate to proceed to joint aspiration ^{11, 12-15}.

Similarly, there is little point in doing more than one x-ray study a year, as the rate of change in radiographic findings is slow. If a bone problem is suspected, other more sophisticated imaging modalities can be used ^16-18.

The cost data obtained from our Trust show that high costs are incurred from new clinic referrals and visits, sophisticated imaging procedures (CT, MRI and bone scans), and surgical procedures – in particular revision surgery. These high costs of investigations would indicate that patients with a painful TKR would be more appropriately investigated and managed by specialist centres with early and meticulous evaluation by surgeons with a special interest in revision knee surgery.

The surgical costs of management of painful TKR’s dwarf the amount of money spent on medical (i.e. non-surgical) approaches. This considerable difference suggests that it is of paramount importance to manage the pain early, irrespective of whether surgery is required. Good pain management will allow the surgeon, and particularly the patient, to evaluate the problem in a clearer manner, weighing up the treatment options and making a decision from a more balanced position.

According to data from the National Joint Registry, over 53,000 TKRs were performed in NHS hospitals in England and Wales in 2009 ¹⁹. Using the estimates of Baker, and Wylde and others on the numbers of these patients who are in pain or dissatisfied, we calculate that over 10,000 patients each year, in this country alone, are acquiring the problem of persistent pain in a TKR ^,7This represents a huge public health problem, and one that, if our Trust’s cost figures are representative, is probably costing the NHS over £10 Million/annum. In view of that, we believe that this issue needs urgent attention from the research community and health care providers.

Figure 1 – Algorithm for assessment of a patient with a painful TKR

Our recommendation is that research is undertaken to document the natural history of pain in a TKR knee, differentiate the main causes of this pain, and develop simple algorithms to help clinicians make the correct diagnosis. We suggest a protocol that can be utilised by healthcare professionals to investigate painful TKR’s to allow correct assessment and diagnosis (Figure 1). We believe that health care providers in major orthopaedic centres should set up interdisciplinary clinics in which surgeons, pain specialists and physiotherapists can work together to help investigate and manage these patients.

Introduction

Lumbar punctures are commonly performed by both medical and anaesthetic trainees but in different contexts. Medically performed lumbar punctures are often used to confirm a diagnosis (meningitis, subarachnoid haemorrhage) whilst lumbar puncture performed by anaesthetists are usually a precedent to the injection of local anaesthetics into cerebrospinal fluid for spinal anaesthesia. The similarity relies on the fact that both involve the potential for iatrogenic infection into the subarachnoid space. The incidence of iatrogenic infection is very low in both fields; a recent survey by the Royal College of Anaesthetists¹ reported an incidence of 8/707 000 whilst there were only approximately 75 cases in the literature after ‘medical’ lumbar puncture.² However, the consequences of iatrogenic infection can be devastating. It is likely that appropriate infection control measures taken during lumbar puncture would reduce the risk of bacterial contamination. The purpose of the present study is to compare infection control measures taken by anaesthetic and medical staff when performing lumbar puncture.

Method

A survey was constructed online (www.surveymonkey.com) and sent by email to 50 anaesthetic and 50 acute medical trainees in January 2011. All participants were on an anaesthetic or medical training programme and all responses were anonymous. The survey asked whether trainees routinely used the following components of an aseptic technique³ when performing lumbar puncture:

• Sterile trolley
• Decontaminate hands
• Clean patient skin
• Apron/gown
• Dressing pack
• Non-touch technique
• Sterile gloves

No ethical approval was sought as the study was voluntary and anonymous.

Results

The overall response rate was 71% (40/50 anaesthetic trainees and 31/50 medical). All anaesthetic trainees routinely used the components of an aseptic technique when performing lumbar puncture. All medical trainees routinely cleaned the skin, decontaminated their hands and used a non-touch technique but only 80.6% used sterile gloves. 61.3% of medical trainees used a sterile trolley, 38.7% used an apron/gown and 77.4% used a dressing pack.

Discussion

This survey shows that adherence to infection control measures differ between anaesthetic and medical trainees when performing lumbar puncture. The anaesthetic trainees have a 100% compliance rate compared to 80% for the medical trainees for all components of the aseptic technique. Both groups routinely cleaned the patient’s skin, decontaminated their hands and used a non-touch technique. However, there were significant differences in the use of other equipment, with fewer medical trainees using sterile gloves, trolleys, aprons and dressing packs.

