Margaret McCartney's Blog Tue, 25 Jul 2017 13:30:31 +0000 en-GB hourly 1 52277273 Inside Health 25/7/17 – PPIs Tue, 25 Jul 2017 13:30:31 +0000 Good overview 

Time line summary 

NICE guidance  and here 

current UK prescribing  study

US veterans study 

WHO essential medicines
surgery for peptic ulcers massively reduced – probably at least in part due to PPIs

JAMA mortality study 


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Babylon – Inside Health Radio 4 11/7/17 Tue, 11 Jul 2017 06:46:16 +0000 FAQ for people in North London – which says this is an ‘independent’ study

see the evidence available for the app  ;

“Our approach enables the reliable use of red-flags which leads to a high recall of 100% (all cases needing A&E will receive that outcome), at the cost of precision (some cases falsely receive A&E out- come), as shown in table 1..

This enables prediction with high precision at the cost of recall (potentially over-triaging for border-line cases).”

this is not a randomised controlled trial; the clinical vignettes are not included; there is no real life testing

one of the authors on this study is from Babylon

other research of note

Performance on appropriate triage advice across the 23 individual symptom checkers ranged from 33% (95% confidence interval 19% to 48%) to 78% (64% to 91%) of standardized patient evaluations.

just over a third of users surveyed say they would have gone to primary and community services such as their GP if 111 hadn’t existed – but 111 actually sends around 60% of callers to these services
There is potential that this type of service increases overall demand for urgent care.”

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RCGP Council 24/6/17 Sat, 24 Jun 2017 16:31:06 +0000 1) COI and relationship council to trustee board
I asked that published literature makes clear that Trustee Board (who are reviewing sponsorship guidance) must report to Council.

2) 5YFW evidence based nonsense
On discussion of the 5 year forward view, I was most concerned that:
there 5 Year Forward View seems to be still regarded positively yet it contains numerous uncosted and non evidenced policy making – especially with regard to ‘innovations’ in technology. If we spend money on this there is less to go elsewhere on evidence based interventions and we all lose out
instead money seems to be getting poured into management consultancies
we need to move urgently to evidence based policy making
we are window dressing a cliff edge to general practice

3) Physican assistants
I said that: positive anecdotes don’t cut it: needs systematic review, investigation of harms and assessment of opportunity costs
If I were designing a true assistant role, I would not start here – GP work involves so much bureaucracy that could be done by someone else trained to do so and allow more time for patient care by GPs

4) mental health
My concern is that the fragmentation of mental health and voluntary sector schemes make it very hard to ensure vulnerable people get cared for and the organisation of negotiation between schemes often seems to fall to GP; also an editorial in the BMJ co authored by Professor Hawthorne implies that training for GPs can only take place in secondary care: this is misleading

5) sponsorship policy
Agreed with John Cosgrove – who said we shouldn’t divide into commercial vs non commercial sponsorship but should look more broadly at organisations who seek power in our work for whatever reason. So e.g. an insurance company or make up brand – different from any drug or tech company. Call to look to Nordic countries for great examples of minimal or no sponsorship, or Evidence Live or Preventing Overdiagnosis conferences for simillar.

6) leadership. without critical thinking it’s nothing. Needs to be able to demand evidence, think critically and be worth following.

7) overdiagnosis group – widely appreciated but bottom line is that we need support internally applying the 5 tests and agreed to discuss this within the college as we are at the limits of the group as to what we can do – agreed would discuss further . Part of proposals are for council staff and CIRC to be more involved with applying the ‘five tests’ of the overdiagnosis group and to work more closely with devolved faculties. Agreed.

8) private screening paper – very supportive comments from council, widely accepted and praised, and discussions to be had about moving this forward with other organisations.

Inside Health 22/3/17 Wed, 22 Mar 2017 22:24:29 +0000

Inside Health 14/3/17 bisphosphonates Tue, 14 Mar 2017 15:27:59 +0000 study in the news

long term studies – JAMA paper  and NEJM and uptodate


Cochrane on HRT


also discussed

Rephill study

Inside Health 7/3/17 Tue, 07 Mar 2017 19:34:18 +0000 Aspirin and here


CRP point of care testing

based on trial published BMJ

and (3) the evidence from systematic reviews and other studies suggests little, if any, benefit is achieved from the prescription of antibiotics, except in elderly patients at high risk of pneumonia.
2005 – said CRP not good enough test – not accurate enough

2009 cluster RCT in Netherlands
4 groups
usual care / CRP testing / enhanced comm skills / enhanced comm skills+ crp testing

most effective to reduce was actually comm skills testing followed by CRP

CRP concentrations were <20, 20-30, 30-50, 50-100, and >100 mg/L in 74%, 8%, 9%, 6%, and 3% of patients, respectively. The proportion with pneumonia in these groups was 3%, 5%, 7%, 15%, and 35% respectively. Positive predictive values of CRP as a univariate (stand-alone) test were 11.8%, 14.8%, 22.5%, and 35.4% for concentrations over 20, 30, 50, and 100 mg/L, respectively. Negative predictive values were 97.4%, 97.2%, 96.8%, and 96.1%. Some 54 patients (3%) with radiographic pneumonia had a CRP concentration <20 mg/L.\

cochrane reivew 2014
Used as an adjunct to a doctor’s clinical examination this reduction in antibiotic use did not affect patient-reported outcomes, including recovery from and duration of illness.However, a possible increase in hospitalisations is of concern. A more precise effect estimate is needed to assess the costs of the intervention and compare the use of a point-of-care biomarker to other antibiotic-saving strategies.

