1,721,077 research outputs found
Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling
No full textBackground: Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma. Objectives: The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care. Design: (1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives. Data sources: For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews (KSR) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used. Review methods: For review 1, cohort and case–control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed. Results: People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5–2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research. Limitations: The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet. Conclusions: Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia)
Diagnosis and management of irritable bowel syndrome in general practice
No full textIrritable bowel syndrome (IBS) is one of the commonest causes of gastrointestinal (GI) consultations in primary and secondary care—it accounts for approximately 3% of all GP consultations. IBS has a prevalence of between 10% and 20%; however, most people (75%) never consult a GP. It is a relapsing and remitting condition and those who do present to general practice have a wide range of symptoms including abdominal pain, bloating, change in bowel habit, fatigue, nausea, backache and bladder symptoms. IBS symptoms can be distressing, leading to time off work, reduced social functioning and a reduced quality of life. This article will outline the key aspects of diagnosing and managing IBS in general practice including highlighting the new NICE guidelines for the diagnosis and management of IBS in adults (published February 2008)
Acute conjunctivitis
No full textAcute conjunctivitis is common. About 2–5% of general practice consultations are related to eye conditions and approximately 40% of these are concerned with conjunctivitis. Thus, on average, a full-time general practitioner sees a patient with conjunctivitis every week. The most common presentation is with a red eye. The main tasks are to exclude potentially serious causes of a red eye and then decide whether the conjunctivitis is infective, allergic or due to other causes so that suitable management can be initiated. <br/
The management of acute infective conjunctivitis in general practice
No full textAcute infective conjunctivitis (AlC) is a common self-limiting condition presenting to general practice. However, evidence is limited on GPs current management of AlC, patients' understanding of conjunctivitis or the most appropriate management strategy for AlC in general practice.The aims of this thesis where to: 1) To determine GPs' current management strategies for AlC 2) To gain an understanding of patients concerns and beliefs about AlC and develop a patient information leaflet (PIL). 3) To assess the effect of common management strategies for AlC on symptom resolution and patients belief in antibiotics.Three complementary studies were used: 1) A postal survey of 300 GPs regarding their diagnosis and management of AlC. 2) A qualitative study involving interviews with 25 patients to explore conjunctivitis from the patients' perspective. 3) An open randomised controlled tria~ with 307 recruits, to assess the effect of different management strategies (immediate, delayed or no offer of antibiotics; a patient information leaflet and an eye swab) for AlC in general practice.The results were: 1) Survey: 95% of responding GPs usually prescribe topical antibiotics for AlC despite 58% stating that they thought at least half of the cases they see are viral in origin. Only 36% of GPs believed they could discriminate between viral and bacterial infection 2) Qualitative study: patients regarded conjunctivitis as a minor illness although some considered it might become more serious if not treated. They stated a preference not to take medication but believed that conjunctivitis would not clear without treatment. However, they were open to alternative management approaches (e.g. delayed prescription approach) because they trusted their GPs judgement. Once aware of the self-limiting nature of conjunctivitis, patients felt they would prefer to wait a few days to see if it improved before seeking medical advice even if this resulted in a few more days of symptoms. 3) Randomised trial: different prescribing strategies did not affect symptom severity in the ftrst 3 days, but duration of moderately bad symptoms was less with antibiotics (control 4.83 days, immediate 3.26 days (p=0.001), delayed 3.86 days (p=0.002)). Compared with no initial offer of antibiotics, antibiotic use was higher in the immediate group (control 30%, immediate 99% (p=0.001), delayed 53% (p=0.004)) as was belief in the effectiveness of antibiotics (control 47%, immediate 67% (p=0.03); delayed 55% (p=0.35)) and intention to re-consult (control 40%, immediate 68% (p=0.001), delayed 41 % (p=0.98)). A patient information leaflet or an eye swab had no affect on the main outcomes, but an eye swab seemed to increase patient worry about AlC and a PIL seemed to increase satisfaction with the consultation and the amount of information received. Re-attendance in the next two weeks was less in the delayed group (delayed OR 0.33 (0.11;0.98); immediate OR 0.65 (0.26; 1.63)).In conclusion: Most general practitioners prescribe topical antibiotics for most cases of acute infective conjunctivitis -a self-limiting condition. Most patients are unaware of the self-limiting nature of AlC. A delayed prescribing approach is probably the most appropriate strategy to use for the management of acute conjunctivitis in primary care - it reduces antibiotic use by nearly 50%, shows no evidence of 'medicalisation', provides similar symptom duration and severity to immediate prescribing and reduces re-attendance in the short term compared with no offer of antibiotics
