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Briefings -
20 items of interest
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1. Cranberries for preventing urinary tract
infections.
The theory goes that cranberries contain a
substance that can prevent bacteria from sticking to the walls of
someone’s bladder. But a recent Cochrane Review has found that we
still await reliable evidence about whether cranberries really are
a useful treatment for urinary tract infections (UTIs), even though
they have been used to prevent and treat UTIs for decades. The
jury’s still out.
Jepson RG, Craig JC. Cranberries for preventing urinary
tract infections. Cochrane Database of Systematic Rev 2008,
Iss1.
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001321/pdf_fs.html
2. Oxycodone: a review of its use in the management of
pain.
Oxycodone is a strong opioid analgesic that
is a suitable alternative to morphine. Its efficacy is well
established for both neuropathic and somatic types of pain. It is
available in oral, intraspinal and parenteral formats. Oxycodone is
particularly effective because of the fast onset of pain relief,
and control of moderate to severe pain for 12 hour
periods.
Riley J, Eisenberg E, Müller-Schwefe G, et al.
Oxycodone: a review of its use in the management of pain. Curr
Med Res Opin 2008; 24(1): 175-192.
http://www.ingentaconnect.com/content/libra/cmro/2008/00000024/00000001/art00019 (abstract
only – full-text requires subscription)
3. Management of infestations in Primary care -
Head Lice, Scabies, Pubic Lice and
Threadworms
Head lice update: careful combing is more
reliable than simply looking to detect active infestation. Treat
only if a live louse has been seen. Try wet combing for at least
four sessions over two weeks or use insecticides: eg malathion 0.5%
lotion or phenothrin 0.5% liquid or dimeticone 4% lotion – two
applications, seven days apart.
Scabies update: diagnose by clinical
examination and history. Try permethrin 5% dermal cream as first
line treatment. Treat all close contacts and household members
simultaneously even if they have no symptoms. Launder, iron or
tumble dry clothing, bedding, towels etc. on first day of treatment
to minimise likelihood of reinfestation.
MeReC and NPC. Management of infestations
in Primary care - Head Lice, Scabies, Pubic Lice and Threadworms.
MeReC Bulletin, 2008; 18(4).
http://www.npc.co.uk/MeReC_Bulletins/pdfs/bulletin_vol18no4_main.pdf
4. Guidelines for UK practice for the diagnosis and
management of methicillin-resistant staphylococcus aureus (MRSA)
infections presenting in the community.
Staph aureus is the major baceterial cause of
skin, soft tissue and bone infections, and one of the commonest
causes of healthcare associated bacteraemia. There has been an
increase in MRSA infections presenting in the community – in those
who have had direct or indirect contact with hospitals, care homes
or other healthcare facilities. The prevalence of community
acquired (CA) MRSA in the UK is currently very low; typically it
may affect young, healthy people – eg students, professional
athletes, military service personnel. It may spread in families and
sports teams. With a predilection for skin and soft tissue it may
produce cellulitis and abscesses. Cultures should be taken from
septic sites if CA-MRSA is suspected; but not routinely from
patients presenting with minor soft tissue infections (SSTIs). Do
not give systemic antibiotics to patients with SSTIs or small
abscesses; drain small abscesses without cellulitis and do not give
antibiotics. For larger abscesses, incise and drain and start
empirical or culture guided systemic antibiotic therapy. Take a
look at the source document for more detail about specific
cases.
British Society for Antimicrobial Chemotherapy
Working Party on Community-onset MRSA Infections. Guidelines for UK
practice for the diagnosis and management of methicillin-resistant
staphylococcus aureus (MRSA) infections presenting in the
community. J Antimicrobial Chemother 2008;
61: 976–994. http://jac.oxfordjournals.org/cgi/reprint/61/5/976
5. Consent: patients and doctors making
decisions together. Guidance for doctors.
When you obtain consent from a patient or
other valid authority before undertaking any examination or
investigation, providing treatment or involving patients in
teaching or research you must:
listen to patients
and respect their views about their health, and their decisions
discuss with
patients what their diagnosis, prognosis, treatment and care
involve
share the
information patients want or need in order to make decisions
maximise patients’
opportunities and their ability to make decisions for
themselves.
Assume that every adult patient has the
capacity to make decisions about their care. Only regard a patient
as lacking capacity if they cannot understand, retain, use or weigh
up information needed to make a decision or communicate their
wishes.
