Specialist Secondary Care Research Articles

Healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective: a scoping review

Objective General practice plays an important role in cancer trajectories, and cancer patients request the continuous involvement of general practice. The objective of this scoping review was to identify healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective. Design, setting, and subjects A scoping review of the literature published in Danish or English from 2010 to 2020 was conducted. Data was collected using identified keywords and indexed terms in several databases (PubMed, MEDLINE, EBSCO CINAHL, Scopus, and ProQuest), contacting key experts, searching through reference lists, and reports from selected health political, research- and interest organizations’ websites. Main outcome measures We identified healthcare practices in cancer trajectories that increase quality care. Identified healthcare practices were grouped into four contextual domains and allocated to defined phases in the cancer trajectory. The results are presented according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR). Results A total of 45 peer-reviewed and six non-peer-reviewed articles and reports were included. Quality of care increases in all phases of the cancer trajectory when GPs listen carefully to the full story and use action plans. After diagnosis, quality of care increases when GPs and practice staff have a proactive care approach, act as interpreters of diagnosis, treatment options, and its consequences, and engage in care coordination with specialists in secondary care involving the patient. Conclusion This scoping review identified healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective. The results support general practice in investigating own healthcare practices and identifying possibilities for quality improvement. KEY POINTS Identified healthcare practices in general practice that increase the quality of care in cancer trajectories: Listen carefully to the full story Use action plans and time-out-consultations Plan and provide proactive care Act as an interpreter of diagnosis, treatment options, and its consequences for the patient Coordinate care with specialists, patients, and caregivers with mutual respect Identified barriers for quality of care in cancer trajectories are: Time constraints in consultations Limited accessibility for patients and caregivers Health practices to increase the quality of care should be effective, safe, people-centered, timely, equitable, integrated, and efficient. These distinctions of quality of care, support general practice in investigating and improving quality of care in cancer trajectories.

An in Depth Analysis of Factors Contributing to Diagnostic Delay in Myeloma: A Retrospective UK Study of Patients Journey from Primary Care to Specialist Secondary Care

IntroductionPatients with Multiple Myeloma (MM) often have a significant delay between onset of symptoms and diagnosis of disease. As a result, a significant number of patients present via emergency routes with severe co-morbidities which affect survival rates. Timely diagnosis relies on the early recognition of symptoms and blood test results which may indicate disease.MethodsWe examined the medical records of 142 newly diagnosed MM patients (121 intact immunoglobulin and 21 light chains) across 2 UK Hospitals. Patients included had not previously been diagnosed with a plasma cell dyscrasia, including Monoclonal Gammopathy of Undetermined Significance (MGUS). Clinical symptoms and blood test results were examined from the time of initial presentation to the healthcare system with symptoms indicative of MM, to the point of diagnosis in order to highlight patterns of symptoms and blood tests results which may give an early indication of disease. Blood tests results recorded included globulin, calcium, creatinine, erythroid sedimentation rate and haemoglobin. Time to diagnosis from presentation with symptoms indicative of MM was also measured as well as the patient pathway from the point of presentation to the point of diagnosis.ResultsThe median time to diagnosis from initial presentation was 77 days (range 0 - 12,986). Initial presentation was most commonly via primary care (58.1%). Urgent secondary care presentation was documented in 28.5% which included acute medical unit (15.6%), the emergency department (7.1%), and other secondary care specialities (5.7%) respectively. Multiple GP visits were common prior to haematology referral with a median of 3 visits (range 1 - 40). Initial presenting symptoms varied, but of those with data recorded (n=107) back/bone pain was the most common (58.2%) followed by anaemia (18.7%), fracture (7.5%), recurrent infection (7.5%) and renal impairment (3.7%) respectively. Interestingly, analysis of evaluable blood test results revealed a raised globulin was most often evident prior to diagnosis with 58% of patients recording an abnormal globulin a median of 140 days (range 3 - 4297) prior to diagnosis of disease.ConclusionsMultiple GP visits prior to establishing a diagnosis of myeloma is very common. Inclusion of abnormal globulin to reflex electrophoresis request and serum free light chain assay may serve as a useful trigger for investigation when interpreted alongside presenting symptoms and other blood test results. Increased awareness of myeloma warning signs in primary care may reduce diagnostic delay and avoid presentation with severe co-morbidities in emergency settings. DisclosuresNo relevant conflicts of interest to declare.