Although the incidence of iatrogenic infection after lumbar puncture is low, it is important to contribute to this low incidence by adopting an aseptic technique. There may be differences with regards to the risks of iatrogenic infection between anaesthetic and medical trainees. Anaesthetic lumbar punctures involve the injection of a foreign substance (local anaesthesia) into the cerebrospinal fluid and may therefore carry a higher risk. Crucially however, both anaesthetic and medical lumbar punctures involve accessing the subarachnoid space with medical equipment and so the risk is present.

There are many reasons for the differing compliance rates between the two specialties. Firstly, anaesthetic trainees perform lumbar punctures in a dedicated anaesthetic room whilst the presence of ‘procedure/treatment rooms’ is not universal on medical wards. Secondly, anaesthetic trainees will always have a trained assistant present (usually an operating department practitioner, ODP) who can assist with preparing equipment such as dressing trolleys.

The mechanism of iatrogenic infection during lumbar puncture is not completely clear.⁴ The source of microbial contamination could be external (incomplete aseptic technique, infected equipment) or internal (bacteraemia in the patient); the fact that a common cause of iatrogenic meningitis are viridans streptococcus strains⁵ (mouth commensals) supports the notion that external factors are relevant and an aseptic technique is important.

It is very likely that improved compliance amongst acute medical trainees would result from a dedicated treatment room on medical wards, but this is likely to involve financial and logistical barriers. The introduction of specific ‘lumbar puncture packs’, which include all necessary equipment (e.g. cleaning solution, aprons, sterile gloves) may reduce the risk of infection; the introduction of a specific pack containing equipment for central venous line insertion reduced colonisation rates from 31 to 12%.⁶ The presence of trained staff members to assist medical trainees when performing lumbar puncture may assist in improved compliance, similar to the role of an ODP for anaesthetic trainees.

The main limitation of this study is that the sample size is small. However, we feel that this study raises important questions as to why there is a difference in infection control measures taken by anaesthetic and medical trainees; it may be that the environment in which the procedure takes place is crucial and further work on the impact of ‘procedure rooms’ on medical wards is warranted.

Definition

Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus.  In most infants with GOR the outcome is benign & self-limiting. ⁽¹⁾

Incidence/Prevalence

Peak incidence of GOR is around 4 months of age, and it resolves spontaneously by 1-2 years of age in most patients. ⁽²⁾

Regurgitation (possetting or spitting up) is the most common presentation in infants with GOR.  Regurgitation of at least one episode a day is seen in:

• 50% of infants 0-3 months
• 67% of infants at 4 months
• 5% at 10 to 12 months of age ⁽³⁾

It is important to note that in infants (younger than 1 year of age) who are otherwise well and symptomatic, regurgitation may be considered entirely normal. ⁽⁴⁾

Causes/Risks

GOR occurs due to the transient, inappropriate relaxation of the lower oesophageal sphincter, which allows the stomach contents to pass into the oesophagus.

GOR can be physiological or pathological:

• Physiological GOR – when the infant has normal weight gain and experiences no complications and is generally well.
• Pathological GOR – also known as gastro-oesophageal reflux disease (GORD) is when reflux is associated with other symptoms like failure to thrive or weight loss, feeding or sleeping problems, chronic respiratory disorders, oesophagitis, haematemesis etc ⁽³⁾

Several anatomical and physiological conditions make infants (younger than 1 year of age) more prone to GORD than older children and adults:

• Short, narrow oesophagus
• Delayed gastric emptying
• Shorter, lower oesophageal sphincter that is slightly above, rather than below, the diaphragm
• Liquid diet and high calorie requirements, putting a strain on gastric capacity
• Larger ratio of gastric volume to oesophageal volume⁽⁴⁾

Most children have no specific risk factors for GORD.  Children with the following conditions are at increased risk for developing GORD and for progressing to severe GORD:

• Severe neurological impairment
• Prematurity
• Cystic fibrosis
• Gastro-oesophageal abnormalities (even after surgical repair), e.g. Oesophageal atresia, diaphragmatic hernia, pyloric stenosis
• Bronchopulmonary dysplasia (preterm infants with lung disease)
• Hiatus hernia
• Oesophageal sphincter disorders
• Raised intra-abdominal pressure⁽⁵⁾

Symptoms

GORD in infants and children can present with a variety of symptoms many of which can be relatively non-specific.  Equally, other pathologies may lead to the development of reflux.  Those in the early years tend to be based on observations by parents, while older, more vocal children express symptoms more akin to adult presentations. 

As such, the history/symptoms will be broadly divided into those expected for infants (<1yr), young children (1-5yrs) and older children (>5yrs).