OMG – this does NOT prove CRP is useful as PoC…

Inside Health 28/2/17 Tue, 28 Feb 2017 18:21:08 +0000 8 GLASSES OF WATER

8 glasses of water a day
1945, US Food and Nutrition Board recommended 2.5 litres water a day. Qualified this by saying that it’s mostly contained within foods

water company advertised
“Healthcare professionals should be encouraged to talk with patients about the calorific content of SSBs [sugar sweetened beverages] when discussing lifestyle modification to manage overweight and/or obesity . . . Consumption of water in preference to other beverages should be highlighted as a simple step towards healthier hydration.” And healthier hydration is? “recommending 1.5 to 2 litres of water daily is the simplest and healthiest hydration advice you can give.”
NHS choices
The Eatwell Guide says we should drink six to eight glasses of fluid a day. Water, lower fat milk and sugar-free drinks including tea and coffee all count.

healthy adults who have free access to water – thirst is very potent at detectng tiny changes in fluid balance – kidneys balancing fluid by concentrating urine almost instantly and thirst to prevent dehydration –
thirst is not dehydration – clinical diagnosis
claims children dehydrated couple of years ago in press – just showed the children could concentrate urine
The results indicate that during free access to water humans become thirsty and drink before body fluid deficits develop, perhaps in response to subtle oropharyngeal cues, and so provide evidence for anticipatory thirst and drinking in man.

thirst is a very good predictor of needs in healthy adults
may be different if people have say dementia or children – may need special care

10,000 STEPS A DAY

JAMA fitness trackers 2016 – more weight gain with tracker than without over 2 years in addition to standard behavioural modifications
NHS choices
“Setting yourself a target of walking 10,000 steps a day can be a fun way of increasing the amount of physical activity you do.
Sometimes overlooked as a form of exercise, walking can help you build stamina, burn excess calories and give you a healthier heart.
average 3-4000 steps per day”

real lack of proof
‘However, many questions remain regarding the effectiveness of this technology for promoting behavior change. Behavior change techniques such as goal setting, feedback, rewards, and social factors are often included in fitness technology.’

‘The fitness tracker market is currently thriving, with estimates of almost 1.5 billion dollars in revenue last year alone’

launched 5 a day in 2003
WHO had recommended 400g fruit and veg a day – 5 portions

denmark 6 a day
‘Prospective studies of fruit and vegetable intake and cardiovascular disease, total cancer and all-cause mortality were included.

There was a 8–16% reduction in the RR of coronary heart disease, 13–18% reduction in the RR of stroke, 8–13% reduction in the RR of cardiovascular disease, 3–4% reduction in the RR of total cancer and 10–15% reduction in the RR of all-cause mortality for each 200 g/day increment in intake of fruit, vegetables, and fruit and vegetables combined. In the nonlinear models, there were 16%, 28%, 22%, 13% and 27% reductions in the RR of coronary heart disease, stroke, cardiovascular disease, total cancer and all-cause mortality, respectively, for an intake of 500 g of fruits and vegetables per day vs 0–40 g/day, whereas an intake of 800 g/day was associated with 24%, 33%, 28%, 14% and 31% reductions in the RR, respectively.

For fruits and vegetables combined the lowest risk was observed at an intake of 550–600 g/day (7–7.5 servings/day) for total cancer, with little evidence of further reductions in risk with higher intakes, whereas for coronary heart disease, stroke, cardiovascular disease and all-cause mortality the lowest risk was observed at 800 g/day (10 servings/day), which was at the high end of the range of intake across studies.’


vast, vast majority of this type food studies are inherently little bit or lot unreliable – recall, not RCTs but cohort


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RCGP council meeting 25/2/16 Sat, 25 Feb 2017 16:01:35 +0000 RCGP sponsorship policy:

The Trustee Board have decided to review this after concerns were brought my myself and others to Council about sponsorship of conference and education.

I’m concerned that because the Trustee Board are also responsible for finances it will be difficult to disentangle the two responsibilities. While the Trustee Board are also responsible for reputational risk, but are not directly elected by members. For these reasons I felt that the review should be designed and led by more than just Trustee Board. I will write again to the Chair of Council regarding this.