Screening for active and latent TB among migrants in France.

SETTING: Migrants to Europe face a disproportionate burden of infections, including TB, yet little is known about the approach taken by primary and secondary care providers to screening and treatment. We therefore explored policy and practice relating to screening of active TB and latent TB infection (LTBI) in France.METHODS: We conducted an online national survey of French primary and secondary care physicians regarding their practices in relation to TB/LTBI screening among migrants.RESULTS: 367 physicians responded to the questionnaire among which 195 (53.1%) were primary care physicians, 126 (34.3%) were TB specialists in secondary care, and 46 (12.5%) other physicians; 303 (85.5%) were involved daily in the care of migrants. Most respondents recommended systematic TB screening with chest X-ray for migrants from medium and high-incidence countries (71.9%). Primary care physicians were less likely to offer screening than physicians in other settings (aOR 0.21, 95% CI 0.09-0.48). 220 (61.8%) offered LTBI screening for children (<15 years) and 34.0% for all migrants from high incidence countries.CONCLUSION: Improving awareness on TB screening is a critical next step to improve health outcomes in migrant groups and meet regional targets for tackling TB.

Quality of life following treatment for T1a glottic cancer with surgery or radiotherapy: outcomes from the Head and Neck 5000 cohort.

To investigate the quality of life in patients treated with either RT or surgery alone for T1a glottic carcinoma. This prospective cohort study aims to assess generic- and disease-specific patient-reported QoL in patients treated with either surgery or RT for T1a glottic carcinoma. Multicentre, secondary care specialist head and neck units in the UK. Participants were recruited as part of the multicentre, prospective Head and Neck 5000 cohort between 2011 and 2014. Baseline demographic data were collected. All participants completed the EORTC QLQ C30 and EORTC QLQ H&N35 questionnaires at baseline, 4months, 12months and after 36months. One hundred and twenty three participants received radiotherapy only (n=68) or surgery only (n=55). Overall QoL scores were similar between both groups. The median (IQR) EORTC QLQ C30summary scores at 12months were 89.3 (79.1, 95.7) and 92.6 (74.4, 97.9) for the radiotherapy and surgery groups respectively. The equivalent summary scores for the EORTC QLQ H&N35 were 91.9 (83.8, 94.9) and 90.4 (85.5, 94.9). There was a modest difference in some QoL subscales between the groups, but no differences existed beyond 4months. Patient-reported QoL is similar following either radiotherapy or surgery for T1a glottic carcinoma. These data support current guidance recommended TLM for this disease.

Epidemiology and organisation of care in medically unexplained symptoms: A systematic review with a focus on cultural diversity and migrants.

BackgroundSince the pathophysiology of medically unexplained symptoms (MUS) remains unclear, healthcare providers often struggle with these patients, especially with a different ethnic and/or cultural background. These challenges are insufficiently addressed in their training and in the organisation of care.AimTo improve healthcare provider‐patient interaction focused on MUS patients in general and in ethnic minorities and refugees in particular through a systematic review of syndromal definitions and epidemiology and organisation of care of MUS patients.MethodsScreening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords ‘Medical unexplained (physical) symptoms (MUPS)’, ‘Somatoform disorder’, ‘Functional syndrome’, ‘Diversity’, ‘Migrants’, ‘Ethnicity’, ‘Care models’, ‘Medical education’, ‘Communication skills’, ‘Health literacy’.ResultsDifferent case definitions result in markedly different epidemiological estimates for MUS patients. Nevertheless, they are prevalent in a wide range of healthcare settings. Literature offers evidence of the effectiveness of structural frameworks in approaching MUS patients. Organisation of MUS care needs to transcend different levels of care: specialist tertiary and secondary care and primary care involving different qualifications of caregivers need to be aligned.ConclusionThe systematic review identified significant gaps and shortcomings in organisation of care. These need to be addressed in order to improve outcomes.