General Medical Council. Consent:
patients and doctors making decisions together. Guidance for
doctors. London: GMC, 2008.
http://www.gmc-uk.org/news/articles/Consent_guidance.pdf
6. Primary Care Service Framework: Alcohol services in primary
care
Opportunistic brief interventions in primary care delivered to
people drinking alcohol excessively can be effective in reducing
alcohol consumption. Good screening tools to use include the
Alcohol Screening Tool [FAST] and AUDIT-C. Incorporate brief
interventions for hazardous and harmful drinking into your routine
care – acting before heavy drinkers progress to require treatment
for alcohol dependence. This England-based review gives good
examples of provision of alcohol services in primary care –
including support for self care.
Department of Health, NHS PCC. Primary
Care Service Framework: Alcohol Services in Primary Care.
London: DH, 2008.
www.primarycarecontracting.nhs.uk/uploads/primary_care_service_frameworks/primary_care_service_framework_-_alcohol_v9_final.pdf
7. Management of invasive meningococcal disease in children and
young
people
It can be difficult to recognise and diagnose meningococcal
disease in its initial stages as early features are non-specific.
Look out for rapidly progressive septicaemia; and intervene
appropriately. Non-specific symptoms such as cold hands or
feet, skin mottling or leg pain can precede classical symptoms or
signs by several hours. There are three illness patterns:
- clinical bacterial meningitis: fever, lethargy, vomiting,
headache, photophobia and neck stiffness with maybe petechiae or
purpura; some infants and young children may have less specific
features – poor feeding, irritability, high pitched cry, full
fontanelle;
- meningococcal septicaemia: with fever, petechiae, purpura and
toxicity;
- mixed picture of septicaemia and meningitis.
If you suspect meningitis start antibiotic treatment before
admission to hospital – administer benzylpenicillin or ceftriaxone
to children as soon as you suspect invasive meningococcal disease,
prior to emergency admission to hospital. Remember children
recovering from meningococcal disease may suffer from hearing loss,
neurological complications, psychiatric or psychological problems,
bone and joint complications, post-necrotic scarring and renal
impairment.
SIGN. Management of invasive meningococcal disease in children
& young people. A national clinical guideline. Guideline
102.Edinburgh: SIGN, 2008.
http://www.sign.ac.uk/pdf/sign102.pdf
8. Osteoarthritis: the care and management of
osteoarthritis in adults
The guidelines emphasise the benefits of taking a holistic
approach to the management of osteoarthritis: a healthy lifestyle
with a focus on exercise and weight management. Plan care with the
patient to take account of their needs and preferences, the nature
of their work, the effect of arthritis on their life. Offer
paracetamol and/or topical NSAIDs for knee and hand arthritis
before considering oral NSAIDs, COX-2 inhibitors or opioids.
Co-prescribe a proton pump inhibitor with an oral NSAID or COX-2
inhibitor. Refer for joint replacement surgery before there is
prolonged and established functional limitation and/or severe
pain.
National Institute of Health and Clinical Excellence, National
Collaborating Centre for Chronic Conditions. Osteoarthritis:
the care and management of osteoarthritis in adults. NICE
Clinical Guideline 59. London: NICE, 2008.
www.nice.org.uk/nicemedia/pdf/CG059FullGuideline.pdf
9. Vertigo - Management in general
practice
Treatment for vertigo is still mainly symptomatic, to minimise
vertigo associated disability and improve the patient’s quality of
life. Supportive treatment, antiemetic and/or vestibular blocking
agents help to relieve an acute vertigo attack. The article
summarises the specific causes of vertigo and recommended
approaches.
Kuo C, Pang L, Chang R. Vertigo - Management in general
practice. Australian Family Physician 2008;
37(6): 409-413.
http://www.racgp.org.au/Content/NavigationMenu/Publications/AustralianFamilyPhys/2008issues/afp200806/200806kuo.pdf
10. Antibiotics and antiseptics for venous leg
ulcers
Where we are now: There is no reliable evidence to justify the
routine use of oral antibiotics to promote healing in venous leg
ulcers – many of which are colonised by bacteria. So….further
research is needed to be sure of the effectiveness (or not) of
systemic antibiotics, topical antibiotics or antiseptics. There is
some evidence to support the use of cadexomer iodine if a topical
preparation is tried. Current guidelines recommend that antibiotics
should not be used for bacterial colonisation- and reserved for
identified infection.
