Margaret McCartney's Blog Tue, 19 Sep 2017 15:12:57 +0000 en-GB hourly 1 52277273 Inside Health 19/9/17- schizophrenia Tue, 19 Sep 2017 13:53:39 +0000 Rethink Mental Illness charity  –

bad use e.g.

wrong use e.g.

academic studies

various calls over time for a renaming

would it help?

don’t know what people with the diagnosis of schizophrenia think

people with schizophrenia are more likely to do themselves harm than others

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summer 2017 – Radio programmes Mon, 28 Aug 2017 12:28:31 +0000
  • a six part series for BBC Radio Scotland, called Cradle to Grave
  • and

    2. A half hour programme for Radio 4 called Too Much Medicine


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    Inside Health 8/8/17 Tue, 08 Aug 2017 18:06:22 +0000
    Radiology, October 2002, Vol. 225:1, pp. 165-175)$File/Position%20Statement%20on%20breast%20density%20and%20screening%20within%20the%20BreastScreen%20Australia%20Program.pdf

    Inside Health 1/8/17 Tue, 01 Aug 2017 20:07:14 +0000 Antibiotics and optimal duration of taking them

    paper in BMJ

    Lancet in 1999 Prof Harold Lambert

    2009 in Clinical Medicine – similar issues
    do patients actually think not completing course is bad?
    cite two studies
    Most believed antibiotic resistance was due to excessive (median 70%, in 11 studies) or unnecessary (median 74%, in 8 studies) antibiotic use and not completing an antibiotic course (median 62%, in 8 studies)

    These patients also had scientifically accepted explanatory models, such as resistance being due to unnecessary or to over-use of antibiotics, and not finishing a course, which might partially treat the infection allowing remaining bacteria to ‘evolve’. Others felt that being prescribed an inappropriate antibiotic could also lead to resistance:

    in fact some researchers have found 5 day course for pneumonia was recommended as being good as longer courses if signs and sx developed …as far back as 1945

    uncertainty ongoing:
    eg NICE

    • There is a lack of evidence on the optimal duration of antibiotic treatment, but expert opinion in Guidelines on the management of cellulitis in adults [CREST, 2005] suggests that uncomplicated cases usually respond to 1–2 weeks of treatment.
    • If there has been a slow response to treatment with oral antibiotics, Public Health England recommends extending the antibiotic course for a further 7 days [PHE, 2014a].!scenario
    numerous studies on UTI duration length ◦ If antibiotic treatment is indicated, a 3-day course of empirical treatment is recommended for most women because there is good evidence from Cochrane systematic reviews that this achieves symptomatic cure in women with uncomplicated UTI; it is more effective than single-dose treatment and as effective as 5–10-day courses [Milo et al, 2005; Lutters and Vogt-Ferrier, 2008]. This is also in line with recommendations from SIGN [SIGN, 2012], the Health Protection Agency [HPA, 2011], and an international guideline [American College of Obstetricians and Gynecologists, 2008].

    ◦ For women with a complicated UTI, a longer course is recommended because there is evidence from a Cochrane systematic review that a 5 to 10-day course produced a higher bacteriological cure rate (but more adverse effects) than a 3-day regimen [Milo et al, 2005]. The Cochrane systematic review concluded that a 5 to 10-day course may be considered for women in whom eradication of bacteriuria is important. CKS has extrapolated this to include women with renal impairment who may be at risk of complications from recurrent UTI, depending on clinical judgement.

    • Antibiotics have little effect on the extent and duration of symptoms of sore throat in most people [NICE, 2001; Spinks et al, 2006].
    • Evidence from a Cochrane review found that the absolute benefits of antibiotic treatment on the duration of symptoms were modest — a reduction of illness of about one day at around day 3 [Spinks et al, 2006].
    ◦ However, studies (included in the systematic review) that used three of four of the Centor criteria for bacterial infection to determine eligibility showed a little more benefit from antibiotics for both symptom resolution and prevention of complications.
    ie – what is the point of prescribing them at all – telling people to stop taking them when feel better might be counter productive because it’s caused by a virus and antibiotics are not going to help and an average cough lasts 3 weeks!



    screening for lung cancer

    UK National Screening Committee recommendation on Lung Cancer screening in adult cigarette smokers. July 2006
    Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening
    The National Lung Screening Trial Research Team
    N Engl J Med 2011; 365:395-409August 4, 2011DOI: 10.1056/NEJMoa1102873
    Yousaf-Khan U, van der Aalst C, de Jong PA, et al Final screening round of the NELSON lung cancer screening trial: the effect of a 2.5-year screening interval Thorax 2017;72:48-56.
    Lung Cancer Early Diagnosis Rates Soar During UK-first CT Community Scanner Pilot in Manchester by UHSM

    Lung Cancer Early Diagnosis Rates Soar During UK-first CT Community Scanner Pilot In Manchester by UHSM

    Khomami N. The Guardian, 13/1/16

    Detection of lung cancer through low-dose CT screening (NELSON): a prespecified analysis of screening test performance and interval cancers
    Horeweg, Nanda et al.
    The Lancet Oncology , Volume 15 , Issue 12 , 1342 – 1350

    Macmillan report 

    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 


    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.”

    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…