An eReferral Management & Triage System for minor Oral surgery referrals from primary care dentists: a cost-effectiveness evaluation

ObjectiveOral surgery referrals from NHS dental practices are rising, increasing the pressures on available hospital resources. We assess if an electronic referral system with consultant or peer (general dental practitioner) led triage of patient referrals from general dental practices can effectively divert patients requiring minor oral surgery into specialist led primary care settings at a reduced cost whilst providing care of the same or enhanced quality. One year of no triage (all referrals treated in secondary care) was followed by one-year of consultant led triage, which in turn was followed by year of peer-led triage.MethodA health economic evaluation of all patient referrals from 27 UK dental practices for oral surgery procedures. The follow-up is over a three-year period at hospital dental services in two general hospitals, one dental hospital, and a single specialist oral surgeon based in two primary care practices. The evaluation is a comparison of mean outcomes in the hospitals and in specialist primary care dental services between the study periods (i.e. periods with and without the triage system). The main outcomes of interest are mean NHS cost saving per referral (costs to the NHS and costs to broader society), proportion of diverted referrals, case-mix of referrals and patient reports of the quality of dentistry services received at their referral destination.ResultsThe proportion of referrals diverted to specialist primary care was similar during both periods (45% under consultant-led triage and 43% under GDP-led triage). Statistically significant savings per referral diverted were found (£116.11 under consultant-led triage, £90.25 under GDP-led triage). There were no statistically significant changes in the case-mix of referrals. Cost savings varied according to the coding (and hence tariff) of referred cases by the provider hospitals. Patients reported similarly high levels of satisfaction scores for treatment in specialist primary care and secondary care settings.ConclusionsImplementation of electronic referral management in primary care, when combined with triage, led to appropriate diversions to specialist primary care. Although cost savings were realised by referral diversion these savings are dependent on the particular tariff allocation (coding) practices of provider hospitals.

The role of trust and hope in antipsychotic medication reviews between GPs and service users a realist review

BackgroundIncreasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support.AimTo explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input.Design & settingRealist review in general practice settings.MethodA realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews.ResultsMeaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory.ConclusionsThe review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.

P205 The contemporary presentation and management of giant cell arteritis with large vessel vasculitis

Abstract Background/Aims Giant cell arteritis with large vessel vasculitis (LV-GCA) represents a distinct, less researched sub-category of giant cell arteritis (GCA). In comparison to cranial GCA, the patient’s diagnostic pathway is less well described and it is thought that LV-GCA is underdiagnosed, including in patients with polymyalgia rheumatica and cranial-GCA. Advances in imaging (e.g. PET-CT) and treatment (tocilizumab), have provided additional options in the diagnosis and management of LV-GCA. The aim was to describe the contemporary clinical journey for patients diagnosed with LV-GCA. Methods The electronic patient health record system in NHS Lothian (TrakCare) was used to collect relevant data. Patients with imaging-confirmed large vessel vasculitis, diagnosed with GCA after 1 January 2017 were included. Follow-up was until August 2020. Results Eighteen patients with LV-GCA were included. The mean age was 65 years and 66.7% were female. Two patients had known cranial-GCA but 89% of patients were diagnosed exclusively with large vessel involvement. The most common symptoms were malaise (55%), weight loss (55%), polymyalgia rheumatica (55%) and limb claudication (44%). Pyrexia of unknown origin was a feature in only 17% of patients. Two patients were asymptomatic and were investigated on the basis of raised inflammatory markers. Mean CRP at baseline was 99mg/L and ESR 85mm/hour. The mean time from symptom-onset to diagnosis was 6.8 months (range 1 to 15 months). Sixteen patients (89%) were reviewed by at least one other secondary care specialist. One third of patients were referred from General Medicine followed by Vascular Surgery (16%) and General Practice (16%). 7/18 patients were inpatients at the time of referral. 56% of patients required two modalities of imaging to confirm large vessel involvement. The most commonly used imaging techniques (in descending order) were CT-Chest/Abdomen/Pelvis, CT-angiogram, PET-CT and Vascular Ultrasound. 50% of patients underwent follow-up imaging, most commonly MR- or CT-angiography. Mean follow-up was for 1.6 years. The mean prednisolone dose at 3 months (n = 18) was 24mg daily and 8mg at 12 months (n = 12). 28% of patients relapsed during the follow-up period at 4, 5, 8, 9 and 24 months post-diagnosis. 7/18 patients were commenced on methotrexate for steroid-side effects or for relapse. 8/18 received subcutaneous tocilizumab in combination with methotrexate in two cases. Three patients were started on azathioprine but only one continued. Conclusion In modern-day clinical practice, patients with LV-GCA experience a longer time to diagnosis than those with cranial symptoms. Patients with LV-GCA can experience an array of constitutional symptoms. Frequently, more than one imaging modality is required to confirm LV-GCA and the majority of patients will have seen other hospital specialists or have been admitted to hospital before diagnosis. Methotrexate and tocilizumab are the most frequently-used and effective steroid-adjunct in this single-centre cohort. Disclosure O. Cronin: None. N.D. McKay: Consultancies; Gilead. Other; Has received support for conference attendance from Pfizer and Gilead, Has received educational support from UCB, Gilead, Celgene, Biogen, Sanofi, Abbvie, Novartis, Pfizer. H. Preston: None. H. Harris: None. B. Hauser: None.

