Telecommunications between GPs and Surgeons

Between 6% and 10% of contacts between patients and primary care result in a referral for a specialist opinion.  Work in the Netherlands has shown such an approach to be productive. A videoconferencing link avoids the need for all participants to be in the same place, while potentially offering the same benefits in communication.  The BMJ recently published an economic evaluation of the virtual outreach project.

They aimed to test the hypotheses that, compared with conventional outpatient consultations, joint tele-consultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.

The cost consequences were measured  alongside a randomised controlled trial in two hospitals; in London and Shrewsbury and 29 general practices. 3170 patients were identified; 2094 eligible for inclusion and willing to participate.  1051 randomised to virtual outreach and 1043 to standard outpatient appointments.

Overall six month costs were greater for the virtual outreach consultations : difference in means £99.  Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost £8.  Loss of productive time was less in the virtual outreach group: difference in mean cost £11 (£10 to £12, P<0.0001). 

The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.

Ref: Web

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Whiplash injury—mythology?

This interesting study contributes to the debate about whiplash—whether it is an injury or a disease, partly, at least, promoted by the possibility of obtaining financial rewards against the person to blame for the vehicle accident

The objective of the study was to compare the frequency and nature of expected 'whiplash' symptoms in Lithuania (a country where the late whiplash syndrome is rare or unknown) with that in Canada.

A symptom checklist was administered to 2 subject groups selected from local companies in Kaunas, Lithuania, and Edmonton, Canada, respectively. Subjects were asked to imagine having suffered a neck sprain (whiplash injury) with no loss of consciousness in a motor vehicle accident, and to check which, of a variety of symptoms, they would expect might arise from the injury. For symptoms they anticipated, they were asked to select the period of time they expected those symptoms to persist.

In both the Lithuanian and Edmontonian groups, the pattern of symptoms anticipated closely resembled the acute symptoms commonly reported by accident victims with acute neck sprain, but while up to 50% of Edmontonians also anticipated symptoms to last months or years, very few Lithuanian subjects selected any symptoms as likely to persist.

The authors conclude that in Lithuania, despite the documented occurrence of neck sprain symptoms in some 50% of individuals following motor vehicle accidents, there is a very low rate of expectation of any sequelae from this injury. What current or previous aspects of society that underlie this remain uncertain. This lack of expectation of chronicity in Lithuania may, in part, determine the low prevalence of the late whiplash syndrome there. Further studies of symptom expectation as an etiologic factor in the late whiplash syndrome are needed.

Ref: Web

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Treatment of tennis elbow: the evidence

Tennis elbow is an overuse syndrome most prevalent in the fourth decade.  Predominant symptoms of lateral elbow pain on gripping or resisted wrist dorsiflexion result in many consultations in primary care and days lost from work.  Most patients will recover within a year.  This should be remembered when considering the results of this Clinical Evidence extract, which is based on a Cochrane review of the subject.

The review identified randomised controlled trials (RCTs) of numerous treatment modalities for lateral elbow pain. The only treatments shown to be beneficial or likely to be beneficial were oral and topical non-steroidal anti-inflammatory drugs, which are often the first line therapy in the early stage of the disease at a point when many cases would shown spontaneous resolution. 

The full Clinical Evidence text (www.clinicalevidence.com) shows that some trials were of poor quality.  For “second line” treatments such as surgery, the review identified a relative lack of RCTs.  This is a reflection of the logistical difficulties encountered with RCTs of surgical treatments.  For these reasons, the treatment of longstanding tennis elbow may best be considered separately.

Though the data was of variable quality, certain recommendations for clinical practice can be made.  In the early phase of the disease, taking non-steroidal anti-inflammatory drugs and avoiding provoking activities is likely to be beneficial.  Corticosteroid injections may be helpful in breaking the pain cycle, but patients should be warned against inflicting further injury by reintroducing activity during the subsequent pain-free “honeymoon period”.  There is a worrying trend for symptoms to recur some months after steroid injection, but in such cases surgical release of the extensor origin may give lasting relief: in a prospective non-randomised study, 51 of 57 patients had an excellent or good result 59 months (range 50 to 65 months) after surgery.

The use of acupuncture, shock wave therapy, orthoses, and long term treatment with non-steroidal anti-inflammatory drugs is not supported by the evidence thus far. 

The orthopaedic community needs to consider the role of prolonged treatment with non-steroidal anti-inflammatory drugs and of physical therapies (orthoses, physiotherapy, and mobilisation) in treating established tennis elbow before reaching for the knife.

Ref: Web

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