Secondary Care (secondary + care)

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Terms modified by Secondary Care

  • secondary care setting

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    Latest news and product developments

    PRESCRIBER, Issue 22 2007
    Article first published online: 28 DEC 200
    Glitazones: benefits outweigh the risks Following a review of the safety of rosiglitazone and pioglitazone, the European Medicines Agency (EMEA) has concluded that their benefits outweigh their risks in the approved indications. The review was prompted by reports of an increased risk of fractures in women and, in patients taking rosiglitazone, ischaemic heart disease. The EMEA concluded that prescribing information for rosiglitazone should now include a warning that, in patients with ischaemic heart disease, it should only be used after careful evaluation of each patient's individual risk, and the combination of rosiglitazone and insulin should only be used in exceptional cases and under close supervision. No change was considered necessary to the prescribing information for pioglitazone. Modern dressings no better? A systematic review has found only weak evidence that modern dressings are better than saline gauze or paraffin gauze for healing acute and chronic wounds (Arch Dermatol 2007;143: 1297-304). The analysis, which included 99 studies, found that only hydrocolloids were demonstrably better than older dressings for healing chronic wounds, and alginates were superior to other modern dressings for debriding necrotic wounds. There was no evidence that modern dressings offered superior overall performance to the older alternatives. Hospital inflation twice primary care level The cost of drugs prescribed in secondary care but dispensed in the community increased by 6.4 per cent in 2006 - twice the rate of inflation in primary care - according to the latest statistics on hospital prescribing in England. The increase follows a reduction in costs in 2005 after the introduction of the new PPRS scheme. Data from The Information Centre (www.ic.nhs.uk) show that hospital medicines make up about 24 per cent of the NHS drugs budget. Secondary care has a consistently better record than primary care in prescribing lower-cost alternatives within therapeutic categories, eg simvastatin and pravastatin among the statins, omeprazole and lansoprazole among PPIs, and ACE inhibitors among drugs acting on the renin angiotensin system. The most expensive drug prescribed by hospital specialists and dispensed in the community is interferon beta. MHRA limits the use of fibrates The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that fibrates should now be reserved for the treatment of isolated severe hypertriglyceridaemia. They should be considered for hypercholesterolaemia only when a statin or other treatment is contraindicated or not tolerated. In the latest Drug Safety Update, the MHRA says there is insufficient evidence of long-term benefits from fibrates, and first-line use is no longer justified because the evidence for the benefits of statins is robust. The MHRA also warns that some breastfeeding infants have increased susceptibility to the adverse effects of codeine taken by their mother, and that St John's wort may affect the hepatic metabolism of any anticonvulsant. Annual zoledronic acid infusion cuts mortality after hip fracture Once-yearly infusion of zoledronic acid (Aclasta) after hip fracture reduces deaths over a two-year period by 28 per cent compared with placebo, US investigators say (N Engl J Med 2007;357:1799-809). The HORIZON Recurrent Fracture Trial randomised 2127 men and women (mean age 75) within 90 days of surgery for hip fracture to zoledronic acid 5mg yearly or placebo. Mortality over 1.9 years of follow-up was 9.6 per cent with zoledronic acid and 13.3 per cent with placebo. Zoledronic acid also significantly reduced the rate of any new clinical fractures (by 35 per cent) and new clinical vertebral fractures(by 45 per cent),but the lower rate of hip fracture (2.0 vs 3.5 per cent with placebo) was not statistically significant. Rivastigmine patch for mild to moderate AD Rivastigmine (Exelon) is now available as a transdermal patch for the treatment of mild to moderate Alzheimer's disease. Applied once daily, the patch delivers 9.5mg per 24 hours and, says manufacturer Novartis, is associated with a lower incidence of nausea and vomiting than a comparable oral dose. The patch is available in two strengths: 4.6mg per 24hr is equivalent to oral doses of 3 or 6mg per day, and the 9.5mg per 24hr patch is equivalent to 9 or 12mg per day orally. The recommended dose of the patch is 9.5mg per day; both strengths cost 83.84 for 30 patches. Women more aspirin resistant than men? The cardioprotective effect of low-dose aspirin may be lower in women than men, say Canadian investigators (BMC Medicine 2007;5:29 doi: 10.1186/1741-70155-29). Their meta-analysis of 23 randomised trials involving a total of 113 494 participants found that aspirin significantly reduced the risk of nonfatal but not fatal myocardial infarction (MI). About one-quarter of the variation in its effects on nonfatal MI was accounted for by the sex mix of the trial population. Separating the results by sex showed the reduction in risk with aspirin use was statistically significant in men (relative risk, RR, 0.62) but not in women (RR 0.87). Look after physical health of mentally ill GPs and other primary care workers should take more responsibility for the physical health of their mentally ill patients, say advocacy groups. Mind and Body: Preventing and Improving Physical Health Problems in Patients With Schizophrenia points out that the mental health needs of patients with schizophrenia are met in secondary care, but their physical health needs should be met in primary care. In particular, the metabolic effects of antipsychotics may lead to obesity, diabetes and cardiovascular disease, and weight gain in particular is a frequent reason for nonadherence to treatment. The Mind and Body Manifesto was developed by SANE, The Mental Health Nurses Association, The National Obesity Forum and The Disability Rights Commission and sponsored by Bristol-Myers Squibb Pharmaceuticals Limited and Otsuka Pharmaceuticals (UK) Ltd. Copies are available from elizabeth.green@ ogilvyhealthworld.com. Health eCard costs Some costs quoted in our article on the Health eCard (The Health eCard: the way ahead for medical records?,5 October issue, pages 28-9) have been revised: the card and initial download will cost patients 39.50, and GPs will be entitled to charge patients 10 per annum for subsequent downloads. NICE appraisals of cytokine inhibitors in RA NICE has endorsed the use of the anti-TNF agents adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade), normally in conjunction with methotrexate, for the treatment of active RA when methotrexate and another DMARD have failed (also see New from NICE below). NICE has provisionally concluded, subject to consultation, that abatacept (Orencia) should not be recommended for the treatment of RA. Boots and BMJ launch health advice site www.askbootshealth.com is a new website providing information about health and medicines for the public produced by Boots using information provided by the BMJ Publishing Group. The website covers many of the topics already available from NHSDirect, with perhaps more information about available treatments. Diabetes care shows small improvement The third National Diabetes Audit in England and Wales has found that more people with diabetes were achieving the targets set by NICE for cholesterol levels, glycaemic control and blood pressure in 2005/06 - but younger patients were doing less well. Overall, the HbA1C target of ,7.5 per cent was achieved in 60 per cent of people with diabetes compared with 58 per cent in 2004/05. However, HbA1C was >9.5 per cent in 30 per cent of children and young people, of whom 9 per cent experienced at least one episode of ketoacidosis. More topics for NICE New topics referred to NICE include clinical guidelines on ovarian cancer, coeliac disease and stable angina, public health guidance on preventing cardiovascular disease, and technology appraisals on insulin detemir (Levemir) for type 1 diabetes, several treatments for cancer and hepatic and haematological disorders, and biological therapies for juvenile arthritis. New from NICE NICE appraisal on anti-TNFs for RA Since NICE published its first appraisal of agents acting against tumour necrosis factor-alpha (anti-TNFs) for the treatment of RA in 2002, the product licences for etanercept (Enbrel) and infliximab (Remicade) have changed and a new agent, adalimumab (Humira), has been introduced. The anti-TNFs act in different ways. Infliximab is a chimeric monoclonal antibody that binds to TNF-alpha, neutralising its activity. Etanercept, a recombinant human TNF-alpha receptor fusion protein, and adalimumab, a human-sequence antibody, both bind to TNF-alpha and block its interaction with cell surface receptors. Adalimumab also modulates some biological responses induced or regulated by TNF-alpha. These agents are recommended for adults with severe active RA (defined as a disease activity score - DAS28 - greater than 5.1) who have already tried two disease-modifying drugs, including methotrexate (if not contraindicated). Prior treatment should have been of at least six months' duration, including two months at the standard dose (unless limited by toxicity). Anti-TNFs should normally be prescribed with methotrexate; when this is not appropriate, etanercept and adalimumab may be prescribed as monotherapy. Treatment with an anti-TNF should be continued beyond six months only if there is an adequate response (defined as an improvement in DAS28 of at least 1.2). Data from the British Rheumatology Society Biologics register show that, after six months, 67 per cent of patients met NICE criteria for an adequate response; this declined to 55 per cent at 18 months. The basic annual cost of treatment is 9295 for adalimumab 40mg on alternate weeks or etanercept 25mg twice weekly; infliximab costs 3777 for a loading dose, then 7553-8812 depending on dose. Assuming no progression of disability, the incremental costs per QALY (compared with sequential DMARDs) were 30 200 for adalimumab, 24 600 for etanercept and 39 400 for infliximab. There are no direct comparative trials of the anti-TNFs, and their clinical trial findings are not directly comparable. Unless other factors determine treatment choice, NICE therefore recommends the least expensive. If the first anti-TNF is withdrawn within six months due to an adverse event, a second may be tried. [source]