Typologies of education and training pathways for general practitioners: a scoping review

ABSTRACT Introduction: Variation in medical education and training amongst countries is well reported but evidence syntheses of similarities and differences are rare. We developed a typology of education and training pathways for General Practitioners (or equivalent) based on a scoping review of international peer-reviewed literature. Methods: Applying search terms such as ‘General practice’ or ‘Family medicine’ and ‘medical education or training’ in Ovid Medline, Embase, and ERIC, identified studies published since 2010 describing education and training pathways for GPs. Inclusion criteria were used to select studies for data extraction and thematic analysis to characterise distinct typologies. Results: 90 articles were included in the scoping review of which 47 discussed both undergraduate and postgraduate programmes and three typologies based on GPs’ role in the healthcare system identified: ‘Gatekeeper’: Patients cannot access secondary or tertiary service without GP referral. ‘Doctor of choice’: Patients can choose to see a specialist and access secondary or tertiary care directly. ‘Team member’: Patients can access a network of health professionals in the community. Conclusion: The typology provides a reference for medical educators and policymakers. Conceptualising the diversity in education and training pathways can inform the implementation of educational and training transformation for GPs in different contexts.

Pharmaceutical care issues in lung cancer: can community pharmacists support patients receiving systemic anticancer therapy?

Most patients receive systemic anticancer therapy (SACT) as day cases and toxicities, if they occur, are likely to appear first in primary care. Pharmaceutical care can be delivered by community pharmacists, but little is known about the epidemiology of SACT toxicities in the community and potential interventions to address these which raise the following questions: what are the typologies of SACT-associated toxicities experienced by community-based patients and what are the associated pharmaceutical care issues (PCIs)? The aim of this study was to identify toxicities and pharmaceutical care issues of patients prescribed SACT for lung cancer and understand the potential for community pharmacists to deliver aspects of cancer care including toxicity management. Retrospective analysis of clinical records of patients prescribed oral and parenteral SACT in 2013-14, to describe patient characteristics; SACT toxicity; PCIs and episodes of unscheduled care. Twelve categories of toxicity and 13 categories of PCIs were identified from 50 patients. More PCIs were observed with oral SACT/oral-parenteral combinations than with parenteral regimens. The PCIs which could be managed by community pharmacists were mucositis; skin toxicity; gastrointestinal toxicity; reinforcing patient education and identification/prevention of drug interactions. Community pharmacists are ideally placed to provide pharmaceutical care to patients with lung cancer prescribed SACT. Cancer specialists in secondary care can signpost patients to community pharmacists for early management of low-grade SACT toxicity.

