Restricting drug choice
Clin Pharmacol Ther 2006; 79: 379-88
As a greater percentage of the population becomes elderly, and more new drugs are developed, the drugs budget will skyrocket. British Columbia, in Canada, where all over-65s receive free drugs, has a policy in place restricting choice of PPI to one drug.
Rabeprazole was chosen because it was of equal efficacy to its competitors but was cheaper. Patients on other PPIs were swapped to it unless there were overriding reasons. Patients were monitored for satisfaction, level of doctor attendance and adverse clinical outcomes.
The results showed that swapping to rabeprazole led to an enormous drugs budget saving. There were no increases in adverse clinical outcomes, but there was a rise in consultations.
Br J Derm 2006; 154: 873-9
In general, dermoscopy is used when there is a clinically suspicious lesion. In theory this means that potentially an early malignant melanoma could be missed if it does not look suspicious.
In this study, patients undergoing periodic examination of their multiple naevii were first examined by usual practice with the dermoscope only used where there was clinical suspicion. This was followed by dermoscopic examination of all their naevii greater than 2mm, which identified a fifth more suspicious lesions. The lesions were predominantly on the limbs or areas of the skin difficult to look at.
Anticoagulation over the phone
Arch Intern Med 2006; 166: 997-1,002
This US study compared a face-to-face anticoagulation service with a telephone service - where the patient is called and told what the next dose should be, rather than going to a clinic to be told. Researchers compared the percentage of time within the correct INR range and adverse events. The results showed no difference with either parameter, indicating that the telephone system is safe and cost-effective. We are ahead of the US given that this service is widespread in the UK already.
Am J Public Health 2006; 96: 670-6
This study compared rates of smoking with the density of tobacco outlets in an area and found a positive correlation. Even after correcting for deprivation (there are more tobacco outlets in poorer areas), the correlation was still there. If there were fewer cigarette shops, the indolent kids would be too idle to go the extra distance and would not smoke. I think the idea has merit.
TURP on aspirin
Ann R Coll Surg Eng 2006; 280-83
It seems that there is a variation among urologists as to what they do with their TURP patients on aspirin. Two thirds stop it for between two to 30 days pre-op and between one to 42 days post-op, believing aspirin causes excess blood loss, and one third do not stop aspirin for a TURP, believing cardiovascular risks are greater.
Naproxen for knee OA
Ann Rheum Dis 2006; 65: 781-4
When treating osteoarthritis (OA) pain, we assume treatment will be efficacious for all joints, but this study showed that naproxen, when tested against placebo, gave better pain relief and quality of life for knee OA than hip OA. Although an NSAID works on one joint, it might not on another.
- Dr Hunter is a GP in Bishops Waltham, Hampshire, and a member of our team who regularly review the journals
Restricted formularies can save money without increasing adverse outcomes.
Early dermoscopy identified a fifth more suspicious lesions than normal practice.
Anticoagulation by phone is safe and cost-effective.
Density of tobacco outlets relates to the number of young smokers.
Stopping aspiring before TURP lacks consensus.
Knee and hip OA responded differently to neproxon treatment.
RESEARCH OF THE WEEK
Discomfort after banding of piles
Ann R Coll Surg Engl
2006; 88: 275-9
Like a lot of things we subject our patients to, banding of piles may have some discomfort attached.
It has now been determined just how sore and for how long the pain will last.
Pain was greatest four hours post surgery, but by a week three quarters of the patients were pain-free. After a week 7 per cent still had moderate to severe pain, 65 per cent had rectal bleeding on the day of the procedure and a third still had it at a week.
A third had vaso-vagal symptoms.
However, 57 per cent would recommend it to their friends.