Multiple Myeloma

Multiple myeloma is a rare but serious haematological malignancy which at any one time affects between 20 000 and 30 000 patients in the UK. Prior to diagnosis, most of these patients present to primary care with non-specific symptoms. A delay in diagnosis is associated with an increase in complications, such as anaemia, bone disease and renal failure. This may have an impact on patients' quality of life as well as their ability to tolerate toxic treatment options. The key steps in primary care are to identify those patients with symptoms suggestive of multiple myeloma, carry out timely investigations and be aware of the appropriate referral pathways. Once the diagnosis is confirmed, the GP has a vital role in supporting the patient throughout what is, for most, a chronic debilitating illness.

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Hyperthyroidism and Graves' Disease

InnovAiT Education and inspiration for general practice ◽

10.1093/innovait/inr139 ◽

2011 ◽

Vol 4 (12) ◽

pp. 698-705

Author(s):

Fiona Grayston

Keyword(s):

Vital Role ◽

Clinical Suspicion ◽

Disease Monitoring ◽

Graves Disease ◽

Important Condition ◽

Primary Contact ◽

Huge Impact ◽

The Uk ◽

Specific Symptoms

Hyperthyroidism is an important condition: it affects 1–2% of the UK population and has a huge impact on quality of life. Because hyperthyroidism often presents asymptomatically or with non-specific symptoms, the diagnosis can be easily missed. A high index of clinical suspicion is required to ensure an early diagnosis and timely management. The GP plays a vital role in managing primary contact with patients with hyperthyroidism, co-ordinating care and organizing disease monitoring and so must have a sound understanding of this disease.

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COVID-19 Pandemic: The Urgent Dental Hub experience from a primary care perspective

Primary Dental Journal ◽

10.1177/20501684211033391 ◽

2021 ◽

Vol 10 (3) ◽

pp. 41-45

Author(s):

Zohaib Khwaja ◽

Awais Ali ◽

Manraj Rai

Keyword(s):

Public Health ◽

Primary Care ◽

Dental Care ◽

Specialist Care ◽

Health Message ◽

Face To Face ◽

General Dental Practitioner ◽

Public Health Message ◽

The Uk

In response to the nationwide lockdown on 23 March 2020 in the UK, urgent dental hubs (UDHs) were established in the community to provide emergency dental care. Consecutive referrals to a primary care UDH were prospectively analysed over a one-month period, from 18 May 2020 to 18 June 2020. Of 400 referrals received, the most common were in relation to pain (87%). In 63% neither a radiograph nor photograph was provided with the referral. Seventy percent of patients were telephone triaged within 24 hours of receipt of referral. Fifty-three percent of referrals were accepted for face-to-face treatment, of which 69% were treated by extraction. Of rejected referrals (n=179; 45%), 79% were due to symptoms having settled or being manageable by the time of triage. A small number of referrals were redirected for specialist care. Referrals that were accepted were more likely to have been prescribed antibiotics and less likely to have been referred by the general dental practitioner (GDP) they regularly saw (p <0.01). Patients that were older and those that identified themselves as not having a regular GDP were less likely to have been referred to an UDH. The quality of referrals was poor and there may be a role for virtual consultations moving forwards. We found pre-referral antimicrobial prescriptions were high and a confused public health message may have been sent.

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Diagnostic and Therapeutic Challenges in the Management of Intermediate and Frail Elderly Multiple Myeloma Patients

Cancers ◽

10.3390/cancers12113106 ◽

2020 ◽

Vol 12 (11) ◽

pp. 3106

Author(s):

Francesca Bonello ◽

Mario Boccadoro ◽

Alessandra Larocca

Keyword(s):

Multiple Myeloma ◽

Elderly Patients ◽

Treatment Options ◽

Real Life ◽

Frailty Status ◽

Frail Patients ◽

Multidimensional Evaluation ◽

Choice Of Treatment ◽

Choice Of Therapy

Multiple myeloma (MM) mostly affects elderly patients, which represent a highly heterogeneous population. Indeed, comorbidities, frailty status and functional reserve may vary considerably among patients with similar chronological age. For this reason, the choice of treatment goals and intensity is particularly challenging in elderly patients, and it requires a multidimensional evaluation of the patients and the disease. In recent years, different tools to detect patient frailty have been developed, and the International Myeloma Working Group frailty score currently represents the gold standard. It identifies intermediate-fit and frail patients requiring gentler treatment approaches compared to fit patients, aiming to preserve quality of life and prevent toxicities. This subset of patients is underrepresented in clinical trials, and studies exploring frailty-adapted approaches are scarce, making the choice of therapy extremely challenging. Treatment options for intermediate-fit and frail patients might include dose-adapted combinations, doublets, and less toxic combinations based on novel agents. This review analyzes the available tools for the assessment of frailty and possible strategies to improve the discriminative power of the scores and expand their use in real-life and clinical trial settings. Moreover, it addresses the main therapeutic challenges in the management of intermediate-fit and frail MM patients at diagnosis and at relapse.