Management of Molar Incisor Hypomineralisation (MIH): A 1-Year Retrospective Study in a Specialist Secondary Care Centre in the UK.

(1) Background: Molar incisor hypomineralisation (MIH) is an enamel defect that affects an estimated 14.2% of children worldwide. Care takes place in primary and secondary care facilities. (2) Aim: To investigate how children with MIH are managed within a specialist centre in the north of England. (3) Method: A retrospective service evaluation within the paediatric dentistry department was registered with the clinical governance unit. Children who attended consultant-led new-patient clinics between 1 January and 31 December 2015 with a diagnosis of MIH were included. The data collected concerned the pre-referral treatment, the history and diagnoses and the treatments completed. (4) Results: Out of 397 records reviewed, 48 (12.1%) had MIH, where 81.3% and 18.8% of patients had severe and mild MIH, respectively. The majority of patients (n = 44 (91.7%)) were referred appropriately. Treatment was completed at the specialist centre for 44 (91.7%) patients. Twenty-five (52.1%) patients had an extraction of one or more first permanent molar teeth. Sixteen patients had the extractions at between 8 and 10 years old and 2 had the extractions later as part of an orthodontic plan. (5) Conclusion: Most children had severe MIH and were referred at an appropriate time to facilitate the consideration of loss of poor prognosis of first permanent molars (FPMs). Most children required specialist management of their MIH.

Determinants of referral of women with urinary incontinence to specialist services: a national cohort study using primary care data from the UK

BackgroundFemale urinary incontinence is underdiagnosed and undertreated in primary care. There is little evidence on factors that determine whether women with urinary incontinence are referred to specialist services. This study aimed to investigate characteristics associated with referrals from primary to specialist secondary care for urinary incontinence.MethodsWe carried out a cohort study, using primary care data from over 600 general practices contributing to the Clinical Practice Research Datalink (CPRD) in the United Kingdom. We used multi-level logistic regression to estimate adjusted odds ratios (aOR) that reflect the impact of patient and GP practice-level characteristics on referrals to specialist services in secondary care within 30 days of a urinary incontinence diagnosis. All women aged ≥18 years newly diagnosed with urinary incontinence between 1 April 2004 and 31 March 2013 were included. One-year referral was estimated with death as competing event.ResultsOf the 104,466 included women (median age: 58 years), 28,476 (27.3%) were referred within 30 days. Referral rates decreased with age (aOR 0.34, 95% CI 0.31–0.37, comparing women aged ≥80 with those aged 40–49 years) and was lower among women who were severely obese (aOR 0.84, 95% CI 0.78–0.90), smokers (aOR 0.94, 95% CI 0.90–0.98), women from a minority-ethnic backgrounds (aOR 0.76, 95% CI 0.65–0.89 comparing Asian with white women), women with pelvic organ prolapse (aOR 0.77, 95% CI 0.68–0.87), and women in Scotland (aOR 0.60, 95% CI 0.46–0.78, comparing women in Scotland and England). One-year referral rate was 34.0% and the pattern of associations with patient characteristics was almost the same as for 30-day referrals.ConclusionsAbout one in four women with urinary incontinence were referred to specialist secondary care services within one month after a UI diagnosis and one in three within one year. Referral rates decreased with age which confirms concerns that older women with UI are less likely to receive care according to existing clinical guidelines. Referral rates were also lower in women from minority-ethnic backgrounds. These finding may reflect clinicians’ beliefs about the appropriateness of referral, differences in women’s preferences for treatment, or other factors leading to inequities in referral for urinary incontinence.

