News & Views
General Practitioner and Associate Clinical Professor, Warwick Medical School and Honorary Editor, RCGP Publications
E-mail: rodger.charlton{at}warwick.ac.uk
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Care for patients with epilepsy—guidelines |
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 TOP Care for patients with... Management of transient...The most difficult consultationCervical cancer and vaccinationUkraine and polyclinicsKnowledge of risk factors...NICE prostate cancer guidelines |
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The latest available epilepsy guidelines are from NICE in 2004 and a National Service Framework in 2005. A useful review appears in Clinical Medicine in August. All patients with suspected seizures should be referred quickly, preferably within 2 weeks. The diagnosis is primarily clinical based on a history and an eyewitness and needs to be differentiated from syncope, or for example drop attacks. Investigations are not used to make a diagnosis of epilepsy but rather confirm the diagnosis and establish a cause. Accurate classification is important to determine both the prognosis and appropriate medication, ideally with monotherapy. Withdrawal of medication should be discussed with patients who have been seizure free for at least 2 years and the Driver and Vehicle Licensing Agency (DVLA) strongly advises that patients should stop driving during the period of withdrawal until 6 months afterwards. Enzyme-inducing drugs may reduce the efficacy of the combined oral contraceptive pill. Pregnancies should be planned and folic acid 5 mg daily given prior to conception and until the end of the first trimester. Shared care with primary and secondary care is important together with an annual review. The issue of medication withdrawal is also the topic of a recent commentary in The Lancet.
Aylward, R. Clinical Medicine (2008) 8(4): p. 433–8.
Schmidt, D. The Lancet (2008) 372: p. 610–11.
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Management of transient ischaemic attack |
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TOPCare for patients with...Management of transient...The most difficult consultationCervical cancer and vaccinationUkraine and polyclinicsKnowledge of risk factors...NICE prostate cancer guidelines |
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Transient ischaemic attack (TIA) needs urgent management as up to 30% can progress to completed stroke within the first month. NICE 2008 guidelines recommend a risk assessment using a validated scoring system such as the ‘ABCD score’:
- A: age; 1 point for age
60 years
- B: blood pressure; 1 point for hypertension at the acute evaluation
- C: clinical features; 2 points for focal weakness, 1 for speech disturbance without weakness
- D: symptom duration; 1 point for 10–59 minutes, 2 points for 60 minutes
Total scores range 0 (lowest risk) to 6 (highest risk). A score of 4 or above should receive specialist assessment and investigation within 24 hours. Lower risk patients should be seen within 7 days. Patients who are fit for surgery and identified with carotid stenosis between 70 and 99% should have intervention within 2 weeks. TIA is a medical emergency analogous to acute coronary syndrome. Centres available to deliver thrombolysis where indicated are also essential. The aim is to prevent strokes as Rudd and colleagues suggest in an editorial in Clinical Medicine. However, as pointed out in British Medical Journal correspondence on the subject; ‘it is very clear that the NHS will require more resources to deliver the recommendations’.
Rudd, A., et al. Clinical Medicine (2008) 8(4): p. 362–3.
Dudley, N. Letter. British Medical Journal (2008) 337: p. 423–4.
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The most difficult consultation |
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TOPCare for patients with...Management of transient...The most difficult consultationCervical cancer and vaccinationUkraine and polyclinicsKnowledge of risk factors...NICE prostate cancer guidelines |
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Perhaps the most difficult consultation is overcoming a patient's expectation for a prescription for an antibiotic for an upper respiratory tract infection (URTI) for what we sometimes refer to as being caused by a ‘virus.’ Can you explain what the difference is between a bacterium and a virus is to a lay person and so arrive at a ‘shared understanding’? There is some interesting British Medical Journal correspondence on the subject which debates whether or not we should refer to the term virus in consultations. As the author, Howitt, reports, it is a word which does not appear in NICE guidelines for respiratory infections. Similarly, the use of the word, ‘infection’ in relation to chest infection is not helpful as infection is associated by lay people with the need for antibiotics. Storring asks if a term such as ‘viral-induced chestiness’ may be more helpful. Whatever you decide, you need to be clear about what terms you are going to use in consultations and a patient with a URTI. This could make the basis of a very useful case-based discussion with your trainer.
Howitt, A., Storring, R. Letters. British Medical Journal (2008) 337: p. 423.
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Cervical cancer and vaccination |
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TOPCare for patients with...Management of transient...The most difficult consultationCervical cancer and vaccinationUkraine and polyclinicsKnowledge of risk factors...NICE prostate cancer guidelines |
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Cervical cancer kills just over 1000 women annually in the UK and is the second most common cancer of women worldwide. The main cause is the human papillomavirus (HPV) of which there are almost 200 types, a fifth of which infect the anogenital tract. High-risk types are HPV 16 and 18 which may cause high-grade dysplasia and so cancer of the cervix, vulva, vagina, penis and anus. The Department of Health has chosen the bivalent vaccine, Cervarix, for the new national vaccination programme in England. This will protect against HPV 16 and 18 which accounts for 70% of carcinoma of the cervix. Following vaccination, protective antibodies are found in over 98% of patients. However, there are two important messages. The vaccination programme will not protect against 30% of cervical cancer and so screening for cervical cancer should continue and second, it does not protect against genital warts which tend to be caused by HPV 6 and 11. Interestingly, Gardasil, a quadrivalent vaccine, protects against HPV 16 and 18 and 6 and 11. Both vaccines require 3 doses over a 6 month period and routine vaccination through schools of girls aged 12–13 has been recommended from September 2008 and a 2 year catch-up programme starting from Autumn 2009 for girls up to 18 years of age. It is estimated that 40% of 15 year olds in England have had sexual intercourse and that up to 80% of sexually active individuals will at some time become infected with HPV.