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Ongoing clinical trials and treatment options for patients with systemic sclerosis–associated interstitial lung disease

Rheumatology ◽

10.1093/rheumatology/key151 ◽

2018 ◽

Vol 58 (4) ◽

pp. 567-579 ◽

Cited By ~ 23

Author(s):

Dinesh Khanna ◽

Donald P Tashkin ◽

Christopher P Denton ◽

Martin W Lubell ◽

Cristina Vazquez-Mateo ◽

...

Keyword(s):

Interstitial Lung Disease ◽

Lung Disease ◽

Treatment Guidelines ◽

Treatment Options ◽

Multiple Organ ◽

Organ Systems ◽

The Uk ◽

Disease Modifying Treatment ◽

Substantial Morbidity

Abstract SSc is a rare CTD that affects multiple organ systems, resulting in substantial morbidity and mortality. Evidence of interstitial lung disease (ILD) is seen in ∼80% of patients with SSc. Currently there is no approved disease-modifying treatment for ILD and few effective treatment options are available. CYC is included in treatment guidelines, but it has limited efficacy and is associated with toxicity. MMF is becoming the most commonly used medication in clinical practice in North America and the UK, but its use is not universal. Newer agents targeting the pathogenic mechanisms underlying SSc-ILD, including fibrotic and inflammatory pathways, lymphocytes, cell–cell and cell–extracellular membrane interactions, hold promise for better treatment outcomes, including improved lung function, patient-related outcomes and quality of life. Here we review ongoing trials of established and novel agents that are currently recruiting patients with SSc-ILD.

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Will changes in primary care improve health outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK

BMJ Quality & Safety ◽

10.1136/qshc.2003.007401 ◽

2004 ◽

Vol 13 (3) ◽

pp. 191-197 ◽

Cited By ~ 26

Author(s):

P McElduff

Keyword(s):

Primary Care ◽

Quality Of Care ◽

Health Outcomes ◽

Financial Incentives ◽

Improve Quality ◽

The Uk ◽

The Impact ◽

Improve Health

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Multidisciplinary cancer conferences as a forum for early identification of patients who can benefit from palliative care.

Journal of Clinical Oncology ◽

10.1200/jco.2015.33.29_suppl.148 ◽

2015 ◽

Vol 33 (29_suppl) ◽

pp. 148-148

Author(s):

Frances Catriona Wright ◽

Hardeep Johal ◽

Marnie MacKinnon ◽

Erin Arthurs

Keyword(s):

Palliative Care ◽

Treatment Options ◽

Baseline Survey ◽

Comfort Levels ◽

Standardized Reporting ◽

Advance Care ◽

Aggressive Care ◽

The Uk ◽

Surprise Question

148 Background: Introducing palliative care early in the cancer journey results in a better quality of life, less aggressive care and longer survival compared to patients receiving standard care. The INTEGRATE Project goal is to identify and manage patients who can benefit from palliative care using the UK Gold Standards Framework Surprise Question (would you be surprised if this person died within the next year?). Multidisciplinary cancer conferences (MCCs) are scheduled meetings for oncology teams to prospectively discuss patient diagnostic tests and treatment options, which were leveraged for the INTEGRATE Project. Methods: A pilot study to test the efficacy of the Surprise Question at MCCs and implementation of a palliative model of care has been implemented in 3 academic and 1 non-academic cancer centres. A survey was completed to identify provider comfort levels in providing palliative care. All sites completed Pallium Canada’s LEAP Onco module, which equips providers with skills to provide primary level palliative care. Patients identified at MCCs received advance care planning, symptom management, referrals and standardized reporting to primary care. Results: Four disease sites (Lung, GI, CNS and Head & Neck) are participating. A baseline survey showed over 50% of providers had no training in palliative care. 161 providers participated in LEAP Onco. Implementation of the Surprise Question at MCCs began in February 2015. Two months of implementation identified 39 patients at the CNS, Lung and GI disease sites out of 108 of patients reviewed. At the CNS MCC, 100% glioblastoma patients were identified. The Lung and GI disease sites had lower identification rates (27% and 10%, respectively). Identified patients will have their healthcare utilization (referrals to community providers, billing patterns, ER visits) analyzed to determine impact of this project. Implementation continues until 2016. Conclusions: MCCs appear to be an excellent forum for identifying patients who can benefit from a palliative approach to care within the CNS, Lung and GI site groups. Further data is being collected to inform provincial recommendations for broader implementation of palliative care in Ontario.