102 - Dementia and primary care – lessons from Europe: Symposium

Primary care doctors /General Practitioners are sometimes criticised for failing to recognise dementia in its early stages. Old age psychiatrists, neurologists or geriatricians take on the tasks of recognition, diagnosis (subtyping) and post-diagnostic support, and some Primary care doctors /General Practitioners welcome this division of labour as a way of avoiding the demanding tasks of dementia recognition and response. However, the rising prevalence of dementia syndromes in an ageing population is undermining the ability of secondary care specialists to fulfil their tasks of timely recognition, diagnosis and support. Primary care doctors /General Practitioners will be encouraged to take over some secondary care tasks. This will pose problems for Primary care doctors /General Practitioners, who may not have been trained to work with people with dementia, and who may not be able to incorporate such work into their practice even when trained. This symposium will explore the current and future challenges Primary care doctors /General Practitioners face in recognising and responding to dementia, and outline some lessons from four European countries (Ireland, Spain, Portugal and England). Themes to be presented include: Barriers to the recognition of dementia,The dementia-specific educational needs of Primary care doctors/General Practitioners,Interprofessional education of community-based primary care teams,Case management of people with dementia in primary care,IT solutions to problems of support for people with dementia.Effective dementia-care interventions in primary care post-diagnostic care pathways,Systemically-inspired brief interventions in primary care.Chair: Emeritus Professor Steve Iliffe, Centre for Ageing Population Studies, University College London [England]; co-chair: Professor Manuel Gonçalves-Pereira, Professor of Behavioural Medicine and Psychiatry, Nova Medical School, Universidade Nova de Lisboa [Portugal]Speakers:Dr Tony Foley, Lecturer Department of General Practice, University College Cork [Ireland]Professor Manuel A. Franco, Head of Psychiatry and Mental Health Department. University Rio Hortega Hospital (Valladolid) [Spain]Dr Conceição Balsinha, General Practitioner &amp; Assistant professor/PhD student, Nova Medical School, Universidade Nova de Lisboa &amp; Professor Manuel Gonçalves-Pereira, Nova Medical School, Universidade Nova de Lisboa [Portugal]Emeritus Professor Steve Iliffe, Centre for Ageing Population studies, University College London [England]

A service evaluation of a group mindfulness-based intervention for distressing voices: how do findings from a randomized controlled trial compare with routine clinical practice?

Person-based cognitive therapy (PBCT) was developed as a treatment for psychosis. The effectiveness of group PBCT was examined in the Mindfulness for Voices (M4V) randomized controlled trial and generated promising results. Group PBCT was implemented as a trans-diagnostic treatment for distressing voices within the Sussex Voices Clinic (SVC), a specialist secondary care mental health service. To conduct a service evaluation of engagement, outcomes and cost of group PBCT within SVC, and to compare engagement and outcomes from routine practice with the M4V trial. Secondary aims were to explore predictors of levels of engagement and change in group PBCT. Service level data from 95 SVC patients were evaluated. Descriptive statistics, hypothesis tests and linear regression models were used. The primary clinical outcome was voice-related distress. Engagement levels and pre-post effect sizes were estimated; associated predictors were explored. Fifty-nine per cent of patients completed group PBCT within SVC, compared with 72% within M4V. Completers within SVC had lower baseline depression scores compared with non-completers. There were significant improvements in voice-related distress (Cohen's d = -0.47; p = 0.001), subjective recovery (Cohen's d = 0.35; p = 0.001) and depression (Cohen's d = -0.20; p = 0.044); these outcomes were comparable to M4V. Higher baseline subjective recovery and lower depression both predicted improvement in voice-related distress. Therapy within SVC cost an average of £214 per patient. PBCT groups can be delivered trans-diagnostically in routine clinical practice. Engagement was lower when compared with an RCT, but outcomes were comparable. The low level of resources involved suggests that group PBCT can offer value for money.

Secondary care specialist visits made by children and young people prescribed antidepressants in primary care: a descriptive study using the QResearch database