    The use of the weber tuning fork test and ,scratch test' in postoperative tympanomastoid surgery

    CLINICAL OTOLARYNGOLOGY, Issue 6 2006
    J.R. Buckland
    Objective., To compare the use of the Weber tuning fork test and ,Scratch test' in postoperative patients following tympanomastoid surgery. Method., Prospective cohort study with control group. Southampton University Hospitals NHS Trust. Secondary care. 19 patients undergoing routine tympanomastoid surgery for middle ear disease and 18 patients undergoing translabyrinthine surgery for lateral skull base lesions. Main Outcome Measures., Localisation of Weber tuning fork. Positive or negative Scratch test: clinician applies a gentle scratch using index finger to the bandage over the operated ear. Postoperative pure tone audiometry. Results., In the context of diagnosing a hearing or non-hearing ear, the Weber test had a specificity of 78% and sensitivity of 100%. The scratch test had a specificity of 100% and sensitivity of 100%. The Weber was 93% specific and 93% sensitive for diagnosing a unilateral conductive hearing loss. Conclusions., As a means of diagnosing an acute postoperative dead ear the Scratch test is an accurate alternative to the Weber test. References 1 Miltenburg D.M. (1994) The validity of tuning fork tests in diagnosing hearing loss. J Otolaryngol. 23, 254,259 2 Behn A., Laszlo C.A., Black D., et al. (2005) Which is mightier, the tuning fork or the bone oscillator? J Otolarygol. 34, 135,139 [source]


    Mental health patients in criminal justice populations: needs, treatment and criminal behaviour

    CRIMINAL BEHAVIOUR AND MENTAL HEALTH, Issue 3 2003
    J. Keene PhD Professor of Primary Care
    Background Government policy requires that health and social care agencies work more closely together and in partnership with the criminal justice system. There is a well-established relationship between crime and mental disorder. Method The Tracking Project provides for the first time in England the means of collating and analysing data on mental disorder (defined as receiving secondary care as patients of a Mental Health Trust) and crime (defined as all those charged with an offence). Data were collected over a three-year period for all individuals who had contact with the criminal justice system and mental health services in an English county. Results In a county population of 800,400, some 30,329 were offenders. More than a third had used a health or social care service during the three-year period; 8.0% were mentally disordered. Those offenders aged 25,64 and who contacted the police more than once were significantly more likely to be mentally disordered. Type of offence was also a relevant variable. The probation service showed broadly similar results. Discussion The research has provided for the first time substantive quantitative evidence of the relationship between crime and mental disorder. The results can be used as the basis for further work to target assessment and risk reduction measures at those most at risk. Copyright 2003 Whurr Publishers Ltd. [source]


    An audit of the time to initial treatment in avulsion injuries

    DENTAL TRAUMATOLOGY, Issue 1 2009
    Betul Kargul
    Good outcome requires education of the general public and non-dental professionals. Aim:, Retrospective observational survey of case records of avulsion injuries attending a dental hospital trauma clinic. Method:, Data collected included: hospital number, date of birth, gender, source of patient's referral, date of trauma, number of avulsed teeth, place of initial presentation, storage, hours till initial presentation, and initial treatment. Results:, One hundred and twenty teeth with avulsion were identified in 75 children. The mean age of the patients was 9.8 years (SD = 2.3 years) at the time of trauma with avulsions recorded in 44 (58.7%) boys and in 31 (41.3%) girls. Only 51 (42.5%) teeth were stored in an appropriate medium before attendance at any site and only 48 (40%) of the teeth were seen within 1 h. 83.3% received emergency treatment at general hospital, 89.7% in dental practice and 92.9% at dental hospital. Conclusions:, A minority of avulsion injuries were seen within the first hour and a minority were in appropriate storage medium at presentation. Geographical location plays a huge role in the time taken to reach secondary care. However, improving public and non-dental professional knowledge about tooth storage in avulsion injuries is critical to long-term prognosis of the teeth. [source]


    Factors affecting treatment outcomes following complicated crown fractures managed in primary and secondary care

    DENTAL TRAUMATOLOGY, Issue 4 2006
    N. G. Jackson
    Abstract,,, The aims of this retrospective observational study were to determine the factors which affect treatment provision and the Median Survival Time (MST) for maintenance of tooth vitality following complicated crown fracture. The survey was carried out for patients treated at Newcastle Dental Hospital (NDH) according to departmental guidelines over a 2-year period following the introduction of a new protocol for management of these types of injuries. Seventy-three cases of complicated crown fracture were identified in 69 children with a mean age of 10.3 years (SD = 2.5 years). Seventy-one percent of the fractures occurred in males (M:F ratio was 2.5:1). Fifty-one percent of the complicated crown fractures were in immature teeth. Of the 73 traumatised teeth, 45% presented initially in general dental practice (GDP), 37% at the dental hospital and 8% at local accident and emergency departments with the remaining 10% seen at other or unrecorded locations. Of the 41 fractures, which presented initially at a location other than the dental hospital, 38% were referred to the dental hospital without the provision of an emergency pulp bandage. The overall definitive treatments provided for the 37 open apex teeth included pulp cap (19%), partial pulpotomy (32%), cervical pulpotomy (8%) and pulpectomy (35%), while for the 36 closed apex teeth it was pulp cap (28%), pulpotomy (11%), and pulpectomy (61%). Of the 30 teeth, which underwent vital pulp therapy (18 open and 12 closed apex), the MST for the 15 teeth treated with pulp caps was 1460 days (95% CI: 1067, 1853) while for the 15 teeth treated with pulpotomies it was 1375 days (95% CI: 964, 1786). There was no statistically significant difference in the MST between teeth treated with pulp caps and pulpotomies. In conclusion, the proportion of patients referred to secondary care with complicated crown fractures without provision of a pulp bandage is of some concern. More conservative treatment of closed apex teeth sustaining complicated crown fractures, utilizing vital pulp therapy techniques would appear to be appropriate. [source]