Infants^(6-10)

1. Excessive possetting/regurgitation
   1. Possetting is a normal phenomenon in infants
   2. Frequent episodes, together with vomiting may indicate underlying GORD
   3. Projectile vomiting may indicate an obstructive pathology
2. Difficult/rapid cessation of feeds
   1. There may be difficulty initiating feeds and latching
   2. Early cessation may be precipitated with the onset of reflux
3. Failure to thrive
   1. No weight loss can be expected
   2. Weight loss crossing centiles on the growth chart must be addressed urgently
4. Sleep disturbance
   1. Particularly after an evening feed
   2. This is often associated with irritability and inconsolable crying
5. Irritability and inconsolable crying
   1. One of the commonest presentations to the GP
   2. This may occur during feeds or shortly afterwards
6. Apnoeic episodes
   1. A witnessed pausing in respiratory effort
   2. Occurring at night, it can mimic obstructive sleep apnoea
   3. This may indicate a more serious underlying pathology and requires urgent assessment
   4. It is likely to be more prevalent in this age group

Young Children^(6-10)

1. Regurgitation/vomiting
   1. Beating/rubbing the chest may be an early sign of this pathology
   2. Reflux symptoms can be typical of those in adults
2. Failure to thrive
3. Refusing food
   1. Similar to the infant, however, the younger child can be more vocal in their refusal
4. Abdominal/chest pain
   1. With increasing age, children may demonstrate gastric irritation with abdominal pain
   2. Acid reflux producing oesophagitis may present as chest discomfort
   3. Both are similar to symptoms adults experience
5. Irritability
6. Persistent/nocturnal cough/wheezing
   1. There may be a dry, non productive cough
   2. Secondary to pharyngeal irritation
   3. There may be no co-morbidities or underlying pathologies
   4. Symptoms can be mistaken for asthma by parents

Older Children ⁽⁹⁾

1. Dyspepsia/vomiting
   1. These symptoms in older children are thought to have a similar reliability in diagnosis as in adults
2. Dysphagia/odynophagia
   1. As children become more articulate they may be able to describe these symptoms in relation to meals
   2. Particularly with chronic GORD and the development of a Barrett’s Oesophagus
3. Abdominal/chest pains
4. Persistent/nocturnal coughing/wheezing

Other Symptoms

Symptoms which can be identified but which maybe considered less life-threatening include:

1. Dental erosions
2. Hiccups
3. Halitosis

Those deserving urgent investigation and intervention include:

1. Forceful/Bilious vomiting
2. Suggesting a possible obstructive pathology
3. This requires urgent surgical referral
4. Force of vomiting may not always indicate the severity of the problem
5. Upper gastrointestinal bleeding/hematemesis
6. This may be a consequence of increased pressure from vomiting
7. Similar to a Mallory-Weiss pathology
8. An urgent review by local Paediatric Gastroenterologists is warranted
9. Profuse diarrhoea or constipation
10. Failure to thrive/weight loss
11. Lethargy
12. Apnoeic episodes

Physical Signs

As with the previous section, physical signs will be considered for each age range as above: infants (<1yr), young children (1-5yrs) and older children (>5yrs).

Infants⁽⁹⁾

1. Irritability when lying flat
   1. Particularly following feeds
   2. Especially when supine
2. Weight loss
   1. Regular monitoring with repeat measurements
   2. A single weight cannot imply loss
   3. This is usually a late sign
3. Arching of the back
   1. Secondary to oesophageal irritation
   2. Can be associated with increased tone and crying
4. Dehydration
   1. Loss of fluid through vomiting
   2. Look for
5. Dry mouth
6. Sunken fontanelle
7. Prolonged capillary refill time
8. Reduced skin turgor
9. Reduced urine output
10. Crying without tears
11. Apnoeas
    1. Periods of reduced respiratory effort
    2. Noted by parents as pauses in breathing

Young Children ⁽⁹⁾

1. Weight loss
2. Dehydration
3. Anaemia
   1. Associated with chronic symptoms and gradual loss of iron
   2. Look for Pallor/pale conjunctivae, Glossitis, Angular stomatits, Pica
4. Dysphagia/choking with food
   1. Particularly with prolonged GOR and development of stricturing
5. Difficulty in breathing/wheezing/lower respiratory tract infection (LRTI)
   1. Similar to asthma on examination
   2. Signs of LRTI on auscultation
   3. Possibly stridor

