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zondag 10 september 2017

DTB: Managing scarlet fever

Managing scarlet fever

Scarlet fever, an infection caused by toxin-producing strains of Streptococcus pyogenes, was associated with high levels of morbidity and mortality when epidemics were common in the 18th and 19th centuries throughout Europe and the USA.1 Although this disease nearly disappeared during the 20th century, several countries, including the UK, have recently experienced a re-emergence of scarlet fever.1-3 However, the reason for these new outbreaks remains unclear.1,4 Despite a general move to reduce the use of antibiotics for many mild self-limiting infections (e.g. tonsillitis, sinusitis), national guidance recommends treating people with scarlet fever with antibiotics regardless of severity of illness to speed recovery, to reduce the length of time the infection is contagious and to reduce the risk of complications.5,6 Here, we discuss the management of scarlet fever in the UK.

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Two new drugs for rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disease that causes inflammation and destruction of the joints.1-3 It can also affect the eyes, the heart and the lungs and is associated with significant disability and increased mortality. RA is estimated to affect just under 1% of the population aged over 16 years, equating to more than 400,000 people in the UK.4 Baricitinib (Olumiant) and tofacitinib (Xeljanz) were launched in the UK in April 2017 and represent a new therapeutic class of medicines known as targeted synthetic disease modifying antirheumatic drugs.5,6 Here, we review the evidence for the safety and effectiveness of these new oral agents.

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The number-needed-to-treat (NNT), a measure used to assess the benefits (NNTB) and harms (NNTH) of medical interventions, can give an indication of the effectiveness of a treatment.1 NNTs are sometimes used by clinicians and healthcare policy makers to compare interventions. However, a recent appraisal found evidence to suggest that nearly one third of studies fail to follow basic methodological recommendations when calculating the NNT.2

The NNT estimates the number of patients who need to be treated with one therapy, rather than a comparator intervention, for one additional patient to experience or avoid an outcome within a defined timeframe. Typically, it is the reciprocal of the absolute risk reduction between two interventions, but recommended methods to calculate the NNT vary depending upon study design. The review's authors searched the top 25 high impact factor general/internal medicine journals...

Do studies calculate the NNT appropriately?

Do studies calculate the NNT appropriately?

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Diagnosis and investigation of fungal skin and nail infections

NHS England has issued a re-formatted quick reference guide on the diagnosis and treatment of fungal skin and nail infections.1 Aimed at primary care prescribers in general practice and out-of-hours settings, including doctors, nurses and pharmacists, the guide's stated intentions are to "provide a simple, effective, economical and empirical approach to the diagnosis and treatment of fungal skin and nail infections [and] to minimise the emergence of antibiotic resistance in the community." The new format consists of a practical checklist with graded evidence, organised into sections and highlighting good practice points.

Of particular importance is the advice to send samples before starting long-term treatment, as only 45% of dermatology samples received are positive for fungal infections. Many nail problems (e.g. psoriasis, injury) can look like fungal infections. Regarding testing, the guide reminds healthcare professionals that samples are not needed for:

  • uncomplicated Athlete's foot (tinea...

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    The value of self-monitoring of blood glucose (SMBG) levels in patients with non-insulin-treated type 2 diabetes in primary care has been assessed in an open-label randomised trial.1 The study's authors suggest that more than 75% of patients in this group regularly perform SMBG, despite conflicting results from studies on whether it improves outcomes.

    The trial's two primary outcomes were improvement in glycated haemoglobin (HbA1c) level and health-related quality of life (HRQOL). Patients with type 2 non-insulin-treated diabetes eligible for the study were aged older than 30 years and had HbA1c levels higher than 6.5% (48mmol/mol) but lower than 9.5% (80mmol/mol) within the 6 months before screening. A total of 450 patients in North Carolina, USA, were randomised to one of three interventions:

  • no SMBG;

  • standard once-daily SMBG consisting of glucose values immediately reported to...

  • Value of SMBG in non-insulin-treated type 2 diabetes

    Value of SMBG in non-insulin-treated type 2 diabetes

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    Antibiotic prescribing: patient need or prescriber habit?

    A Canadian retrospective cohort study has examined influences on the initiation, selection and duration of antibiotic treatment for patients in long-term care facilities.1 Whether a patient was prescribed antibiotics, which antibiotic they were prescribed and for how long they were prescribed it, all varied greatly depending on who their doctor was and on that doctor's prescribing habits.