    Patient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysis

    DIABETIC MEDICINE, Issue 2 2006
    R. F. Dijkstra
    Abstract Aims Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost-effectiveness estimates. This study reports empirical findings on the cost-effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient-related and intervention-related cost. Patients and methods In a clustered-randomized controlled trial design, 13 Dutch general hospitals were randomly assigned to a control group, a professional-directed or a patient-centred implementation programme. Professionals received feedback on baseline data, education and reminders. Patients in the patient-centred group received education and diabetes passports. A validated probabilistic Dutch diabetes model and the UKPDS risk engine are used to compute lifetime disease outcomes and cost in the three groups, including uncertainties. Results Glycated haemoglobin (HbA1c) at 1 year (the measure used to predict diabetes outcome changes over a lifetime) decreased by 0.2% in the professional-change group and by 0.3% in the patient-centred group, while it increased by 0.2% in the control group. Costs of primary implementation were < 5 Euro per head in both groups, but average lifetime costs of improved care and longer life expectancy rose by 9389 Euro and 9620 Euro, respectively. Life expectancy improved by 0.34 and 0.63 years, and quality-adjusted life years (QALY) by 0.29 and 0.59. Accordingly, the incremental cost per QALY was 32 218 Euro for professional-change care and 16 353 for patient-centred care compared with control, and 881 Euro for patient-centred vs. professional-change care. Uncertainties are presented in acceptability curves: above 65 Euro per annum the patient-directed strategy is most likely the optimum choice. Conclusion Both guideline implementation strategies in secondary care are cost-effective compared with current care, by Dutch standards, for these patients. Additional annual costs per patient using patient passports are low. This analysis supports patient involvement in diabetes in the Netherlands, and probably also in other Western European settings. [source]


    Survey of dietetic provision for patients with diabetes

    DIABETIC MEDICINE, Issue 8 2000
    M. Nelson
    SUMMARY Aims To survey dietitians involved in diabetes care regarding the provisions for patients with diabetes. Methods A national survey of 512 dietitians known to be engaged in provision of diabetes care was conducted in 1997 and 391 (76%) responded. Results Nationally the median provision of dietetic care for diabetes reported was 10.7 h per 100 000 general population per week, but the provision was uneven ranging from 2.0 to 27.6 h per 100 000. Eighty-five per cent of dietitians worked in areas where the provision was less than 22 h per 100 000 general population per week (the current recommended minimum standard). Dietetic provision was greater in secondary care (median 9.1 h per 100 000 general population per week) than in general practice, residential homes and other locations (median 4.4 h per 100 000 general population per week). Provision was greater in those areas in which a designated dietitian had responsibility for co-ordinating the dietetic service for diabetes than in areas where the co-ordinator was not a dietitian or where there was no co-ordinator. Over 90% of dietitians reported following British Diabetic Association (BDA) recommendations regarding advice on carbohydrate, sugar, fat and fibre consumption, but only one-third routinely advised on salt restriction. Of the 17% of dietitians who continue to use carbohydrate exchanges, all combine this method with other approaches. Of the recommendations made by the Clinical Standards Group, only 69% of dietitians reported seeing more than half of newly diagnosd adult patients within four weeks, and less than 50% reported offering half or more of their patients an annual review. Amongst the literature in current use, 98% of dietitians use BDA literature for teaching patients and 90% use BDA publications in their own education. Seventy-six per cent of dietitians believed that there was a role for commercial slimming organizations in weight management of people with diabetes Conclusions Given the proven value of dietetic input in diabetes management, there would be advantages to correcting the regional inequalities in dietetic provision for diabetes care in the UK. [source]


    Prevalence and impact of pain in diabetic neuropathy

    EUROPEAN DIABETES NURSING, Issue 2 2009
    M Geerts M
    Abstract Background: Diabetic neuropathy (DNP) is a serious and common complication of diabetes mellitus, with a prevalence of around 30-50%. Aims: To describe the prevalence, severity and medical treatment of painful DNP (PDNP) experienced by patients treated in secondary care; to determine quality of life (QoL) impact and the relationship between severity of pain and severity of DNP. Methods: Cross-sectional, two-phase survey. First, a pain interview was conducted by telephone (219 DNP patients), which covered types of pain, location and duration. Secondly, 50 patients were visited at home. Patients completed the Brief Pain Inventory, the Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale. Results: Prevalence of PDNP was 57.5%. Average and worst pain scores were 5.3 2.1 and 6.4 2.2, respectively (0-10 scale, 10 = worst pain imaginable). In 70% of patients, average pain was severe (score ,5). Substantial interference by pain (score ,4) was found in walking ability, sleep and normal activities. PDNP patients had a decreased QoL for all SF-36 domains (p,0.01) except for health change. Moreover, symptoms of anxiety (36%) and depression (34%) were reported frequently. Medical treatment was prescribed in 46% of patients, in whom treatment was ineffective in 39%. Physical functioning scores were lower in patients with severe versus moderate DNP (p,0.01). Conclusions: The prevalence of severe PDNP was high. Severity of DNP was not related to pain severity. PDNP was associated with loss of QoL and with symptoms of anxiety and depression. A considerable proportion of patients did not have medical treatment and, if treatment was given, its impact was disappointing. Medical treatment of PDNP was unsatisfactory and clearly needs to be improved. Copyright 2009 FEND [source]


    Clinical features associated with medically unexplained stroke-like symptoms presenting to an acute stroke unit

    EUROPEAN JOURNAL OF NEUROLOGY, Issue 2 2005
    F. S. Nazir
    In many areas of secondary care, symptoms unexplained by disease account for around one-third of all patients seen. We sought to investigate patients presenting with medically unexplained stroke-like symptoms to identify distinguishing features which may help to identify a non-organic aetiology. Patients given a discharge diagnosis of medically unexplained stroke-like symptoms over the preceding 11 years were identified retrospectively from a prospectively completed stroke unit database. Age- and sex-matched controls with ischaemic or haemorrhagic stroke or transient ischaemic attack were also identified. Clinical features on presentation, ischaemic risk factors, alcohol history, marital status and history of depression or anxiety were examined. Previous or subsequent admissions with medically unexplained syndromes were also examined via record linkage with hospital discharge records. A medically unexplained syndrome was assumed to be present if an International Classification of Diseases 9 discharge code for one or more of the thirteen conditions forming recognized functional syndromes was given. Logistic regression was applied to determine predictors of non-organicity. One hundred and five patients and controls, 1.6% of all stroke unit admissions were identified, 62% (65 patients) were females. Mean age was 50.3 14.9. Compared with age- and sex-matched controls patients with medically unexplained stroke-like symptoms were significantly more probable to have a headache at presentation (47% vs. 26%, P = 0.0004), have a diagnosis of one or more additional medically unexplained syndromes (24% vs. 11%, P = 0.007) but significantly less probable to present with symptoms of vertebrobasilar dysfunction (32% vs. 61%, P < 0.0001). A history of anxiety or depression, as recorded in the notes, was not found to be associated with a medically unexplained presentation. Medically unexplained stroke-like presentations are common (1.6% of all stroke presentations), they are most strongly predicted by the presence of other functional somatic syndromes, headache and the absence of symptoms of vertebrobasilar dysfunction. [source]