BackgroundAntidepressants may be used to manage a number of conditions in children and young people including depression, anxiety, and obsessive-compulsive disorder. UK guidelines for the treatment of depression in children and young people recommend that antidepressants should only be initiated following assessment and diagnosis by a child and adolescent psychiatrist. The aim of this study was to summarise visits to mental health specialists and indications recorded around the time of antidepressant initiation in children and young people in UK primary care.MethodsThe study used linked English primary care electronic health records and Hospital Episode Statistics secondary care data. The study included 5–17-year-olds first prescribed antidepressants between January 2006 and December 2017. Records of visits to paediatric or psychiatric specialists and potential indications (from a pre-specified list) were extracted. Events were counted if recorded less than 12 months before or 6 months after the first antidepressant prescription. Results were stratified by first antidepressant type (all, selective serotonin reuptake inhibitors (SSRIs), tricyclic and related antidepressants) and by age group (5–11 years, 12–17 years).ResultsIn total, 33,031 5–17-year-olds were included. Of these, 12,149 (37%) had a record of visiting a paediatrician or a psychiatric specialist in the specified time window. The majority of recorded visits (7154, 22%) were to paediatricians. Of those prescribed SSRIs, 5463/22,130 (25%) had a record of visiting a child and adolescent psychiatrist. Overall, 17,972 (54%) patients had a record of at least one of the pre-specified indications. Depression was the most frequently recorded indication (12,501, 38%), followed by anxiety (4155, 13%).ConclusionsThe results suggest many children and young people are being prescribed antidepressants without the recommended involvement of a relevant specialist. These findings may justify both greater training for GPs in child and adolescent mental health and greater access to specialist care and non-pharmacological treatments. Further research is needed to explore factors that influence how and why GPs prescribe antidepressants to children and young people and the real-world practice barriers to adherence to clinical guidelines.

Oromandibular dystonia: a diagnosis not to miss.

Oromandibular dystonia (OMD) is characterised by sustained or repetitive involuntary movements of the jaw, face, and tongue. People with the condition may present to their dentist, general practitioner, or a secondary care specialist with non-specific symptoms including jaw or facial pain, bruxism, subluxations or dislocations of the jaw; fractured teeth or dental restorations, or both; or jaw tremor. Many clinicians are not aware of the disorder and this can lead to delayed diagnoses, unnecessary complications, and inappropriate treatment. OMD is an important diagnosis not to miss because referral for specialist management can provide good long-term results. To aid early, accurate diagnosis, this paper focuses on the key clinical features of the disorder and its dental and medical mimics.

A systematic review of UK-based long-term nonsurgical interventions for people with severe obesity (BMI ≥35kgm-2 ).

IntroductionThe aim of this project was to systematically review UK evidence on the effectiveness of long‐term (≥12 months) weight management services (WMSs) for weight loss and weight maintenance for adults (≥16 years) with severe obesity (body mass index ≥35 kg m−2), who would generally be eligible for Tier 3 services.MethodsFour data sources were searched from 1999 to October 2018. ResultsOur searches identified 20 studies, mostly noncomparative studies: 10 primary care interventions, nine in secondary care specialist weight management clinics and one commercial setting intervention. A programme including a phase of low energy formula diet (810–833 kcal day−1) showed the largest mean (SD) weight change at 12 months of –12.4 (11.4) kg for complete cases, with 25.3% dropout. Limitations or differences in evaluation and reporting (particularly for denominators), unclear dropout rates, and differences between participant groups in terms of comorbidities and psychological characteristics, made comparisons between WMSs and inferences challenging.ConclusionsThere is a persistent and clear need for guidance on long‐term weight data collection and reporting methods to allow comparisons across studies and services for participants with severe obesity. Data could also include quality of life, clinical outcomes, adverse events, costs and economic outcomes. A randomised trial comparison of National Health Service Tier 3 services with commercial WMSs would be of value.

The expectations of transgender people in the face of their health-care access difficulties and how they can be overcome. A qualitative study in France.

Our objective was to explore the difficulties experienced by transgender people in accessing primary health-care services and their expectations towards primary care providers to improve their health-care access. Because transgender people are exposed to many discriminations, their health-care access is particularly poor. Guidelines recommend greater involvement of primary care providers in the processes because of the accessibility feature of primary care services. A qualitative study using semi-directed interviews was conducted among 27 transgender people (February 2018 - August 2018). These voluntary participants were recruited through different means: local trans or LGBTI (lesbian, gay, bisexual, trans, and/or intersex) associations, primary care providers, and social networks. The data analysis was based on reflexive thematic analysis in an inductive approach. Difficulties in accessing health-care occurred at all the levels of the primary health-care system: primary care providers - transgender people interaction, access to the primary care team facility (starting with the secretariat), access to secondary care specialists, and continuity of care. Transgender people report ill-adapted health-care services as a result of gender-based identification in health-care settings. Their main expectation was depsychiatrization and self-determination. They supported mixed health network comprising primary care providers and transgender people with a coordinating role for the general practitioner. These expectations should be priorities to consider in our primary health-care system to improve access to health-care for transgender people.

