ADHD

NICE Guidance on Attention Deficit Hyperactivity Disorder has recently been published. Follow on letters in the BMJ (BMJ 2008; 337:a2287 and BMJ 2008; 337:a2284) draw attention to the risk of diversion and abuse of methylphenidate and the flimsy nature of the evidence on which the guidance to prescribe stimulants as a first line treatment in those with "severe" ADHD.
Clearly the management of this condition remains controversial and prescribers need to bear in mind the risks involved.

Aspirin

BMJ 2008; 337 :a1806 and
This story got coverage in the popular press and clearly indicates that aspirin is a secondary prevention drug only. We should not be using it for primary prevention, even in patients with diabetes.
We certainly need to change our practice.

Osteoporosis

I'm back after a break - with news from the BMJ.
The latest guidance from the National Osteoporosis Guideline Group is now available. This is interim guidance as we wait for NICE to release its osteoporosis appraisal. The NICE appraisal is held up by a second appeal (BMJ 2008;337:a2204).
What is in the guidance? Well the news bit for me was in two parts. Firstly - postmenopausal women with prior fragility fractures don't need to wait for a Bone Mineral Density scan before starting treatment. Secondly there is the availability of a tool to estimate risk (the FRAX tool - see the website) which is recommended for opportunistic use in:

• Men aged 50 years or more (with or without fracture) but with a WHO risk factor or a BMI <>
• All postmenopausal women without fracture but with a WHO risk factor or a BMI <>

This results in categorisation of people into low, intermediate and high risk groups.

We could be working opportunistically to identify those at high risk and starting treatment where appropriate.

Management of Infertility

BMJ 2007;335:608-11 AH Balen and AJ Rutherford

This BMJ review of fertility opens with intriguing figures that seem worth recalling for primary care fertility discussions:
"For women up to 25 the cumulative conception rate is 60% at 6 months and 85% at a year, but conception rates are more than halved by 35 or over"
Furthermore the point is made that the risk of congenital abnormalities increases with age.

These are patient education points that could usefully be included in contraceptive pill checks.

Ovarian reserve may be assessed with FSH measurement in the first 3 days of the cycle - other tests can supplement this but the validity of using these tests for making long term predictions about fertility is uncertain.

Schizophrenia

A recent BMJ article provided an update on schizophrenia. This condition seems to be slowly moving on.
More is known now about its aetiology compared to what was known when I was trained as an undergraduate. Excess dopamine activity in the mesolimbic system is acknowledged to be a key part of the neurochemical changes in schizophrenia, with one theory holding that dopamine has a role in "salience" and that the excesses can increase the salience of mundane things, turning a glance from a stranger to a glare with malevolent thoughts. Lifetime risk of the disease is 1% in the population but 6.5% in those with first degree relatives and 40% in monozygotic twins of affected individuals. Environmental factors play a role, people born following a complicated obstetric history, those of low birth weight, migrants, people who are socially isolated and city dwellers are all more likely to develop the condition. Misuse of cannabis, lsd and amphetamine are all associated with the condition.
Diagnostic criteria seem to me to be similar to what they were in the mid 1980's.

At least one present most of the time for a month:

• Thought echo, insertion or withdrawal, or thought broadcast
• Delusions of control referred to body parts, actions, or sensations
• Delusional perception
• Hallucinatory voices giving a running commentary, discussing the patient, or coming from some part of the patient's body
• Persistent bizarre or culturally inappropriate delusions
  

Or at least two present most of the time for a month

• Persistent daily hallucinations accompanied by delusions
• Incoherent or irrelevant speech
• Catatonic behaviour such as stupor or posturing
• Negative symptoms such as marked apathy, blunted or incongruous mood

Here are some suggested screening questions:

• Do you hear voices when no one is around? What do they say?
• Do you ever think that people are talking or gossiping about you, maybe even thinking about trying to get you?
• Do you ever think that somehow people can pick up on what you are thinking or can manipulate what you are thinking?

Treatments have evolved with an emphasis on early treatment and the use of atypical antipsychotic agents. Clozapine remains a useful option for resistent patients but requires monitoring because of the (<1%)>

Cervical cytology

In the last 18 months I have moved from taking a smear with an Ayelsbury spatula to the use of liquid based cytology and taking a smear with the cervical brush. This new method has clearly meant some changes at the lab, they now get a bottle of cells rather than a slide with preservative on it. beyond this the new process was a mystery to me.
The BMJ has come to my rescue and explained how automated the new process has become. Reassuringly it seems that the new technique is at least as sensitive as the old one.