Older Children ⁽⁹⁾

1. Weight loss
2. Dehydration
3. Anaemia
4. Dysphagia/Choking with food
5. Difficulty in breathing/Wheezing/LRTI
6. Persistent sinusitis

Signs requiring urgent intervention include ⁽⁹⁾:

1. Hematochezia
   1. Unaltered blood in stool
   2. Stools take on a red appearance
2. Onset of vomiting after 6 months of life
3. Fever
   1. Uncommon with GOR
   2. Indicating an infective pathology
4. Hepatosplenomegaly
   1. An underlying condition other than GOR is likely
   2. Important pathologies must not be missed
5. Bulging fontanelle
   1. Indicating increased intracranial pressure and an alternative pathology underlying the reflux
6. Macro/microcephaly
   1. Suggestive of hydrocephalus or a congenital malformation
7. Seizures
   1. Related to a number of other problems
   2. Metabolic pathologies should figure highly in any differential diagnosis
8. Abdominal distension with reduced bowel sounds
   1. Tinkling bowel sounds and an pain may suggest bowel obstruction

Differential diagnoses

Common differential diagnoses have been noted in Table 1, however, this is by no means a definitive list of conditions or presentations.  It should be taken as an indication to the diverse presentations that can mimic or precipitate GOR (adapted from ⁽⁹⁾ and ⁽¹⁰⁾).

Table 1

Investigations and management of infants (<1 yr old)

Complicated cases of GORD (not gaining weight/faltering growth or non-GI symptoms e.g. cough), should be referred to a Paediatrician while investigating for causes and instituting simple management.

Simple investigations to do in primary care:

1. Abdominal examination for hernias/pyloric stenosis (test feed)
2. Urine dip to rule out UTI
3. Blood tests for electrolyte abnormalities, coeliac screen (if weaned)

Referral to a Paediatrician will result in imaging investigations such as Abdominal x-ray and upper GI contrast study to rule out malrotation/hiatus hernia/achalasia in older children, sometimes GORD can be seen on contrast studies.   The Paediatrician may go on to arrange a pH/impedance study, upper GI endoscopy or allergy testing.

Management

1. Calculate feed requirements, parents may be over feeding, e.g. approximate fluid requirement 100-120ml/kg/day every 3-6hrs (depending on age and whether weaned on to solids)
2. In thriving infants there is no evidence that pharmacological therapy will make a significant difference to symptoms.
3. Therefore the mainstay of management is reassurance. Simple pharmacological intervention can be tried with feed thickener (in formula fed babies) or Alginates e.g. Gaviscon (can be mixed with water for breast fed babies)
4. If there are continued concerns refer to Paediatrician for on going investigations and management.
5. Recent evidence shows that some infants may have cow’s milk protein intolerance ⁽⁹⁾.  Therefore for breast fed babies the mother could try cutting out dairy from her diet (important to have supervision from dietician re: nutritional requirements while breast feeding).  Formula fed babies can have a 2 week trial of hydrolysed/amino acid based formula e.g. Progestimil, Nutramigen, Neocate.  
6. Reviews from ESPGHAN ⁽⁹⁾ and DTB ⁽¹¹⁾ recommend H2RA (H2 receptor antagonists eg. Ranitidine) may help, though there is little evidence – these could be commenced while waiting for an appointment with the Paediatrician.
7. (Currently there is no role for Domperidone.  The next medication a Paediatrician may try is Omeprazole ± omission of cow’s milk protein) ⁽¹¹⁾

Investigation and management of older children (>18mths)

As before, complicated cases of GORD (not gaining weight/faltering growth or non-GI symptoms e.g. cough), should be referred to a Paediatrician while investigating for causes and instituting simple management.

Investigations

1. Urine dip, if there are symptoms of vomiting
2. Stool H. Pyloti antigen test
3. Bloods tests inc. inflammatory markers, H. Pylori antigen, celiac screen

Management

1. If main symptom heartburn with no evidence of H. Pylori:
2. Reassurance and lifestyle changes (weight loss, dietary changes, timing of meals), up to 4 week trial of PPI (Proton pump inhibitor e.g. lansoprazole, omeprazole).
3. If symptoms improve then continue PPI for up to 6 months, then wean off over 4 weeks (evidence that if stopped suddenly patients may get rebound symptoms) ⁽¹⁰⁾.
4. If PPI doesn’t help or symptoms recur after stopping the PPI, then refer to a Paediatrician.
5. The Paediatrician may investigate with more blood tests e.g. Autoimmune screen, allergy testing, imaging, pH/impedance study, endoscopy.