    Stochastic league tables: an application to diabetes interventions in the Netherlands

    HEALTH ECONOMICS, Issue 5 2005
    Raymond C. W. Hutubessy
    Abstract The aim of this paper is to discuss the use of stochastic league tables approach in cost-effectiveness analysis of diabetes interventions. It addresses the common grounds and differences with other methods of presenting uncertainty to decision-makers. This comparison uses the cost-effectiveness results of medical guidelines for Dutch diabetes type 2 patients in primary and secondary care. Stochastic league tables define the optimum expansion pathway as compared to baseline, starting with the least costly and most cost-effective intervention mix. Multi-intervention cost-effectiveness acceptability curves are used as a way to represent uncertainty information on the cost-effectiveness of single interventions as compared to a single alternative. The stochastic league table for diabetes interventions shows that in case of low budgets treatment of secondary care patients is the most likely optimum choice. Current care options of diabetes complications are shown to be inefficient compared to guidelines treatment. With more resources available one may implement all guidelines and improve efficiency. The stochastic league table approach and multi-intervention cost-effectiveness acceptability curves in uncertainty analysis lead to similar results. In addition, the stochastic league table approach provides policy makers with information on affordability by budget level. It fulfils more adequately the information requirements to choose between interventions, using the efficiency criterion. Copyright 2004 John Wiley & Sons, Ltd. [source]


    Services for erectile dysfunction in the UK , a 12-month review of referrals to a west Midlands NHS clinic

    INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 7 2010
    G. Hackett
    Summary Introduction:, Few studies have addressed the health economics of the provision of services for sexual dysfunction within the National Health Service. Aim:, To evaluate the referral patterns, workload and prescribing costs in secondary care resulting from government guidance on erectile dysfunction (ED). Method:, A review of 324 consecutive referral letters to the Good Hope Hospital Erectile Dysfunction Clinic was conducted to assess the purpose of referral. Prescribing data and costs were assessed over the same 2-year period. Results:, Severe distress was the main reason for referral in 54% of referrals. Long term prescribing according to government guidance doubled the cost of care and created an unsustainable increase in clinic and pharmacy workload. Conclusions:, Existing regulations designed to control costs of ED therapy have created health inequalities, waste of resources and have increased the overall cost of care. [source]


    The effect of concurrent pain on the management of patients with depression: an analysis of NHS healthcare resource utilisation using the GPRD database

    INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 5 2009
    L. Watson
    Summary Introduction:, Patients with depression frequently report painful physical symptoms. However, there are scant data from the UK concerning differences in primary and secondary care resource use between depressed patients with and without pain treated in general practice. Methods:, Patients with depression codes were identified from the General Practice Research Database (GPRD) excluding those with psychoses. The observation period was 1st January 2000,31st December 2006. Patients were further categorised into three groups: (i) no painful physical symptom codes ever in the observation period (NO PAIN); (ii) patients with no other diagnostic or test codes 30 days either side of a pain code (PAIN MINUS DIAGNOSIS) and (iii) patients with pain codes and other diagnostic codes (PAIN PLUS DIAGNOSIS). Rates of general practitioner (GP) visits, antidepressant and concomitant prescribing and switching, secondary care referrals and diagnostic tests were reported per group with 95% confidence limits (CI). Results:, A total of 145,784 patients with depression aged 18,50 years were selected. Of these, 48,615 (33.3%) were classed as NO PAIN, the remaining 66.6% having pain. PAIN MINUS DIAGNOSIS patients constituted 5654 (5.8%) of those with pain. PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS had a significantly higher rate of GP visits than NO PAIN patients, 10.37 (95% CI 10.23, 10.52); 11.15 (11.11,11.20) and 7.04 (7.00, 7.08) respectively. Inter and intraclass drug switching was high with 13% of PAIN MINUS DIAGNOSIS and 14% of PAIN PLUS DIAGNOSIS patients having three or more switches compared with 7% of NO PAIN patients. Referral rates to secondary care were significantly higher in both pain groups compared with patients with no pain. Diagnostic testing was significantly greater in PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS groups than NO PAIN patients for all test types, with X-rays being the most common test; 3.85 (3.69,4.00); 2.77 (2.74,2.80); 0.91 (0.89, 0.94) respectively. Conclusion:, Patients in general practice diagnosed with depression and concurrent painful physical symptoms have higher resource use in primary and secondary care. [source]


    Contemporary referral of patients from community care to cardiology lack diagnostic and clinical detail

    INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 5 2006
    S. Bodek
    Summary The quantity of referrals to secondary care is increasing. That the quality of medical referrals is decreasing is a common allegation yet has rarely been assessed. We report a time-limited, cross-sectional survey evaluating cardiological referral information quality. Referral letters (n = 218, excluding direct access pro formas) from GPs to the Cardiology Department at City Hospital, Birmingham, were collated and analysed over 2 months. A subset (n = 49) of these patients completed questionnaires assessing their knowledge and patient communication of the referral. Information quality was poor (length, diagnosis, expectation, prior treatment and investigation) with almost half of all letters containing only outline symptomatic complaints without diagnosis. The majority of patients referred had not been investigated or treated in any way before referral. Despite lack of understanding of the reason for referral, typically the majority of patients expressed themselves as satisfied with the process. Given most referrals are seen as appropriate, information exchange between secondary and primary care is crucial. By contrast, the standard of even basic clinical assessment communicated between primary care and secondary care was severely limited. The reason(s) why medical assessment is lacking are unclear but must be explored to give more support to primary care to complete basic medical task particularly if investment is to flow into this source. [source]


    Neck pain and disability: A cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic

    INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 2 2005
    A.O. Frank
    Summary This hospital-based cross-sectional cohort study examines the clinical and demographic features of neck pain, disability (using the Northwick Park neck pain questionnaire) and relationships to handicap in employment. Of 173 consecutive referrals to a rheumatology clinic with neck pain, 70% had neck/arm pain without neurological involvement, 13% other conditions, 11% nerve involvement and 5% other spinal pain. 141 patients (mean age 50 years) had mechanical or degenerative neck pain, of which 13% was probably work-related and 13% was trauma-related. 44 had taken sickness absence for an average of 30 weeks. Comorbidities were frequent (lumbar pain 51%). Those in work were significantly less disabled than those not working (p = 0.001) and those off sick (p < 0.01). Those reporting sleep disturbance, tearfulness and crying were significantly more disabled (p = 0.0001) than those who did not. Neck pain in secondary care is complicated by physical and emotional comorbidities. Comprehensive management requires a biopsychosocial model of care. [source]


    Is there an association between referral population deprivation and antibiotic prescribing in primary and secondary care?