How do GPs diagnose and manage acute infective conjunctivitis? A GP survey
No full textObjective: to determine GPs’ diagnosis and management of acute infective conjunctivitis (AIC)—one of the commonest but least researched acute infections seen in primary care. Methods: a postal questionnaire survey of 300 GPs from two Health Authorities in Southern England. Results: 236 (78%) GPs returned the questionnaire. 92% of those responding felt confident or very confident in the diagnosis of AIC. 95% usually prescribe topical antibiotics for AIC despite 58% stating that they thought at least half of the cases they see are viral in origin and only 36% believing that they could discriminate between bacterial and viral infection. There was considerable variability in GPs’ use of individual signs to make the diagnosis of AIC (from 99% using eye discharge to 31% using conjunctival oedema) and in the features used to discriminate viral from bacterial infection (from 87% using type of discharge to 47% using amount of discharge). GPs rarely perform eye swabs or give patient information leaflets to patients with AIC. Conclusion: most GPs still prescribe topical antibiotics for most cases of AIC—a condition where only half of the cases are likely to be due to a bacterial infection, and even bacterial infections are self-limiting. Further research is needed to explore the potential benefits and disadvantages of topical antibiotics, and to develop clinical or microbiological methods to help GPs to target antibiotic prescription
Empathico Feasibility Trial Interview Transcripts
No full textQualitative interview transcripts generated during feasibility trial of a new digital training package (EMPathicO) to enhance primary care practitioners’ communication of clinical empathy and realistic optimism. Dataset includes verbatim transcripts from 11 interviews with clinicians and 30 interviews with patients. Personal details (e.g., names, dates) have been removed but sensitive data may remain (e.g., health, experiences of medical consultations). Transcripts saved as .doc and .docx.
The data is available on request only to Bone Fide researchers with ethical clearance. Please complete the attached request from and send to [email protected]</span
Assessing and managing chronic insomnia in the healthy pre-adolescent child
No full textInsomnia (difficulty falling asleep or staying asleep) is reported by parents of 20-30% of children in the developed world [1,2,3,4]. Reliable data from developing countries is lacking, but adult data suggests that insomnia is a global phenomenon [5]. Children born in the new millennium are likely to have around 70 minutes less total sleep time than generations born 100 years ago [6]. This is a public health concern as short sleep is associated with multiple adverse outcomes [7-18] (Figure 1) and sleep problems in early childhood may constrain brain development. In a population based prospective cohort study, parent report of sleep problems after 2 years of age predicted reduced grey matter volume at 7 years in 720 Dutch children [19]. Importantly, childhood insomnia can have an erosive effect on parents. Only one week of sleep disruption produces measurable changes in mood, emotional regulation and decision making in adults [20,21]. Many parents experience months or years of sleep loss before seeking help. Despite the importance of sleep to children, general practitioners rarely ask about sleep [22], perhaps reflecting limited undergraduate education in sleep medicine [23]. Presenting sleep problems could be caused by over 50 different sleep disorders in six recognised categories as defined by the International Classification of Sleep Disorders [24]. Text box 1. This article offers a toolkit for the generalist to manage the commonest childhood sleep disorder, chronic insomnia.<br/
Empathico Feasibility Trial Clinician Interview Excerpts
No full textSelected anonymised excerpts from qualitative interview transcripts generated during feasibility trial of a new digital training package (EMPathicO) to enhance primary care practitioners’ communication of clinical empathy and realistic optimism. Dataset includes excerpts from 11 interviews with clinicians, grouped under high level descriptive codes. </span
Empathico Feasibility Trial Patient Interview Excerpts
No full textSelected anonymised excerpts from qualitative interview transcripts generated during feasibility trial of a new digital training package (EMPathicO) to enhance primary care practitioners’ communication of clinical empathy and realistic optimism. Dataset includes excerpts from 30 interviews with patients, grouped under high level descriptive codes. </span
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