O'Meara S, Al-Kurdi D, Ovington LG. Antibiotics and
antiseptics for venous leg ulcers. Cochrane Database of
Systematic Rev 2008, Iss1.
www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003557/pdf_fs.html
11. Hormone replacement therapy and risk of venous
thromboembolism in postmenopausal women: systematic review and
meta-analysis.
Oral oestrogen in hormone replacement
therapy increases the risk of venous thromboembolism, especially
during the first year of treatment (2.5 times the risk). Taking
transdermal oestrogen as opposed to oral oestrogen seems safer (1.2
times the risk). Women who are obese who take oral oestrogen are
more at risk of a venous thromboembolism.
Canonico M, Plu-Bureau G, Lowe GDO, et
al. Hormone replacement therapy and risk of venous
thromboembolism in postmenopausal women: systematic review and
meta-analysis. BMJ 2008; 336:
1127-31.
www.bmj.com/cgi/content/full/bmj.39555.441944.BE
12. Prophylaxis against infective
endocarditis
Brush up on which cardiac conditions render people
most at risk of infective endocarditis – valve replacement,
structural congenital heart disease, valvular heart disease. Advise
patients at risk about prevention. Antibiotic prophylaxis is no
longer recommended by NICE for people at risk of infective
endocarditis undergoing dental, obstetric, gastrointestinal and
respiratory procedures – because clinical effectiveness is not
proven and bearing in mind the potential risk of anaphylaxis from
an unnecessary treatment.
National Institute for Health and Clinical Excellence.
Prophylaxis against infective endocarditis: antimicrobial
prophylaxis against infective endocarditis in adults and children
undergoing interventional procedures. NICE Clinical Guideline
64. London: NICE, 2008.
www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf
13. Chronic heart failure: overview of diagnosis and
drug treatment in primary
care .jpg "heart")
An overview: Treatment of chronic heart failure involves
promoting a healthy lifestyle as well as prescribed drugs.
Treatment with angiotensin-converting enzyme (ACE) inhibitors,
beta-blockers and diuretics should be optimised in terms of initial
doses and titrated up to control symptoms, as tolerated. Additional
specialist treatments include an aldosterone antagonist or
angiotensin-2 receptor antagonist; digoxin may be considered for
patients in sinus rhythm who remain symptomatic.
National Prescribing Centre. Chronic heart failure: overview of
diagnosis and drug treatment in primary care. MeReC
Bulletin 2008; 18(3)
www.npc.co.uk/MeReC_Bulletins/pdfs/merec_bulletin_vol18_no3.pdf
14. Lipid modification: cardiovascular risk
assessment and the modification of blood lipids for the primary and
secondary prevention of cardiovascular disease
The NICE guideline describes the primary prevention of
cardiovascular disease (CVD) for people aged 40-74 years old.
People should be prioritised from an estimate of their CVD risk
based on personal information already recorded in their medical
notes; then risk factors managed according to best practice. Statin
therapy should be given for the primary prevention of adults with a
≥ 20% ten year risk (based on their Framingham risk score) of
developing CVD. Statins (simvastatin 40mg daily) should be
initiated for all adults with clinical evidence of CVD as secondary
prevention; push dose to simvastatin 80mg or equivalent if total
cholesterol ≥ 4 mmol/litre or LDL cholesterol ≥ 2 mmol/litre.
National Institute of Health and Clinical Excellence. Lipid
modification: cardiovascular risk assessment and the modification
of blood lipids for the primary and secondary prevention of
cardiovascular disease. Clinical Guideline 67. London: NICE,
2008. www.nice.org.uk/nicemedia/pdf/CG67NICEguideline.pdf
15. Helicobacter pylori test and treat versus proton
pump inhibitor in initial management of dyspepsia in primary care:
multicentre randomised controlled trial (MRC-CUBE
trial).