General Information 

1. Vertigo is the hallucination of movement of the environment around the patient, or of the patient with respect to the environment ¹. It is not a fear of heights.
2. Vertigo is not necessarily the same as dizziness
3. Dizziness is a non-specific term which can be categorised into four different subtypes according to symptoms described by the patients:
   
   1. Vertigo
   2. Presyncope: the sense of impending faint, caused by a reduced total cerebral perfusion
   3. Light-headedness: often described as giddiness or wooziness ²
   4. Disequilibrium: a feeling of unsteadiness or imbalance when standing ²

Classification Vertigo may be classified as:

1. Central - due to a brainstem or cerebellar disorder
2. Peripheral - due to disorders of the inner ear or the Vestibulocochlear (VIII^th) cranial nerve

Incidence/Prevalence: Most patients who complain about dizziness do not have true vertigo:

1.    5 community based studies into dizziness indicated that around 30% of patients were found to have vertigo,     rising to 56.4% in an older population ³
2.   A postal questionnaire study which examined 2064 patients, aged 18-65, 7% described true vertigo in the       previous year ³
3.   A full time GP can therefore expect between 10-20 patients with vertigo in one year ³
4.   93% of primary care patients with vertigo have either benign paroxysmal positional vertigo (BPPV), acute         vestibular neuronitis, or Ménière's disease ⁴. These conditions are highlighted in Table 2 

Causes A wide range of conditions can cause vertigo, and identifying whether deafness or CNS signs are present, can help narrow the differential diagnosis, as shown in Table 1. 

 Symptoms 

1. Vertigo may be due to central lesions or peripheral lesions. Vertigo may also be psychogenic or occur in conditions which limit neck movement, such as vertigo caused by cervical spondylosis, or following a “whiplash” flexion-extension injury.
2. It is essential to determine whether the patient has a peripheral or central cause of vertigo ¹.
3. Information obtained from the history that can be used to make this distinction includes ¹: 
   
   1. The timing and duration of the vertigo
   2. Provoking or exacerbating factors
   3. Associated symptoms such as
      
      1. Pain
      2. Nausea
      3. Neurological symptoms
      4. Hearing loss
4. Central vertigo:
   
   1. The vertigo usually develops gradually
   2. Except in: an acute central vertigo is probably vascular in origin, e.g. CVA
   3. Central lesions usually cause neurological signs in addition to the vertigo
   4. Auditory features tend to be uncommon.
   5. Causes severe imbalance
   6. Nystagmus is purely vertical, horizontal, or torsional and is not inhibited by fixation of eyes onto an object
5. The duration of vertigo episodes and associated auditory symptoms will help to narrow the differential diagnosis ⁵. This is illustrated for various pathologies that cause vertigo, in Table 2
   

   Table 2 Timing of symptoms
   Pathology	Duration Of Episode	Associated Auditory Symptoms	Peripheral or Central Origin
   Benign Paroxysmal Positional Vertigo	Seconds	No	Peripheral
   Vestibular Neuronitis	Days	No	Peripheral
   Ménière's Disease	Hours	Yes	Peripheral
   Perilymphatic Fistula	Seconds	Yes	Peripheral
   Transient Ischemic Attack	Seconds / Hours	No	Central
   Vertiginous Migraine	Hours	No	Central
   Labyrinthitis	Days	Yes	Peripheral
   Stroke	Days	No	Central
   Acoustic Neuroma	Months	Yes	Peripheral
   Cerebellar Tumour	Months	No	Central
   Multiple Sclerosis	Months	No	Central

   It is important to differentiate vertigo from non-rotatory dizziness (presyncope, disequilibrium, light-headedness). Patients can be asked whether they “felt light headed or felt as if the world was spinning around” during a dizzy spell ³.

6. Important points in the history:
   
   1. Onset - specific provoking events such as flying or trauma
   2. Duration:
      
      1. Seconds - Benign positional vertigo
      2. Hours - Ménière's Disease
      3. Weeks - Labyrinthitis, Post-head trauma, Vestibular neuronitis
      4. Years - may be psychogenic
   3. Associated auditory symptoms - rare in primary CNS lesion
   4. Other associated symptoms
      
      1. Nausea and vomiting in a vestibular cause
      2. Neurological symptoms such as visual disturbance, dysarthria in a central lesion