    INTERNATIONAL JOURNAL OF PHARMACY PRACTICE, Issue 4 2008
    Christopher Curtis head of pharmaceutical services
    Objective The study was designed to explore the presence of any relationship between NHS secondary care antibiotic prescribing rates or primary care antibiotic prescribing rates and the levels of deprivation experienced within the referred primary care population. The study also aimed to determine whether the antibiotic prescribing rates for each care sector were correlated. Method The study was conducted in 12 English hospital trusts of mixed size and case-mix. Antibiotic usage data (Anatomical Therapeutic Chemical (ATC) category J01) for the financial year, ending March 2001/2002 were used to calculate hospital trust prescribing rates (using the defined daily dose/finished consultant episode indicator). Primary care antibiotic prescribing data were obtained from the Prescription Pricing Authority (antibiotic items prescribed per 1000 residents) for the year 2001/2002. Index of Multiple Deprivation (IMD) 2000 deprivation data were obtained from the regional public health observatory websites for each of the primary care trusts within the relevant study areas. Key findings No correlation could be established between the weighted index of multiple deprivation of the treated population and antibiotic prescribing rates at each hospital trust. Primary care antibiotic prescribing rates were not found to correlate with antibiotic prescribing rates in the geographically associated hospital trust. Data from all 12 sites showed that the IMD 2000 measures and primary care prescribing rates were weakly correlated, with higher antibiotic prescribing rates being generally observed in areas of primary care exhibiting the worst levels of deprivation Conclusions The likely explanations for the present findings are that deprivation-related illnesses are principally treated within primary care, whereas hospital antibiotic prescribing principally results from procedures isolated within secondary care or through the additional influence of nosocomial infection. Therefore, medicines management measures geared to controlling antibiotic prescribing in secondary care should not focus upon the levels of deprivation in the referred population, whereas those in primary care should. [source]


    Perceptions of a service redesign by adults living with type 2 diabetes

    JOURNAL OF ADVANCED NURSING, Issue 7 2009
    Joan R.S. McDowell
    Abstract Title.,Perceptions of a service redesign by adults living with type 2 diabetes. Aim., This article is a report of a study conducted to explore the perceptions of adults with type 2 diabetes towards the service redesign. Background., Diabetes is reaching epidemic proportions and the management of this chronic illness is changing in response to this challenge. In the United Kingdom, there is ongoing restructuring of healthcare services for people with chronic illnesses to ensure that their general health and clinical needs are met predominantly in primary care. Method., An explorative qualitative approach was used. Eight focus groups were conducted with 35 people with type 2 diabetes in one urban location between 2003 and 2004. Five focus groups were conducted with people who had recently experienced the restructured service and three groups with people who had up to 2 years' experience of the new service. Concurrent data collection and thematic analysis were conducted by three researchers and credibility and verification sought by feedback to participants. Findings., Five main themes were identified: impact of living with diabetes; understanding diabetes; drivers for organizational change; care in context and individual concerns. Participants identified issues for ongoing development of the service. Conclusion., People with type 2 diabetes appreciate their care management within the primary care setting where there has been investment in staff to deliver this care. Healthcare resources are required to support the development of staff and the necessary infrastructure to undertake management in primary care. Policy makers need to address the balance of resources between primary and secondary care. [source]


    A review of the impact and effectiveness of nurse-led care in dermatology

    JOURNAL OF CLINICAL NURSING, Issue 1 2007
    Cert Ed, Molly Courtenay BSc
    Aims and objectives., To identify systematically, summarize and critically appraise the current evidence regarding the impact and effectiveness of nurse-led care in dermatology. Background., A diverse range of nurse-led models of care exist in dermatology. Primary studies have been conducted evaluating these models, but review and synthesis of the findings from these studies have not been undertaken. Method., Systematic searches of CINAHL, MEDLINE, British Nursing Index (BNI) and the RCN Library Catalogue from 1990 until March 2005. The searches were supplemented by an extensive hand search of the literature through references identified from retrieved articles and by contact with experts in the field. Results., Fourteen relevant publications were identified and included findings from both primary and secondary care. The evidence indicates that nurses are treating a number of dermatological conditions, primarily using treatment protocols, across a broad range of clinical settings. However, some nurses working in primary care, lack confidence to treat some of these conditions and the educational needs of these nurses are frequently unmet. A reduction in the severity of the condition and more effective use of topical therapies are benefits of nurse interventions on service delivery. Faster access to treatment, a reduction in referrals to the general practitioner or dermatologist and an increase in knowledge of their condition are benefits reported by patients. Conclusions., Findings of the review are generally positive. However, there are methodological weaknesses and under researched issues, e.g. cost effectiveness of nurse-led care and the prescription of medicines by nurses for patients with dermatological conditions that point to the need for further rigorous evaluation. Relevance to clinical practice., Nurse-led care is an integral element of the dermatology service offered to patients. This review highlights the impact of this care and the issues that require consideration by those responsible for the development of nurse-led models of care in dermatology. [source]


    Managing oral anticoagulation therapy: improving clinical outcomes.

    JOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 6 2008
    A review
    Summary Many physicians are reluctant to prescribe oral anticoagulation therapy (OAT) because of the fear of haemorrhagic complications. Changes in patient health, lifestyle or diet and other drugs can alter the effectiveness of oral anticoagulants. These potential interferences, added to the fact that each individual has a different reaction to these drugs, requires that therapy is monitored regularly. This article aims to review those strategies which help to achieve optimal anticoagulation control and improve the outcomes of OAT. Relevant articles were identified through a search of MEDLINE and included publications reporting on intensity of anticoagulation, the initiation of therapy and the role of pharmacogenetics, the transition from primary to secondary care, management by specialized clinics using decision support software and home-testing. Implementation of these strategies would increase the use of oral anticoagulants by physicians and offers the potential to improve patient safety and reduce adverse events. [source]


    Factors affecting the uptake of new medicines in secondary care , a literature review

    JOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 4 2008
    D. Chauhan BPharm MRPharmS MSc
    Summary Background and Objective:, The rate of uptake of new medicines in the UK is slower than in many other OECD countries. The majority of new medicines are introduced initially in secondary care and prescribed by specialists. However, the reasons for relatively low precribing levels are poorly understood. This review explores the determinants of uptake of new medicines in secondary care. Methods:, Nine electronic databases were searched covering the period 1992,2006. Once the searches had been run, records were downloaded and those which evaluated uptake of new medicines in secondary care were identified. UK studies were of primary interest, although research conducted in other countries was also reviewed if relevant. With the exception of ,think pieces', eligibility was not limited by study design. Studies published in languages other than English were excluded from the review. Determinants of uptake in secondary care were classified using Bonair and Persson's typology for determinants of the diffusion of innovation. Results:, Almost 1400 records were screened for eligibility, and 29 studies were included in the review. Prescribing of new medicines in secondary care was found to be subject to a number of interacting influences. The support structures which exist within secondary care facilitate access to other colleagues and shape prescribing practices. Clinical trial investigators and physicians who sit on decision-making bodies such as Drug and Therapeutic Committees (DTCs) appear to have a special influence due to their proximity to their research and understanding of evidence base. Pharmaceutical representatives may also influence prescribing decisions through funding of meetings and academic detailing, but clinicians are wary of potential bias. Little evidence on the influence of patients upon prescribing decisions was identified. The impact of clinical guidelines has been variable. Some guidelines have significantly increased the uptake of new medicines, but others have had little discernible impact despite extensive dissemination. However given the increasing influence of the National Institute for Health and Clinical Excellence, guidelines may become more important. The impact of financial prescribing incentives on secondary care prescribing is unclear. Although cost and budget may influence hospital prescribing of new drugs, they are of secondary importance to the safety and effectiveness profile of the medicine. If a drug has a novel mechanism of action, or belongs to a class with few alternatives, clinicians are more likely to consider it favourably as a prescribing option. Conclusions:, Although price does not appear to be a primary factor behind prescribing decision-making, in secondary care there has long been a historical need for formal purchasing decisions through the DTC, which differentiates it from primary care. This, in addition to increasing pressures for cost-effectiveness within the NHS means that cost will appear more frequently on clinician consciousness. As a result, guidelines are more likely to be implemented using the strong professional networks in existence within secondary care, and although the influence of patients has not been addressed by the literature, they are likely to have an increasing input into the prescribing decision, given the importance of patient involvement in current UK policy. [source]