It is as cost effective to prescribe a proton pump inhibitor
(PPI) for people who present with dyspepsia (who have no alarming
symptoms of gastrointestinal cancer) as to arrange to first test
for and treat (if present) H pylori. Effects, costs and patient
satisfaction were reportedly similar at 12 months in this study. So
you can discuss the alternative approaches with patients when they
present with dyspepsia and let them choose whether to test for H
pylori initially or only if symptoms persist, and opt for acid
suppression
Delaney BC, Qume M, Moayyedi P, et al. Helicobacter pylori test
and treat versus proton pump inhibitor in initial management of
dyspepsia in primary care: multicentre randomised controlled trial
(MRC-CUBE trial). BMJ 2008, 336: epub 18
Mar 2008.
www.bmj.com/cgi/content/full/bmj.39479.640486.AEv2?q=rss_home
16. Type 2 diabetes
This guideline updates previous NICE guidance on the management
of type 2 diabetes and for patients with hypertension, raised
lipids, renal disease, or retinopathy. It emphasises involving the
patient in managing their diabetes and enabling them to make
decisions; so structured education for every person with diabetes
and/or their carer at diagnosis and successive annual reviews; and
a personalised management approach.
National Institute of Health and Clinical Excellence. Type 2
diabetes. The management of type 2 diabetes. This is an update
of NICE clinical guidelines E, F, G and H. Clinical Guideline
66. London: NICE, 2008. www.nice.org.uk/nicemedia/pdf/CG66NICEGuidance.pdf
17. BSACI guidelines for the management of allergic and
non-allergic rhinitis
Update: comprehensive description of classification and
aetiology of rhinitis, diagnosis, examination, recommended
interventions - with 234 references. Some key points:
• Topical nasal corticosteroids are the preferred treatment
for moderate to severe allergic rhinitis.
• Treatment of allergic rhinitis improves asthma
control.
• Infective rhinitis can be caused by viruses, and less
commonly by bacteria, fungi and protozoa.
Scadding GK, Durham SR, Mirakian R., et al. BSACI guidelines for
the management of allergic and non-allergic rhinitis. Clin Exp
Allergy 2008; 38(1): 19-42.
www.blackwell-synergy.com/doi/pdf/10.1111/j.1365-2222.2007.02888.x
18. Emergency treatment of anaphylactic reactions.
Guidelines for healthcare providers
The ABCDE approach to the recognition and management of an
anaphylactic reaction dictates that you consider the: airway,
breathing, circulation, disability (level of consciousness) and
exposure (of the skin). Treatment of choice is intramuscular (IM)
injection of adrenaline (25mm needles for all ages except 38mm
needles for the obese); intravenous (IV) administration of
adrenaline should only be used by those skilled and experienced, in
specialist settings with cardiac monitoring. Look up age ranges and
doses for adrenaline (500mcg or 0.5ml in adult), hydrocortisone
(200mg in adult IM or slow IV) and chlorphenamine (10 mg in adult
IM or slow IV).
Resuscitation Council (UK). Emergency treatment of
anaphylactic reactions. Guidelines for healthcare providers.
London: Resuscitation Council (UK), 2008. www.resus.org.uk/pages/reaction.pdf
19. UK Resuscitation Council guidelines on emergency
treatment of anaphylactic reactions: a primary care
perspective.
Recommends you as a GP write down the doses of drugs you’ll give
in emergencies, in this case anaphylactic reaction, and stick on
your emergency drug bag; and put the anaphylaxis algorithm
(www.resus.org.uk/pages/reaction.pdf
) on your clinic wall. Refer patients who’ve suffered
anaphylaxis to an allergy clinic (if available) for advice on long
term management and prevention.
Burton C, Worth A. UK Resuscitation Council guidelines on
emergency treatment of anaphylactic reactions: a primary care
perspective. Prim Care Respir J 2008; Apr 14.
www.thepcrj.org/journ/aop/SG00146.pdf
20. Topical or oral ibuprofen for chronic knee pain in
older people. The TOIB
study. 
Topical NSAIDs have an equivalent effect to
oral NSAIDs for chronic knee pain in older people. Not surprisingly
this study showed that those on oral NSAIDs had more adverse
effects such as dyspepsia, than those using topical medication. But
older people with more severe or widespread pain preferred the oral
version of NSAIDs as they believed it might help other areas of
pain elsewhere in their body.
Underwood M, Ashby D, et al. Topical or oral
ibuprofen for chronic knee pain in older people. The TOIB study.
Health Technol Assess 2008;
12(22) http://www.hta.ac.uk/fullmono/mon1222.pdf
Antenatal Care>>
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EGP2. Oct 2008