Physical/signs 

1. Examination of ear drums (Otoscopy/ Pneumatic otoscopy) for:
   
   1. Vesicles (Ramsay Hunt syndrome)
   2. Cholesteatoma
2. Tuning fork tests for hearing loss – Rinne/Weber tests
3. Cranial nerve examination. Cranial nerves should be examined for signs of :
   
   1. Nerve palsies
   2. Sensorineural hearing loss
   3. Nystagmus ³ 
4. Hennebert's sign ¹
   
   1. Vertigo or nystagmus caused by pushing on the tragus and external auditory meatus of the affected side
   2. Indicates the presence of a perilymphatic fistula.
5. Gait tests:
   
   1. Romberg's sign (not particularly useful in the diagnosis of vertigo ¹)
   2. Heel-to- toe walking test
   3. Unterberger's stepping test ¹ (The patient is asked to walk on the spot with their eyes closed – if the patient rotates to one side they have labyrinth lesion on that side
6. Dix-Hallpike manoeuvre ¹
   
   1. The most helpful test to perform on patients with vertigo¹
   2. If rotational nystagmus occurs then the test is considered positive for BPPV. During a positive test, the fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground.
7. Head impulse test/head thrust test
   
   1. Useful in recognizing acute vestibulopathy ⁶
8. Caloric tests
   
   1. Cold or warm water or air is irrigated into the external auditory canal
   2. Not commonly used

Investigations/Testing to consider:

1. Special auditory tests
   
   1. Audiometry helps establish the diagnosis of Ménière's disease
2. The history is most important and may give a quite good indication of the cause of vertigo. General medical causes such as anaemia, hypotension and hypoglycaemia may present with dizziness, and therefore should be investigated.
3. If features of CNS causes is suspected from the history or examination:
   
   1. CT/MRI Brain imaging as appropriate

Treatment 

1. Treatment should ideally aim at the cause of the vertigo ⁷:
   
   1. Medical management – as described below.
   2. Vestibular rehabilitation exercises – e.g. Cawthorne-Cooksey exercises ⁵.
      
      1. These exercises aim to help the patient return to normal activity more quickly.
      2. Moving the eyes from side to side and up and down while in bed or sitting down - then moving the head, first with your eyes open and then closed
      3. Other forms use gaze and gait stabilising exercises. Most exercises involve head movement

2. For most patients the main priority is effective control of the symptoms.
   
   1. For acute attacks, treatments include ^5,8: -
      
      1. Betahistine hydrochloride 8-16mg upto TDS
      2. Cinnarizine, 15-30 mg TDS or
      3. Prochlorperazine should be reserved for rapid relieve of acute symptoms only ^8,12 - tablets 5-10 mg or buccal 3mg TDS or injection 12.5 mg IM or 25mg PR suppository - if vomiting
   2. Preventive measures for recurrent attacks include:
      
      1. Restrict salt and fluid intake - stop smoking and restrict excess coffee or alcohol ^9,10
      2. Betahistine hydrochloride 16mg regularly TDS seems most effective in Ménière's
      3. Cinnarizine 15-30 mg TDS
   3. Points to consider
      
      1. Warn patients when drugs may sedate ¹⁰.
      2. Prochlorperazine is less sedating than some other recommended antihistamines, but may cause a dystonic reaction (particularly in children and young women) ¹¹.
      3. Benzodiazepines are not recommended ⁹.
   4. Recurrent vertigo
      
      1. The most important first step in the management of recurrent vertigo is to distinguish vertigo from 'dizziness'.
      2.  In attacks of vertigo there is a sense of mobile disequilibrium ("the room spinning") which, if severe, results in uncontrolled staggering in one direction which may be only prevented by grabbing a solid object ¹⁰.
   5. Epley's manoeuvre

         a.     Aims to remove debris from the semicircular canals and deposit it in the utricle where hair cells are not                     stimulated ¹¹      b.     Contraindications include ¹⁰:                                         i.     Severe carotid stenosis                                         ii.     Unstable heart disease                                         iii.    Severe neck disease (cervical spondylosis with myelopathy)                                         iv.    Advanced rheumatoid arthritis Consultation and referral:
   

   1. Refer to secondary care if ¹⁰ :
      
      1. Recurrent separate episodes
      2. Neurological symptoms e.g. dysphasia, paraesthesiae or weakness
      3. Associated sensorineural deafness
      4. If there is an inadequate visualisation of the entire tympanic membrane or an abnormality (e.g. cholesteatoma)
      5. Atypical nystagmus e.g. non-horizontal, persisting for weeks, changing in direction or differing in each eye
      6. Positive fistula sign: pressure on the tragus reproducing symptoms (suggests endolymphatic fistula
   2. If the patient has hearing problems in addition to vertigo then referral should be made to an ENT specialist. Other cases should be referred to a neurologist ¹⁰.
   3. While awaiting referral:
      
      1. Consider symptomatic drug treatment  for no longer than 1 week because prolonged use may delay vestibular compensation
      2. It is important that the person stops symptomatic treatment 48 hours before seeing a specialist, as it will interfere with diagnostic tests such as the Dix-Hallpike manoeuvre.
      3. If the person's symptoms deteriorate, seek specialist advice.