    Pharmacist prescribing in the UK , a literature review of current practice and research

    JOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 6 2007
    A. P. Tonna MRPharmS MSc
    Abstract Objective:, To review the research literature to date on pharmacist prescribing in the United Kingdom (UK) and to explore the main areas of care and practice settings including any benefits and limitations. Findings:, There are two models of pharmacist prescribing in the UK: pharma\cist supplementary prescribing (SP) introduced in 2003, involving a voluntary partnership between the responsible independent prescriber (a physician or a dentist), the supplementary prescriber and the patient, to implement an agreed patient-specific clinical management plan; and pharmacist independent prescribing (IP) introduced in 2006, responsible for the assessment and consequent management, including prescribing of both undiagnosed and diagnosed conditions. There have been narrative reports of pharmacist SP in different health care settings including primary care, community pharmacies, secondary care and at the primary/secondary care interface; published research within these areas of care is conflicting as to which setting is more suitable for pharmacist prescribing. Initial research reports that almost 50% of pharmacist supplementary prescribers self-reported prescribing with both benefits of and barriers to implementing SP. Research involving other healthcare professionals has indicated that encroachment of traditional roles is likely to occur because of the advent of pharmacist prescribing. A small-scale study has concluded that patients are likely to accept pharmacist prescribing favourably, with another study showing pharmacist prescribing leading to improved adherence to guidelines. There is no published research yet available about practices involving pharmacist IP. Discussion:, Most of the literature focuses on pharmacists' perceptions of SP, with little information referring to other stakeholders, including patients. There is also limited published research focusing on clinical and economic outcomes of pharmacist SP. Conclusion:, This is a rapidly changing aspect of pharmacy practice in the UK, particularly with the more recent introduction of pharmacist IP. It is likely that this area of research will expand rapidly over the coming years. [source]


    Is there a correlation between vaginal chlamydia infection and cervical smear abnormalities?

    JOURNAL OF OBSTETRICS AND GYNAECOLOGY RESEARCH (ELECTRONIC), Issue 1 2006
    A community-based study in the Al-Ain district, United Arab Emirates
    Abstract Aim:, The purpose of this study was to determine the correlation between vaginal chlamydia infection and cervical abnormalities. The data on the prevalence of chlamydia infection and cervical abnormalities have been presented elsewhere and in this article we provide the results of a correlation analysis. Methods:, In this cross-sectional, community-based survey, women attending primary and secondary care in the Al-Ain medical district, United Arab Emirates, were offered cervical screening using the Papanicolaou smear, and chlamydia testing. A total of 793 women underwent cervical screening and 728 were tested for chlamydia. A commercially available kit was used to determine the prevalence of chlamydia. The correlation between cervical abnormalities and chlamydia infection was tested using the chi-squared test or Fisher's exact test, as appropriate. Results:, The prevalence of abnormal smears was 1.51% (95% confidence interval [CI], 0.66,2.4). Twelve subjects had abnormal smears, including smears showing atypical squamous cells of undetermined significance. The prevalence of chlamydia infection in this population was 2.5% (95% CI, 1.2,3.3). Statistical analysis showed no association (,2 0.6, P = 0.4) between the prevalence of chlamydia infection and cervical abnormalities. Conclusion:, Although there have been earlier reports of an association between vaginal chlamydia and cervical abnormalities, our study does not provide evidence to support this association. [source]


    Psychosocial well-being of patients with skin diseases in general practice

    JOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY, Issue 5 2007
    EWM Verhoeven
    Abstract Background, Skin diseases are a substantial part of the problems dealt with by general practitioners. Although the psychosocial consequences of skin diseases in secondary care has been extensively studied, little is known about the psychosocial well-being of patients with skin diseases in primary care. Objective, To investigate the psychosocial well-being of patients with skin diseases in primary care. Patients/methods, Questionnaires about the psychosocial consequences of skin diseases were sent to patients with a skin disease who were registered within a research network (continuous morbidity registration) of general practices that continuously have recorded morbidity data since 1971. Questionnaires completed by 532 patients were eventually suitable for analyses. Results, Compared with the general population, patients with skin diseases reported significantly lower scores for psychosocial well-being. Furthermore, a lower psychosocial wellbeing was significantly related with higher levels of disease-severity, lower disease-related quality of life, longer disease duration, more comorbidity and more physical symptoms of itch, pain and fatigue. After demographic variables and comorbidity were controlled for, sequential regression analyses showed that disease duration, disease severity and physical symptoms (itch, pain and fatigue) were significant predictors of psychosocial well-being. Conclusion, The psychosocial well-being of patients with skin diseases in primary care is lower than that of the general population. Special attention has to be directed to those patients with lowered psychosocial well-being who might be at risk of developing severe psychosocial impairments such as clinical depression. [source]


    Knowledge management in secondary care: a case study

    KNOWLEDGE AND PROCESS MANAGEMENT: THE JOURNAL OF CORPORATE TRANSFORMATION, Issue 3 2010
    Krystin Zigan
    The purpose of this research is to analyse the knowledge management activities of a university hospital and to examine what impact contextual factors have on these activities. For this research, a case study approach was chosen, encompassing 22 semi-structured interviews with managers and front-line staff from different organisational levels. The findings describe how at the top management level, knowledge management activities were neglected while at departmental level, such activities were purposefully undertaken. This suggests that knowledge management activities can be effectively implemented at departmental level without having the support and strategic objective of the top management of the hospital. The findings further show that factors, such as the effective utilisation of other intangible resources, such as social capital, highly contribute to the effectiveness of knowledge management activities. The paper shows some limitations due to the qualitative nature of the research with regard to sample size and the subjectivity of the interpretations. The paper proposes that knowledge management activities can be implemented in organisations, when having the right attitude of staff who support its implementation. The paper enhances the understanding of the meaning of knowledge management in the context of healthcare organisations. The paper further provides insights into contextual factors that influence the success of knowledge management initiatives. Copyright 2010 John Wiley & Sons, Ltd. [source]


    Review article: recognition and treatment of eating disorders in primary and secondary care

    ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 4 2000
    Robinson
    Eating disorders are serious illnesses affecting 1,2% of young women. Patients may present to any doctor, sometimes atypically (e.g. unexplained weight loss, food allergy, infertility, diarrhoea), delaying diagnosis and leading to needless investigation. The cardinal signs are weight loss, amenorrhoea, bingeing with vomiting and other compensatory behaviours, and disturbances in body image with an exaggeration of the importance of slimness. When other causes have been excluded, useful investigations are serum potassium, bone mineral density scanning and pelvic ultrasound. In emaciated patients multiple systems may fail with pancytopaenia, neuromyopathy and heart failure. Clinical assessment of muscle power is used to monitor physical risk. Treatment may involve individual, group or family sessions, using cognitive-behavioural, psychodynamic and family approaches. More severe or intractable illness is treated with day care, with in-patient care in a medical or specialist psychiatric unit reserved for the most severely ill patients. Antidepressants have a place in the treatment of bulimia nervosa unresponsive to psychological approaches, and when severe depressive symptoms develop. The children of people with eating disorders may have an increased risk of difficulties. Support for the patient and family, and effective liaison between professionals, are essential in the treatment of severe eating disorders. [source]


    ,All singing from the same hymn sheet': Healthcare professionals' perceptions of developing patient education material about the cardiovascular aspects of rheumatoid arthritis

    MUSCULOSKELETAL CARE, Issue 4 2009
    Holly John BM BS, MRCP
    Abstract Objective:,Cardiovascular disease (CVD) is the leading cause of death in Britain, and its prevention is a priority. Rheumatoid arthritis (RA) patients have an increased risk of CVD, and management of modifiable classical risk factors requires a programme with patient education at its heart. Before a programme for RA patients is implemented, it is important to explore the perceptions of patients and relevant healthcare professionals and consider how these could influence the subsequent content, timing and delivery of such education. Here, we assess healthcare professionals' perceptions. Methods:,Qualitative focus group methodology was adopted. Four group meetings of healthcare professionals were held using a semi-structured interview schedule. The focus group transcripts were analysed using interpretative phenomenological analysis. Results:,Three superordinate themes emerged: professional determinations about people with RA, including their perceptions about patients' priorities and motivations; communication about CVD risk, including what should be communicated, how, to whom and when; and responsibility for CVD management, referring to patients and the healthcare community. Conclusions:,Although healthcare professionals agree that it is important to convey the increased CVD risk to patients with RA, there is concern they may be less proactive in promoting risk management strategies. There was uncertainty about the best time to discuss CVD with RA patients. Maintaining a close relationship between primary and secondary care was thought to be important, with all healthcare professionals ,singing from the same hymn sheet'. These findings can inform the development of novel education material to fulfil a currently unmet clinical need. Copyright 2009 John Wiley & Sons, Ltd. [source]


    Evidence based guidelines and current practice for physiotherapy management of knee osteoarthritis

    MUSCULOSKELETAL CARE, Issue 1 2009
    Nicola E. Walsh MSc MCSP
    Abstract Objectives:,To document physiotherapy provision for patients with knee osteoarthritis (OA) in relation to the United Kingdom (UK) recently published National Institute of health and Clinical Excellence (NICE) guidelines for osteoarthritis. Design:,Questionnaire survey of chartered physiotherapists. Method:,300 postal questionnaires were distributed to Physiotherapy Departments requesting information regarding source of referrals, treatment aims, preferred methods of treatment and service delivery. Results:,Responses were received from 83 physiotherapists (28 %), predominantly working in the UK National Health Service. Approximately equal numbers of referrals came from primary and secondary care. Aims of physiotherapy management were to; encourage self-management; increase strength and range of movement; reduce pain; and improve function. To achieve these, exercise was utilised by 100% of practitioners, often supplemented with electrotherapeutic modalities (66%), manual therapy (64%) and acupuncture (60%). The majority of patients received individual treatment for a total contact time of 1,2 hours, whilst most group interventions lasted 5,6 hours. Approximately half (54%) of respondents reported using outcome measures to determine treatment efficacy. Conclusions:,Although knee OA is usually managed in primary care, the similar number of referrals from primary and secondary care may suggest a deviation from evidence-based management guidelines. The guidelines' recommendations of exercise, patient education and self-management are observed by physiotherapists, but other modalities are often used despite poor or no research evidence supporting their efficacy. Whether any of these interventions are clinically beneficial is speculative as treatment outcomes were frequently under-evaluated. Copyright 2008 John Wiley & Sons, Ltd. [source]


    The Walker Project: a longitudinal study of 48 000 children born 1952,1966 (aged 36,50 years in 2002) and their families

    PAEDIATRIC & PERINATAL EPIDEMIOLOGY, Issue 4 2004
    Gillian Libby
    Summary The Walker cohort is a database of over 48 000 birth records that has recently become available. It contains meticulously recorded details of pregnancy, labour, birth and care before discharge for babies born in hospital in Dundee, Scotland between 1952 and 1966. These babies accounted for 75% of all births in Dundee at this time. Over 34 000 (73%) of these subjects can be identified and this presents the opportunity to link this birth information with a large number of current health-outcome databases covering both primary and secondary care. Further, it allows linkage of records across siblings and over two and, in future, three generations. The number of birth records available and linkage to current databases make this a unique birth cohort with huge potential for the investigation of the fetal origins of adult disease. [source]


    Improving communication between primary and secondary care

    PRACTICAL DIABETES INTERNATIONAL (INCORPORATING CARDIABETES), Issue 5 2003
    Florence Brown Diabetes Nurse Specialist
    No abstract is available for this article. [source]


    Improving communication between primary and secondary care

    PRACTICAL DIABETES INTERNATIONAL (INCORPORATING CARDIABETES), Issue 5 2003
    Miles Fisher Consultant Physician
    No abstract is available for this article. [source]