    The study assessed data on physicians who prescribed to residents in long-term care facilities in Ontario in 2014.1 It focused on variability in antibiotic prescribing among physicians based on three measures: start of treatment with antibiotics, antibiotic treatment that exceeded 7 days and the use of fluoroquinolones. The study's authors hypothesised that these three factors would vary across prescribers more than would be expected by chance or explained by resident characteristics, and that a clinician's historical prescribing tendency would strongly predict their current prescribing practice.

    Physicians...

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    Vortioxetine is from a new class of psychotropic drugs, the bis-aryl-sulfanyl amines, that acts on the serotonin system.1 It is licensed for the treatment of major depression in adults and the Summary of Product Characteristics includes details of its impact on depression rating scales, as well as its effect on some measures of cognitive function in patients with depression.2 A Cochrane review has assessed the efficacy and acceptability of vortioxetine compared with placebo and other antidepressant drugs in the treatment of acute depression in adults.3

    The review included 15 randomised controlled trials (7,746 participants); seven studies were placebo controlled and eight studies compared vortioxetine with serotonin-norepinephrine reuptake inhibitors (SNRIs).3 The reviewers found no studies comparing vortioxetine with antidepressant drugs from other classes, such as selective serotonin reuptake inhibitors (SSRIs).

    The primary...

    {blacktriangledown} Vortioxetine for acute depression in adults

    Vortioxetine for acute depression in adults

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    Brimonidine gel and adverse cardiovascular effects

    A safety update on brimonidine gel (Mirvaso) has been issued by the Medicines and Healthcare products Regulatory Agency (MHRA).1 Brimonidine, an alpha2 adrenergic receptor agonist, is available as a topical gel indicated for the symptomatic treatment of facial erythema of rosacea in adults.2 The MHRA statement warns against using the product on damaged or irritated skin, including after laser therapy. This follows reports of systemic cardiovascular effects including bradycardia, hypotension and dizziness.

    Post-marketing reports (including some Yellow Cards) identified by a routine European review were consistent with systemic alpha2 adrenergic effects, including bradycardia, hypotension, orthostatic hypotension and dizziness. Dizziness is reported to occur uncommonly, with an estimated frequency of less than 10 in 1,000 patients using brimonidine gel. The frequency of hypotension and bradycardia are reported as rare, estimated at less than 1 in 1,000 patients.

    The advice for healthcare professionals notes that...

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    The European Commission (EC) has highlighted the need for prudent use of antimicrobials in human health.1 Addressing all those involved in the use of antimicrobials, the EC has issued guidance based on a technical report prepared by the European Centre for Disease Prevention and Control (ECDC), with input from EU Member States experts and stakeholders. The guidance document applies to governments, healthcare commissioners, healthcare organisations and individual clinicians.

    The EC recognises that ultimate responsibility for the prudent use of antimicrobials lies with national, regional or local governments. Key elements for government action include:1

  • reviewing the legal provision for supply of antimicrobials via the internet;

  • supporting availability of innovative and generic antimicrobials

  • tackling shortages of supplies;

  • limiting the use of last-resort antimicrobials to safeguard their effectiveness;

  • reducing inappropriate antimicrobial prescribing through antimicrobial stewardship...

  • European guideline on antimicrobial resistance

    European guideline on antimicrobial resistance

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    Vitamin D and adolescents: a forgotten 'at risk group?

    In recent years, vitamin D has captured the attention of the scientific and medical communities, government and regulatory bodies, the media and the general public. This has led to an expansion in the scientific literature, re-evaluation of dietary recommendations and an increase in requests for vitamin D tests. In July 2016, the UK Scientific Advisory Committee on Nutrition (SACN) published revised vitamin D dietary requirements for the UK population, which included – for the first time – a recommendation of 10µg/day (400iu/day) being set for those aged 4 years and older based on musculoskeletal health outcomes.1 Population sub-groups 'at risk' of vitamin D deficiency have typically included pregnant and breastfeeding women, infants, older people and some ethnic populations. However, 20% of UK adolescents have year-round vitamin D deficiency (plasma 25-hydroxyvitamin D concentration <25nmol/L), rising to 40% during the winter months.2 Furthermore, European population studies suggest...

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