   When to consider hospitalization
   

   1. Admit the patient to hospital if they have severe nausea and vomiting, and are unable to tolerate oral fluids ⁹.
   2. Admit or urgently refer the person to a neurologist if they have:
      
      1. Very sudden onset of vertigo (within seconds) that persists.
      2. Acute vertigo associated with neurological symptoms or signs (e.g. new type of headache - especially occipital, gait disturbance, truncal ataxia, numbness, dysarthria, weakness) which may suggest CVA, TIA, or multiple sclerosis ⁹.
   3. Admit or refer the person as an emergency to an ENT specialist if they have acute deafness without other typical features of Ménière’s disease (tinnitus and a sensation of fullness in the ear). Sudden onset unilateral deafness would suggest acute ischaemia of the labyrinth or brainstem, but can also occur with infection or inflammation.
      
      1. Emergency treatment may restore hearing. The person should be seen within 12 hours of the onset of symptoms ⁹
   4. The urgency of referral depends on the severity of symptoms (e.g. requirement for intravenous fluids because of excessive vomiting) and the suspected diagnosis ⁹.

    Patient InformationThe Ménière's Society www.menieres.org.ukwww.patient.co.uk/doctor/Vertigo.htm

    

Chlamydia Screening In General Practice
Sexually transmitted infections are reaching epidemic proportions in Britain and Chlamydia is the commonest sexually transmitted bacterial infections.
 
Prevalence
Chlamydia is thought to be prevalent in 5-10% of 20-24 years old. About 75% of women and 50% of men are asymptomatic. The National Chlamydia Screening Programme currently finds about 8% of young people tested to be positive ¹ but this may represent selective testing of higher risk individual.
 
National Chlamydia Screening Programme (NCSP)
This was initiated in 2003.The aims & objectives were early detection and treatment of asymptomatic infection, to reduce the onward transmission and to prevent the development of sequelae by screening all sexually active under the age of 25 years annually or with each change of sexual partner.
 
The positive rate for this group in 2008 was 8.7% ¹.
 
An ideal setting to provide screening is General Practice. The nationally agreed target is for 25% of 15-25 years olds-males and females to be screened by 2009/2010 and 35% by 2010/2011.
 
Pathogenesis
Chlamydia is an intracellular bacteria and causes disease by chronic inflammation which is exacerbated by re-infection. It infects the female & male genital tract and is primarily sexually acquired. It can be carried in the throat, thus oral sex can transmit the bacteria.
 
Symptoms
Over 70% of women and 50% of men are asymptomatic.
 
Women may experience:
•  post coital or inter- menstrual bleeding
•  pelvic pain
•  dysuria
•  increased vaginal discharge
•  P.I.D with infertility (10-40% incidence)
 
Men may experience:                      
•   urethral discharge
•   dysuria
•   epididymo- orchitis
•   urinary frequency
 
Symptoms in both men and women:
•   rectal discharge
•   rectal bleed following rectal infection
•   pharyngeal infection - rare.
 
History
Early diagnosis and treatment will reduce the risk of long term complications. A detailed history of following should be taken-
1) History of discharge-Enquire about:
•   colour & consistency of the discharge
•   odour
•   is it aggravated by sexual intercourse
•   any associated itching
•   when was it first noticed
•   any past history of the discharge
•   was it diagnosed and treated earlier
•   any association of the discharge with menstrual cycle
2) Sexual history:
•   date of last sexual intercourse
•   were condoms used
•   and if so were they used consistently
•   regular partner or not
•   any other partners in the last six months
•   has she or her partner had sex with some one else of the same sex
•   any history of sex with a partner from a different country
•   any drug abuse in either the woman or her partner
3) Contraception and cytology:
•    which contraception does she use
•    any recent change of contraception 
•    whether she is up to date with cervical cytology
•    whether all previous screens have been normal
4) Menstrual history:
•    date of LMP
•    are periods regular or have they altered recently
•    any bleeding in between periods or after intercourse
5) History of sexually transmitted infection:
•    any past history of STI
•    was it treated
•    was the partner also treated
•    did they have a test of cure
6) Others symptoms:
•   ower abdominal pain
•   dysparunia
•   dysuria
•   any soreness or warts.
7) History of treatment:
•   any medication been prescribed.
•   any usage of over the counter medications
 