    Latest news and product developments

    PRESCRIBER, Issue 22 2007
    Article first published online: 28 DEC 200
    Glitazones: benefits outweigh the risks Following a review of the safety of rosiglitazone and pioglitazone, the European Medicines Agency (EMEA) has concluded that their benefits outweigh their risks in the approved indications. The review was prompted by reports of an increased risk of fractures in women and, in patients taking rosiglitazone, ischaemic heart disease. The EMEA concluded that prescribing information for rosiglitazone should now include a warning that, in patients with ischaemic heart disease, it should only be used after careful evaluation of each patient's individual risk, and the combination of rosiglitazone and insulin should only be used in exceptional cases and under close supervision. No change was considered necessary to the prescribing information for pioglitazone. Modern dressings no better? A systematic review has found only weak evidence that modern dressings are better than saline gauze or paraffin gauze for healing acute and chronic wounds (Arch Dermatol 2007;143: 1297-304). The analysis, which included 99 studies, found that only hydrocolloids were demonstrably better than older dressings for healing chronic wounds, and alginates were superior to other modern dressings for debriding necrotic wounds. There was no evidence that modern dressings offered superior overall performance to the older alternatives. Hospital inflation twice primary care level The cost of drugs prescribed in secondary care but dispensed in the community increased by 6.4 per cent in 2006 - twice the rate of inflation in primary care - according to the latest statistics on hospital prescribing in England. The increase follows a reduction in costs in 2005 after the introduction of the new PPRS scheme. Data from The Information Centre (www.ic.nhs.uk) show that hospital medicines make up about 24 per cent of the NHS drugs budget. Secondary care has a consistently better record than primary care in prescribing lower-cost alternatives within therapeutic categories, eg simvastatin and pravastatin among the statins, omeprazole and lansoprazole among PPIs, and ACE inhibitors among drugs acting on the renin angiotensin system. The most expensive drug prescribed by hospital specialists and dispensed in the community is interferon beta. MHRA limits the use of fibrates The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that fibrates should now be reserved for the treatment of isolated severe hypertriglyceridaemia. They should be considered for hypercholesterolaemia only when a statin or other treatment is contraindicated or not tolerated. In the latest Drug Safety Update, the MHRA says there is insufficient evidence of long-term benefits from fibrates, and first-line use is no longer justified because the evidence for the benefits of statins is robust. The MHRA also warns that some breastfeeding infants have increased susceptibility to the adverse effects of codeine taken by their mother, and that St John's wort may affect the hepatic metabolism of any anticonvulsant. Annual zoledronic acid infusion cuts mortality after hip fracture Once-yearly infusion of zoledronic acid (Aclasta) after hip fracture reduces deaths over a two-year period by 28 per cent compared with placebo, US investigators say (N Engl J Med 2007;357:1799-809). The HORIZON Recurrent Fracture Trial randomised 2127 men and women (mean age 75) within 90 days of surgery for hip fracture to zoledronic acid 5mg yearly or placebo. Mortality over 1.9 years of follow-up was 9.6 per cent with zoledronic acid and 13.3 per cent with placebo. Zoledronic acid also significantly reduced the rate of any new clinical fractures (by 35 per cent) and new clinical vertebral fractures(by 45 per cent),but the lower rate of hip fracture (2.0 vs 3.5 per cent with placebo) was not statistically significant. Rivastigmine patch for mild to moderate AD Rivastigmine (Exelon) is now available as a transdermal patch for the treatment of mild to moderate Alzheimer's disease. Applied once daily, the patch delivers 9.5mg per 24 hours and, says manufacturer Novartis, is associated with a lower incidence of nausea and vomiting than a comparable oral dose. The patch is available in two strengths: 4.6mg per 24hr is equivalent to oral doses of 3 or 6mg per day, and the 9.5mg per 24hr patch is equivalent to 9 or 12mg per day orally. The recommended dose of the patch is 9.5mg per day; both strengths cost 83.84 for 30 patches. Women more aspirin resistant than men? The cardioprotective effect of low-dose aspirin may be lower in women than men, say Canadian investigators (BMC Medicine 2007;5:29 doi: 10.1186/1741-70155-29). Their meta-analysis of 23 randomised trials involving a total of 113 494 participants found that aspirin significantly reduced the risk of nonfatal but not fatal myocardial infarction (MI). About one-quarter of the variation in its effects on nonfatal MI was accounted for by the sex mix of the trial population. Separating the results by sex showed the reduction in risk with aspirin use was statistically significant in men (relative risk, RR, 0.62) but not in women (RR 0.87). Look after physical health of mentally ill GPs and other primary care workers should take more responsibility for the physical health of their mentally ill patients, say advocacy groups. Mind and Body: Preventing and Improving Physical Health Problems in Patients With Schizophrenia points out that the mental health needs of patients with schizophrenia are met in secondary care, but their physical health needs should be met in primary care. In particular, the metabolic effects of antipsychotics may lead to obesity, diabetes and cardiovascular disease, and weight gain in particular is a frequent reason for nonadherence to treatment. The Mind and Body Manifesto was developed by SANE, The Mental Health Nurses Association, The National Obesity Forum and The Disability Rights Commission and sponsored by Bristol-Myers Squibb Pharmaceuticals Limited and Otsuka Pharmaceuticals (UK) Ltd. Copies are available from elizabeth.green@ ogilvyhealthworld.com. Health eCard costs Some costs quoted in our article on the Health eCard (The Health eCard: the way ahead for medical records?,5 October issue, pages 28-9) have been revised: the card and initial download will cost patients 39.50, and GPs will be entitled to charge patients 10 per annum for subsequent downloads. NICE appraisals of cytokine inhibitors in RA NICE has endorsed the use of the anti-TNF agents adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade), normally in conjunction with methotrexate, for the treatment of active RA when methotrexate and another DMARD have failed (also see New from NICE below). NICE has provisionally concluded, subject to consultation, that abatacept (Orencia) should not be recommended for the treatment of RA. Boots and BMJ launch health advice site www.askbootshealth.com is a new website providing information about health and medicines for the public produced by Boots using information provided by the BMJ Publishing Group. The website covers many of the topics already available from NHSDirect, with perhaps more information about available treatments. Diabetes care shows small improvement The third National Diabetes Audit in England and Wales has found that more people with diabetes were achieving the targets set by NICE for cholesterol levels, glycaemic control and blood pressure in 2005/06 - but younger patients were doing less well. Overall, the HbA1C target of ,7.5 per cent was achieved in 60 per cent of people with diabetes compared with 58 per cent in 2004/05. However, HbA1C was >9.5 per cent in 30 per cent of children and young people, of whom 9 per cent experienced at least one episode of ketoacidosis. More topics for NICE New topics referred to NICE include clinical guidelines on ovarian cancer, coeliac disease and stable angina, public health guidance on preventing cardiovascular disease, and technology appraisals on insulin detemir (Levemir) for type 1 diabetes, several treatments for cancer and hepatic and haematological disorders, and biological therapies for juvenile arthritis. New from NICE NICE appraisal on anti-TNFs for RA Since NICE published its first appraisal of agents acting against tumour necrosis factor-alpha (anti-TNFs) for the treatment of RA in 2002, the product licences for etanercept (Enbrel) and infliximab (Remicade) have changed and a new agent, adalimumab (Humira), has been introduced. The anti-TNFs act in different ways. Infliximab is a chimeric monoclonal antibody that binds to TNF-alpha, neutralising its activity. Etanercept, a recombinant human TNF-alpha receptor fusion protein, and adalimumab, a human-sequence antibody, both bind to TNF-alpha and block its interaction with cell surface receptors. Adalimumab also modulates some biological responses induced or regulated by TNF-alpha. These agents are recommended for adults with severe active RA (defined as a disease activity score - DAS28 - greater than 5.1) who have already tried two disease-modifying drugs, including methotrexate (if not contraindicated). Prior treatment should have been of at least six months' duration, including two months at the standard dose (unless limited by toxicity). Anti-TNFs should normally be prescribed with methotrexate; when this is not appropriate, etanercept and adalimumab may be prescribed as monotherapy. Treatment with an anti-TNF should be continued beyond six months only if there is an adequate response (defined as an improvement in DAS28 of at least 1.2). Data from the British Rheumatology Society Biologics register show that, after six months, 67 per cent of patients met NICE criteria for an adequate response; this declined to 55 per cent at 18 months. The basic annual cost of treatment is 9295 for adalimumab 40mg on alternate weeks or etanercept 25mg twice weekly; infliximab costs 3777 for a loading dose, then 7553-8812 depending on dose. Assuming no progression of disability, the incremental costs per QALY (compared with sequential DMARDs) were 30 200 for adalimumab, 24 600 for etanercept and 39 400 for infliximab. There are no direct comparative trials of the anti-TNFs, and their clinical trial findings are not directly comparable. Unless other factors determine treatment choice, NICE therefore recommends the least expensive. If the first anti-TNF is withdrawn within six months due to an adverse event, a second may be tried. [source]