Results of the feasibility phase of the managed activity graded exercise in teenagers and pre-adolescents (MAGENTA) randomised controlled trial of treatments for chronic fatigue syndrome/myalgic encephalomyelitis

BackgroundChronic fatigue syndrome (CFS) also known as myalgic encephalomyelitis (ME) is relatively common in young people and causes significant disability. Graded exercise therapy (GET) and activity management are recommended by the National Institute for Health and Care Excellence (NICE) despite a limited evidence-base for either treatment in paediatric CFS/ME. This paper reports on feasibility and acceptability measures from the feasibility phase of the ongoing MAGENTA randomised controlled trial (RCT) investigating GET versus activity management for young people with CFS/ME.MethodsSetting: Three specialist secondary care National Health Service (NHS) Paediatric CFS/ME services (Bath, Cambridge and Newcastle).Participants: Young people aged 8–17 years with a diagnosis of mild to moderate CFS/ME. Young people were excluded if they were severely affected, referred to cognitive behavioural therapy (CBT) at initial assessment or unable to attend clinical sessions.Interventions: GET and activity management delivered by physiotherapists, occupational therapists, nurses and psychologists. Families and clinicians decided the number (typically 8–12) and frequency of appointments (typically every 2–6 weeks).Outcome Measures: Recruitment and follow-up statistics. We used integrated qualitative methodology to explore the feasibility and acceptability of the trial processes and the interventions.Results80/161 (49.7%) of eligible young people were recruited at two sites between September 2015 and August 2016, indicating recruitment to the trial was feasible. Most recruitment (78/80; 97.5%) took place at one centre. Recruitment consultations, online consent and interventions were acceptable, with less than 10% in each arm discontinuing trial treatment. Response rate to the primary outcome (the SF36-PFS at 6 months) was 91.4%. Recruitment, treatment and data collection were not feasible at one centre. The site was withdrawn from the study.In response to data collected, we optimised trial processes including using Skype for recruitment discussions; adapting recruiter training to improve recruitment discussions; amending the accelerometer information leaflets; shortening the resource use questionnaires; and offering interventions via Skype. These amendments have been incorporated into the full trial protocol.ConclusionsConducting an RCT investigating GET versus activity management is feasible and acceptable for young people with CFS/ME.Trial registrationISRCTN23962803 https://doi.org/10.1186/ISRCTN23962803, date of registration: 03 September 2015

The role of a clinical nurse specialist in managing patients with trigeminal neuralgia.

Patients with trigeminal neuralgia (TN) can be overwhelmed with information they are given when first seen in a specialist secondary care clinic. The purpose of this study is to evaluate the extent to which a telephone service provided by the clinical nurse specialist (CNS) with independent prescribing rights improves patient management and satisfaction and reduces costs. All patients with a diagnosis of TN who used the CNS telephone service in 2015 were contacted by two medical students (independent observers) using a semi-structured questionnaire. Patients who could not be contacted were sent the same questionnaire and asked to return it by post. Fifty-two patients were identified and 34 replied to a telephone call and 10 to a questionnaire, response rate 85%. Overall, 61% of patients rated their care outstanding or excellent. Four patients could not remember their consultation, others had used it on multiple occasions. Reasons for the consultation were pain management 50%, changeover of drugs 25%, advice about drug schedules 17%, and dealing with side effects 8%. The number of general practitioner (GP) consultations decreased as a result of this service. Patients suggested that the service should be available more than once a week. The CNS telephone service cut down on the number of outpatient appointments needed and reduced travel costs. Patients were appreciative that the CNS was in contact with GPs and this ensured prescriptions were filled in a timely manner and strengthen links with practices.