Examination
Examination of the female patient is usually normal but may show some muco -purulent discharge with contact bleeding. If pelvic inflammation is present there will be tenderness on uterine and adnexal bimanual palpation. The patient may sometimes be unwell with temperature. In suspected rectal chlamydia, Proctoscopy may be normal or may show changes of bloody/muco-purulent discharge or ulceration of mucosa.In men with epididymo-orchitis there may be epididymal and testicular tenderness with or with out systemic features.
 
Investigations
•  The older less sensitive (EIAs) Enzyme immunoassays are replaced by Nucleic acid amplification tests (NAATs) .They are based on polymerase chain reaction technology.
•  In some areas a combined NATT is in use for diagnosis of both Chlamydia & gonorrhoea. NATTs are not licensed for rectal or pharyngeal sampling.
•  Men should have a first void urine sample tested. In symptomatic women an endocervical swab is the sample of choice. If the patient does not require a per speculum examination a blind vulvovaginal swab could be an appropriate sample. These are almost as accurate and have become the basis for self test kits, now available widely.
•  A first catch urine (FCU) sample may be taken for women (having not passed urine for at least one hour before) but this is less sensitive in women than in men²
•  Sexually transmitted infection screen should include serological testing for HIV and syphilis. Current guidelines for HIV testing can be found at www.bashh.org.
 
Prevention
No opportunity should be lost to discuss safe sex with young people at the time of new patient check up and when prescribing contraception. It is a good practice to screen Chlamydia with informed consent when performing cervical screening in sexually active women under 25 and those over 25 with two or more partners in the last year or a change of partner in the past year.
 
Management
•  It is appropriate to treat Chlamydia in a general practice setting. Treatment is with either macrolides or tetracyclines.
•  Oral Azithromycin (Zithromax) 1gm stat should be the first choice as it avoids compliance issues. Patients must be advised to avoid sex for 7 days after the treatment. An alternative is oral Doxycycline (Vibramycin) 100 mg twice daily for 7 days or oral Erythromycin (Erymax) 500 mg twice daily for 14 days.
•  Interaction with oral contraceptive pill should be discussed. In pregnant women or those at risk of pregnancy, Azithromycin is still an option.
•  Retesting to verify cure is not advocated, partly because of the high cure rate and partly the test using NAA may remain positive for up to five weeks causing confusion.
•  All at risk partners in the last six months for females and asymptomatic males or four weeks for symptomatic males should be informed. They should be invited and treated even if the test is negative ³.The discussion and treatment can take place by the GP if the patient is registered with the practice or by referral to local genitourinary clinic.
 
Locally Enhanced Service
Each primary care trust has a Chlamydia screening officer. This year the target from the Department of Health is to screen 25% of patients aged 16 to 25 years registered at the practice who are sexually active.
 
Fee Structure
On agreeing a service plan with the PCT the general practice can receive: ( this may vary from one PCT to another PCT)
•  £4.50 per test received in the laboratory for coverage of ≤ 10% of the practice population aged 15-24 years.
•  £5.00 per test received in the laboratory for coverage of 10% to ≤20% of the practice population aged 15-24 years.
•  £6.50 per test received in the laboratory for coverage of 20% to ≤25% of the practice population aged 15-24 years.
•  £8.00 per test received in the laboratory for coverage of over 25% of the practice population aged 15-24 years.
 
How To Achieve Targets
•  Do a computer search of all the target patients.
•  Have a practice meeting
•  Involve the whole team: practice nurses, health care assistants and receptionists
•  Delegate, delegate and delegate! Practice nurses or health care assistants can screen at risk groups
• “new patient health check” is an ideal opportunity to offer screening. Involve the receptionist to hand out leaflets, forms and urine pots
• Make sure the reception area is suitable for handing out these items otherwise use a side room to ensure privacy
• Decide who would be dealing with positive results, treatment and partner notification
• To earn the money for extra effort you and your staff has made, make sure you use the appropriate read codeand ask the practice manager to send the claims monthly
• Remember only patients tested with in the practice premises are included when calculating the percentage screened 

• Make sure you reward your staff appropriately with the money otherwise their enthusiasm may soon vanish