Issue
13
Guidelines in
general practice
One of the problems of using guidelines in general practice is that
relatively little research is primary care based. GPs also see a very wide range of
problems and can hardly be expected to remember the most up-to-date guideline for them
all.
A researcher, Toby Lippman, in Newcastle looked at 413 presentations of
problems to GPs. The top ten presented in roughly a third of consultations, 26 further
problems presented in about another third, but there were no fewer than 122 different
problems in the remaining third.
Obviously guidelines would be useful for patients in the top 10 which
included hypertension and depression. But what about the other 148! You'd need to search
for evidence at least before you leave the building or have an very good memory.
The Bro Taf District Medical Committee Professional Guidance, Jan 1998
obtainable from Bro Taf HA HQ, Churchill House, will help for some of these, though not
all problems.
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Drug treatment
during pregnancy
What better time than a celebration of a birth to look at drug
treatment during pregnancy. The BMJ last month had an excellent review of the subject
Drugs that can affect foetal growth and development |
Drug |
Possible effect |
Angiotensin
converting enzyme inhibitors |
Renal failure |
Antithyroid
drugs |
Hypothyroidism
(in excessive dose) |
Benzodiazepines |
Drug dependence |
Beta blockers |
Growth
retardation may occur |
Barbiturates |
Drug dependence |
NSAIDs |
Constriction of
ductus arteriosus |
Tetracyclines |
Tooth
discoloration; inhibit bone growth (briefly first trimester prob. not harmful) |
Warfarin |
Bleeding |
Drugs to be avoided while breast feeding |
Drug |
Possible
effects |
Amiodarone HCL |
Poss.
hypothyroidism |
Aspirin |
? Reye’s
syndrome |
Barbiturates |
Drowsiness |
Benzodiazepines |
Lethargy |
Carbimazole |
Hypothyroidism
(use lowest dose) |
Combined oral
contraceptives |
May diminish
milk supply and nitrogen, protein in milk |
Cytotoxic drugs |
Immune
suppression and neutropenia |
Ephedrine HCl |
Irritability |
Tetracyclines |
Theoretical risk
of tooth discoloration |
Commonly used drugs that are teratogenic |
Phenytoin
Carbamazepine
Sodium valproate
Lithium |
Warfarin
Retinoids
Danazol |
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The quality
of care in acute psychiatric wards
Many readers will have seen reference to this study from the Sainsbury
Centre for mental health in the papers, but its message is so important that we cover it
here.
Twenty to 25 patients admitted consecutively to 38 wards across the
country were recruited to the study, totalling 215 people in all. Most patients left acute
care in a better mental state than when they came in. However, people’s long term,
underlying needs were not being met during their hospital stay; and in particular social
needs were not being addressed.
In some cases staff and patients disagreed about the patient’s
most pressing needs. Nearly half of all patients said that they had not received enough
information about their illness and the possible treatments.
Many patients receive only limited therapeutic input and
multi-disciplinary care was absent for the majority. Patients had few contacts with staff
other than doctors and nurses, averaging one contact per patient per stay. Few are
involved in planned programmes of social activity. 40% of all patients undertook no social
or recreational activity.
Most patients stayed longer than necessary, because of a lack of
alternatives in the community. Staff believed that nearly one in five patients no longer
needed inpatient care at the end of the first week of their stay, 45% by the end of the
second week and 70% after 8 weeks. The main reasons for inability to discharge were lack
of accommodation and lack of home-based support.
Discharge is often unplanned with inadequate involvement of community staff, patients
and carers. Use of the Care Programme Approach (CPA) is variable and is often resented by
staff. A third of patients had a discharge planning meeting. Most patients had no idea
that they were to be discharged until a few days before they left, and had little
involvement in discussions about their future. Half of all patients’ case notes did
not identify the level or intensity of care they required under the CPA.. The report makes
depressing reading for anyone involved with acute adult psychiatric services. Nevertheless
we recommend it, especially the 10 recommendations.
Reference: Sainsbury Centre for Mental Health Acute Problems
Briefing 4
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Treatment of cancer in adults
and children
In the USA >70% of paediatric patients with cancer are entered into
at least one clinical trial; only 2% of adults with cancer are entered into trials. In the
past 25 years survival times and side-effects from treatment have improved dramatically
for children with cancer (eg from 40% to 70% cure rates) in contrast to minor improvements
for adults with cancer even though there have been no new "frontline"
therapeutic agents.
it seems that paediatric oncologists have been doing EBM for a quarter of a century:
putting evidence into practice and getting practice into evidence. Why have other
specialities not followed the example of the paediatric oncologists?
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What a NICE man
The government promises that the National Institute for Clinical
Excellence will "give a strong lead on clinical and cost effectiveness, drawing up
new guidelines and ensuring they reach all parts of the health service".
Professor Rawlins a clinical pharmacologist, best known for his
chairmanship of the Committee on Safety of Medicines, is the Chairman designate. His other
responsibilities include directing the WHO collaborating centre for drug policy and drug
safety research and co-ordinating the European pharmacovigilance research group. He starts
work in April
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