Sonnex, C. Top tips in 2 minutes: HPV. British Journal of General Practice (2008) 58: p. 662–3.
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Ukraine and polyclinics |
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TOPCare for patients with...Management of transient...The most difficult consultationCervical cancer and vaccinationUkraine and polyclinicsKnowledge of risk factors...NICE prostate cancer guidelines |
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On opening the September issue of the College journal, this article immediately caught my attention, perhaps because I had just returned from a holiday in Ukraine. It is reported how health care in Eastern Europe has changed and is moving from consultations in polyclinics with specialists towards an integrated community-based family medicine service. It is a gradual process as although there are over 7000 trained family doctors, the population is approximately 47 million people. Also, family medicine is not recognized as a specialty by peers in secondary care or the government. There are no financial resources for teacher training in family medicine and poor financial reward means that many trained family medicine doctors are returning to hospital medicine or leaving health care completely. Important health-care issues include overcoming wide variation in treatment protocols for cardiovascular disease and diabetes. Ukraine is within the top 5 European countries for teenage abortion where only 2.8% of fertile females are using hormonal contraception. It is reported that Ukraine is facing one of the fastest growing HIV epidemics in the world where 1.4% of people aged between 15 and 49 are HIV positive and 45% of new cases are found in teenage drug abusers. This article reports on how Ukraine family medicine is moving forward and workshops have been run on the development of clinical guidelines and developing youth-friendly services.
Gibbs, T., et al. British Journal of General Practice (2008) 58: p. 654–7.
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Knowledge of risk factors in cancer |
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TOPCare for patients with...Management of transient...The most difficult consultationCervical cancer and vaccinationUkraine and polyclinicsKnowledge of risk factors...NICE prostate cancer guidelines |
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A short survey of adults attending eight general practices in Northern England is reported in the letter section of the College journal where 1556 questionnaire surveys were returned as to patients' knowledge of risk factors for cancer. Respondents were asked to select 6 from 12 possible risk factors, where 6 of the factors were false; exposure to traffic fumes, exposure to microwaves, lack of iron in the blood, lack of vitamin C, eating spicy food and drinking very hot drinks. Results suggest that publicity about risk factors including smoking, exposure to sunlight, being overweight and taking excess alcohol has worked. However, less so in relation to a lack of fruit and vegetables and not taking regular exercise and so this is a new possible direction for cancer prevention campaigns. Interestingly, a significant proportion considered traffic fumes and microwaves to be risk factors. These have received media attention and perhaps this indicates that some of the population distrust much of the information they receive from ‘official’ sources.
Knowles, J., Hamilton, W. British Journal of General Practice (2008) 58: p. 650–1.
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NICE prostate cancer guidelines |
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TOPCare for patients with...Management of transient...The most difficult consultationCervical cancer and vaccinationUkraine and polyclinicsKnowledge of risk factors...NICE prostate cancer guidelines |
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Prostate cancer is the commonest cancer in men with 32 000 new cases annually Neal reports in an editorial in the College journal. However, deaths from prostate cancer are relatively stable at 10 000 deaths a year. In relation to prostate cancer, many of the recommendations are based on consensus opinion rather than a clear evidence base. This is because prostate cancer has a variable natural history as for many men prostate cancer is relatively inactive. Also there are more diagnoses as a result of increased prostate-specific antigen (PSA) tests and the discovery of disease at an early stage. Ascertaining which patients will develop prostate cancer that follows an aggressive course is currently difficult and so for example which patients should be offered a radical prostatectomy with its many local side effects such as urinary problems and sexual dysfunction for an absolute 5% risk reduction compared with ‘watchful waiting’. Neal suggests that it is helpful to distinguish between watchful waiting and ‘active surveillance’. Watchful waiting is recommended in primary care for local disease when there are no clear benefits of radical treatments and may have potential harms. The disease can be monitored with PSA measurements and urinary symptoms. Active surveillance is recommended for the management of men with low-risk localized disease who may benefit from radical treatments in the face of disease progression and so active monitoring through PSA tests and biopsies. This should be by the secondary care multidisciplinary team who undertake biopsies at defined intervals and PSA assays in between. Guidelines recommended for those men 2 years post treatment with a stable PSA are that follow-up should be in primary care with at least an annual PSA. The guidelines will change and become more rigorous and robust with time as further research is undertaken and it is possible to identify for more clearly which treatments are most effective and those men whose prostate cancer is aggressive and needs active treatment and follow-up.
Neal, R. British Journal of General Practice (2008) 58: p. 607–8.
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