Anorexia Nervosa

This clinical review (Jane Morris and Sara Twaddle BMJ 2007;334:894-8) takes a refreshing look at anorexia nervosa management. Evidence for the benefits of various treatments is poor because engaging this group in treatment is difficult and engaging them in research is harder still. As a GP the take home messages were:

• It's common (0.3% prevalence in young women) and has the highest mortality of any psychiatric disorder.
• It takes years to recover - so there are no quick fixes.
• Rapid changes in weight are dangerous, as are substance misuse, deliberate overdose and misuse of prescribed insulin.
• Medication has little benefit, side effects risk is high.
• Involving the family in the management can be helpful.

Usefully the article references several possible sources of additional educational support for patients, carers and health professionals.

Reading the Fillers

"Dreamkiller" John Frey, British Journal of General Practice, May 2007, Vol 57, No. 538, p424.

Reading the non-clinical opinion articles is probably what attracts many of us to open our journals - it's either that or the obituaries!

In "Dreamkiller", John Frey writes with US perspective on free health care. I have tended to link free access to high quality health care with poverty, believing that it is essential for low and no income families to be able to enjoy the same quality of care as their wealthier neighbours. My UK perspective has been shaped by Tudor Harts inverse care law.

Frey gives me a different point of view. The situation in the US actually prevents people from making other choices in life because if they move from an employer with health care cover to a different job without that cover, they will not be able to afford even basic health care insurance for them and their families. Moreover, it prevents people from taking early retirement because Medicare cover doesn't kick in until 64.5 years.

HRT in the news

The Guardian reports on HRT and this time it's the risks rather than the benefits that get the into the press. A timely review which appeared before the Guardian article (BMJ, Roberts, H;334 p736 to 741, Managing the Menopause) provides a good grounding on which we can develop our clinical practice.

Firstly I was reassured by the advice on use of topical oestrogens. This form of HRT is useful in reducing dyspareunia and recurrent uti and is not associated with significant systemic absorption so can be used safely as a long term treatment. Women with a uterus do not need progesterone treatment in addition to the oestrogen.

Long term HRT has no role in the prevention of chronic disease. There is a significant increase in the risk of stroke, dvt, gall bladder disease with both oestrogen and combined oestrogen-progestogen treatments. Breast cancer and dementia are also increased in women over 65. Some evidence of protection against fractures and colorectal Ca in combined therapy is noted.

The consensus advice seems to be that we should use the lowest dose of hormone for the shortest duration to give symptom relief.

Dog Bites

M Morgan in a BMJ Clinical review (BMJ 2007:334:413-417) is informative about the management of dog bites - not an uncommon problem in rural primary care.

I was surprised to learn that Pasteurella multocida infection can strike within 12 hours of a bite. I would always emphasise the need for good wound care and learnt that because of drug resistence P multocida does not respond to flucloxacillin/erythromycin - co-amoxiclav is to be preferred.

Antibiotic treatment should be preferred in immunocompromised patients and in those patients with a more than superficial wound. In established infection the duration of treatment depends on the type of infection. In primary care most establised infection will be cellulitic - 10-14 days treatment is adequate in these cases.

Sinusitis

In BMJ 2007:334:358-361 ENT specialists from the Aberdeen Royal Infirmary summarise the knowledge base on sinusitis - which they refer to as rhinosinusitis. As a simple GP, what I would like to know is how should I diagnose and treat the problem. As usual, things are not as simple as they seem. Has the patient got acute (rhino)sinusitis; <12 weeks duration and 2 or more of blockage/congestion, discharge, facial pain and loss of smell. If so then analgaesia helps, topical steroid nasal spray can help and antibiotics have a small but significant improvement in cure rate.
Chronis sinusitis is >12w duration with one of : facial pain or pressure, discoloured discharge and reduction or loss of smell. Topical steroids are the first line of treatment here and oral steroids may also be considered.
These days surgery for these problems is usually done endoscopically. In acute cases it is used to release pus and in chronic cases to restore sinus ventilation and drainage.