Membership by assessment: I raised various concerns about proposals to change criteria: especially doctors who are struggling. I think competence based assessments are already in place and ‘grading’ of Fellowship would have adverse consequences.

Referral management:

Two problems: 1) is this being done to reduce demand. If being done because of austerity politics, then it is crucial that rationing is made explicit and the public are given full information about why. And referral management systems don’t reduce demand and research hasn’t assessed harms. 2) Is it being done to improve quality: if so, this should be done in different ways, again there is evidence that referral management systems don’t improve quality, and we have seldom learned from the past in terms of what does help.

and again, when do we measure harms – so much of my work is now taken up with trying to deal with specialities (especially psychiatry) who want to refer patients away from them.

RCGP Clinical Priorities

I’m concerned that the Overdiagnosis principles haven’t been applied to the current iteration of clinical priorities. For example, in sepsis, some of the tools being applied to GP have not been tested for accuracy or safety. It was agreed this will be reviewed.


Inside Health 21/2/16 Tue, 21 Feb 2017 21:11:54 +0000 PTSD after heart attack 

We found that a considerable proportion of patients with acute coronary syndromes develop elevated PTSD symptoms, and elevated intrusion symptoms in particular. Further, our results confirm and extend prior findings of an association between post-ACS PTSD symptoms and increased risk of recurrent MACE/ACM.anxiety as a risk factor for cardiovascular disease …The findings of the present study demonstrate that patients who have intrusive, emotionally-charged thoughts, nightmares, or flashbacks related to their ACS may be at especially high risk for MACE recurrence and mortality.


Anxiety disorders are associated with an elevated risk of a range of different cardiovascular events, including stroke, coronary heart disease, heart failure, and cardiovascular death. Whether these associations are causal is unclear.”

Lancet PSTD studies 

other studies

bereavement and mortality
Within 30 days of their partner’s death, 50 of the bereaved group (0.16%) experienced an MI or a stroke compared with 67 of the matched nonbereaved controls (0.08%) during the same period (IRR, 2.20 [95% CI, 1.52-3.15]).

We found a dose-response association between psychological distress across the full range of severity and an increased risk of mortality (age and sex adjusted hazard ratio for General Health Questionnaire scores of 1-3 v score 0: 1.20, 95% confidence interval 1.13 to 1.27; scores 4-6: 1.43, 1.31 to 1.56; and scores 7-12: 1.94, 1.66 to 2.26; P<0.001 for trend). This association remained after adjustment for somatic comorbidity plus behavioural and socioeconomic factors. A similar association was found for cardiovascular disease deaths and deaths from external causes. Cancer death was only associated with psychological distress at higher levels.
association increased mortality for CVS death

carers and stress 
participants who were providing care and experiencing caregiver strain had mortality risks that were 63% higher than noncaregiving controls (relative risk [RR], 1.63; 95% confidence interval [CI], 1.00-2.65). Participants who were providing care but not experiencing strain (RR, 1.08; 95% CI, 0.61-1.90) and those with a disabled spouse who were not providing care (RR, 1.37; 95% CI, 0.73-2.58) did not have elevated adjusted mortality rates relative to the noncaregiving controls.
Among those participants with disabled spouses, about 81% were providing care and about 56% of those reported caregiver strain.
After 4 years of follow-up, 103 deaths (12.6%) occurred among the total sample. Death occurred in 40 (9.4%) of the 427 participants whose spouses were not disabled at baseline, in 13 (17.3%) of the 75 subjects whose spouses were disabled but who were not providing help, in 19 (13.8%) of the 138 subjects who were providing care but were not strained, and in 31 (17.3%) of the 179 who were providing care and reported caregiver strain ( χ23, 9.38; P<.025). As would be expected, there was a strong linear trend (χ21, 31.59; P<.001) in mortality rates for physical health status: no prevalent or subclinical disease (14/261 [5.4%]); subclinical (no prevalent) disease (39/336 [11.6%]); and prevalent disease (50/222 [22.5%]


Christmas BMJ – Dutch football matches and heart attacks 

natural disasters and heart attacks  also here and here, summary review

“numerous clinical triggers of MI have been identified, including blizzards, the Christmas and New Year’s holidays, experiencing an earthquake, the threat of violence, job strain, Mondays for the working population, sexual activity, overeating, smoking cigarettes, smoking marijuana, using cocaine, and particulate air pollution


Vitamin D

BMJ paper

BMJ editorial

earlier BMJ study

PLOS study

Scottish gov recommendations 

english recommends 

Inside Health 31/1/17 Tue, 31 Jan 2017 14:29:25 +0000 Hernia repair and outcomes 

and in Bristol 

original RCTs – note how many people didn’t take part

overview from NZ 


other papers of note

[PDF]Systematic review of the clinical effectiveness and cost … – NICE…/assessment-report-laparoscopic-surgery-for-inguinal-hernia-r.

Procedures for managing individual funding requests

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