Whooping cough in children with persistent cough
BMJ 2014; 348: g3668
This study examined the prevalence and clinical severity of whooping cough in children aged five to 15 years with persistent cough (two to eight weeks' duration).
The setting was general practices in the Thames Valley region and 279 children took part. Evidence of recent pertussis infection was found in 56 children (20%) (95% CI, 16-25%), including 39 (18%) (95% CI, 13-24%) of the 215 children who had been fully vaccinated.
The researchers concluded that pertussis is found in 20% of school-age children presenting with persistent cough. However, the risk was more than three times higher in children who had received the preschool pertussis booster more than seven years previously.
Although the main aim of pertussis vaccination is to reduce severe infection during infancy, the prevalence of pertussis in older and vaccinated children provides weight for the introduction of an adolescent booster vaccine to the UK schedule.
Low-dose calcium for the prevention of pre-eclampsia
BJOG 2014; 121(8): 951-7
There is an epidemiological link between low dietary calcium intake and pre-eclampsia.
Current recommendations suggest 1.5-2g per day calcium supplementation from 20 weeks' gestation for low-intake women.
These authors point out that too much calcium (>1.5g per day) can be harmful and may cause rebound postnatal bone demineralisation. Large tablets are also a barrier to compliance.
This review looked at the effects of daily low-dose calcium (LDC) supplements (<1g per="" day="" on="" pre-eclampsia="" risk="" p="">
Analysis of nine trials suggested that pre-eclampsia was reduced consistently with LDC with or without co-supplements (RR 0.38; 95% CI, 0.28-0.52).
There was limited evidence that LDC with antioxidants starting at eight to 12 weeks reduced miscarriage, but the samples were small (60 women; RR 0.06; 95% CI, 0.00-1.04) and not statistically significant. The authors felt their findings were important but larger RCTs were needed.
Access to GPs and visits to A&E
Br J Gen Pract 2014; 64(624): e434-9
The background to this study was the NHS England 2013 review of urgent and emergency care, which raised the role of access to primary care in preventing A&E attendance.
The study was a cross-sectional analysis of a survey of adults registered with a GP in England, using the GP Patient Survey 2012-2013.
Using statistical analysis, the researchers estimated 5.77m (99.9% CI, 5.49-6.05m) A&E attendances were preceded by the patient being unable to obtain a GP appointment.
These figures comprise 26.5% of unplanned A&E attendances in England in 2012-2013. They are estimates, but the authors argue that the robust statistical analysis makes the figures likely to represent reality.
Clinical diagnosis of PID
Sex Transm Infect 2014; doi:10.1136/sextrans-2014-051646
PID can have mild symptoms and signs, making it challenging at times to diagnose clinically.
Clinical features include recent lower abdominal pain, abnormal bleeding, deep dyspareunia, bimanual examination tenderness (cervical motion, uterine and/or adnexal) and mucopurulent discharge.
About 25% of UK cases of PID are attributed to Chlamydia trachomatis (CT) or Neisseria gonorrhoea.
In this cross-sectional study in a UK sexual health clinic, 3,804 women were assessed by 36 clinicians with varying levels of experience.
Of cases diagnosed by experienced clinicians, 63.7% met the US Centers for Disease Control and Prevention key clinical criteria for PID, as opposed to 41.2% of those diagnosed by inexperienced clinicians.
The proportion of CT-positive PID diagnosed also increased with experience. The CT prevalence in PID cases diagnosed by inexperienced clinicians (8.8%) was no greater than in all women assessed (9%).
These findings suggest poorer discriminatory skills among inexperienced clinicians. The authors suggest clinicians should focus on the presence of lower abdominal pain with pelvic tenderness and consider the presence or absence of the clinical features detailed above to improve their diagnostic skills.
Safety of patients under the care of crisis resolution home treatment services
Lancet Psychiatry 2014; doi:10.1016/S2215-0366(14)70250-0
Psychiatric community care by home treatment teams (HTTs) is used increasingly as an alternative to inpatient admission during a crisis. It is more cost-effective than admission and more acceptable to patients.
This study was a retrospective longitudinal analysis of all adult patients who died by suicide while under the care of HTTs.
The average rate of suicide under HTTs (14.6 per 10,000 patient episodes) appeared higher than the average rate of suicide among psychiatric inpatients (8.8 per 10,000 admissions). However, the rate of suicide fell by 18% between the first and last two years of the study. This was a result of the growing number of patients under the care of HTTs as the study progressed.
Of patients under HTTs who died by suicide, 44% lived alone and 49% had experienced a recent life event, of which the most common were relationship break-up (22%), workplace stress (19%) and financial problems (11%).
The median age at death was 48 years and a third of all suicides happened within three months of discharge from inpatient care.
These are sobering figures but may help us to target the most vulnerable patients.
- Dr Croton is a GP in Birmingham and a member of our team who regularly review the journals
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