Hypertension and pregnancy
BMJ 2014; 348: g2301
It is estimated that chronic hypertension complicates 1-5% of pregnancies, but recent demographic changes in the antenatal population are likely to make this inaccurate.
To revise the data, these US authors carried out a meta-analysis of 55 studies from 25 countries, including 795,221 pregnancies and spanning four decades.
Compared with the US general pregnancy population, the average incidence of superimposed pre-eclampsia in women with chronic hypertension across study populations was nearly eight times higher compared with pre-eclampsia. RRs were 7.7 (95% CI 5.7-10.1) for superimposed pre-eclampsia, compared with pre-eclampsia at 1.3 (1.1-1.5).
Women with chronic hypertension have an approximately threefold increased risk of delivery before 37 weeks, birthweight <2,500g and neonatal intensive care admission, and a fourfold increased risk of perinatal death compared with the US general pregnancy population.
The researchers concluded that pre-pregnancy counselling and increased antenatal surveillance were paramount.
Improving anticoagulation in AF
Br J Gen Prac 2014; doi: 10.3399/bjgp14X679705
In this inner London based study, 143 general practices, with 800,000 patients, registered with the Anticoagulation Programme East London (APEL) in April 2011.
The intervention included new guidelines sent to the practices, new computer-based software and multidisciplinary meetings to reinforce the guidelines.
By 2013, data were available from 139 practices. In the three years before the intervention, the proportion of patients with a CHA2DS2-VASc ?1 (score for stroke risk in AF) on anticoagulants increased from 50.8% to 52.6%. This rose to 59.8% in the two-year intervention period (trend difference P<0.001). One in six practices achieved a score >70%.
The estimated cost per PCT of running the programme was £15,000, but it could save £150,000 over five years, making it highly cost-effective. The authors noted that the national target of 80% anticoagulation would be difficult to achieve.
Hand hygiene in Australia
Med J Aust 2014; doi: 10.5694/mja13.11203
In 2009, under the National Hand Hygiene Initiative, Australian hospitals began a scheme based on the WHO programme, Five Moments for Hand Hygiene.
This study took information from three cross-sectional datasets to look at compliance of medical and nursing staff for each hospital size (>400 beds, 301-400 beds, 201-300 beds and 101-200 beds); the proportion of hospitals with compliance rates at or above, or below the national threshold of 70%, and Staphylococcus aureus bloodstream infection (SABSI) rates.
Medical staff were consistently below the national threshold; nurses were consistently above it. Hand hygiene had little impact on SABSI rates. The authors concluded that a new initiative should target doctors.
Lies, damned lies and statistics
JAMA Intern Med 2014 doi: 10.1001/jamainternmed.2014.1059
In 1978, a small study showed that most physicians, house officers and students overestimated the positive predictive value of a laboratory test result using prevalence and false positive rate. These US authors repeated the question, asking a similar group:
'If a test to detect a disease whose prevalence is 1/1,000 has a false positive rate of 5%, what is the chance that a person found to have a positive result actually has the disease, assuming you know nothing about the person's symptoms or signs?'
I would have said 95%, as did 44% of respondents, but we were all wrong - the correct answer is 1.96%.
Preventive home visits for elderly
Fam Pract 2014 doi: 10.1093/fampra/cmu015
In this cross-sectional study in the Netherlands, 562 randomly selected patients were compared with 1,180 purposefully selected, based on the following criteria: last visit to general practice >6 months ago, partner or child(ren) deceased within past 12 months, cognitive or psychosocial functioning unknown to GP, two or more chronic conditions; taking five or more drugs and/or living alone.
Their conclusions were in favour of purposeful selection, targeting older patients with more than two chronic conditions, taking five or more drugs, who were female, older, living alone and less educated.
- Dr Palmer is a former Hampshire GP now working in Australia and a member of our team who regularly review the journals.
CPD IMPACT: EARN MORE CREDITS
These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.
- Perform a database search and review young female patients who have hypertension.
- Consider a programme similar to APEL for your practice.
- Invite an infectious disease nurse to discuss Five Moments for Hand Hygiene at a practice meeting.
- Present a medical statistics update at a practice meeting.
Save this article and add notes with your free online CPD organiser at gponline.com/cpd Take clinical tests and claim certificates for CPD at myCME.com/gp
0.5 CPD CREDITS - For 30 minutes of learning activity and reflection based on this article