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Identification of mental health and quality of life outcomes in primary care databases in the UK: a systematic review

BMJ Open ◽

10.1136/bmjopen-2019-029227 ◽

2019 ◽

Vol 9 (7) ◽

pp. e029227 ◽

Cited By ~ 3

Author(s):

Helena Carreira ◽

Rachael Williams ◽

Helen Strongman ◽

Krishnan Bhaskaran

Keyword(s):

Quality Of Life ◽

Primary Care ◽

Sexual Dysfunction ◽

Sleep Disorders ◽

Cognitive Dysfunction ◽

Life Outcomes ◽

Fatigue Syndrome ◽

Self Harm ◽

The Uk

ObjectivesTo summarise the definitions and combinations of codes used to identify outcomes of anxiety, depression, fatigue, cognitive dysfunction (including mild cognitive dysfunction and dementia), sexual dysfunction, pain, sleep disorders, and fatal and non-fatal self-harm in studies using electronic health records from primary care databases in the UK.DesignSystematic review.Data sourcesMedline, Embase and lists of publications of the main primary care databases in the UK.Eligibility criteriaIncluded data from a UK primary care database and studied outcome(s) of interest.Data extraction and synthesisWe abstracted information on the outcomes definition and codelists. When necessary, authors were contacted to request codelists.Results120 studies were eligible. Codelists were available for 17/42 studies of depression; 21/41 studies of fatal and non-fatal self-harm; 17/27 studies of dementia/cognitive dysfunction; 5/12 studies of anxiety; 4/8 studies of pain; 3/6 studies of fatigue and sexual dysfunction; 1/2 studies of sleep disorders. Depression was most often defined using codes for diagnoses (37/42 studies) and/or antidepressants prescriptions (21/42 studies); six studies reported including symptoms in their definition. Anxiety was defined with codes for diagnoses (12/12 studies); four studies also reported including symptoms. Fatal self-harm was ascertained in primary care data linked to the Office for National Statistics mortality database in nine studies. Most studies of cognitive dysfunction included Alzheimer’s disease, and vascular and frontotemporal dementia. Fatigue definitions varied little, including chronic fatigue syndrome, neurasthenia and postviral fatigue syndrome. All studies of sexual dysfunction focused on male conditions, principally erectile dysfunction. Sleep disorders included insomnia and hypersomnia. There was substantial variability in the codelists; validation was carried out i21/120 studies.ConclusionsThere is a need for standardised definitions and validated list of codes to assess mental health and quality of life outcomes in primary care databases in the UK.

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Systematic review of early abortion services in low- and middle-income country primary care: potential for reverse innovation and application in the UK context

Globalization and Health ◽

10.1186/s12992-020-00613-z ◽

2020 ◽

Vol 16 (1) ◽

Author(s):

Jacy Zhou ◽

Rebecca Blaylock ◽

Matthew Harris

Keyword(s):

Primary Care ◽

Service Delivery ◽

Middle Income ◽

Middle Income Countries ◽

Service Delivery Models ◽

Primary Care Settings ◽

The Uk ◽

Delivery Models ◽

Low And Middle Income

Abstract Background In the UK, according to the 1967 Abortion Act, all abortions must be approved by two doctors, reported to the Department of Health and Social Care (DHSC), and be performed by doctors within licensed premises. Removing abortion from the criminal framework could permit new service delivery models. We explore service delivery models in primary care settings that can improve accessibility without negatively impacting the safety and efficiency of abortion services. Novel service delivery models are common in low-and-middle income countries (LMICs) due to resource constraints, and services are sometimes provided by trained, mid-level providers via “task-shifting”. The aim of this study is to explore the quality of early abortion services provided in primary care of LMICs and explore the potential benefits of extending their application to the UK context. Methods We searched MEDLINE, EMBASE, Global Health, Maternity and Infant Care, CINAHL, and HMIC for studies published from September 1994 to February 2020, with search terms “nurses”, “midwives”, “general physicians”, “early medical/surgical abortion”. We included studies that examined the quality of abortion care in primary care settings of low-and-middle-income countries (LMICs), and excluded studies in countries where abortion is illegal, and those of services provided by independent NGOs. We conducted a thematic analysis and narrative synthesis to identify indicators of quality care at structural, process and outcome levels of the Donabedian model. Results A total of 21 indicators under 8 subthemes were identified to examine the quality of service provision: law and policy, infrastructure, technical competency, information provision, client-provider interactions, ancillary services, complete abortions, client satisfaction. Our analysis suggests that structural, process and outcome indicators follow a mediation pathway of the Donabedian model. This review showed that providing early medical abortion in primary care services is safe and feasible and “task-shifting” to mid-level providers can effectively replace doctors in providing abortion. Conclusion The way services are organised in LMICs, using a task-shifted and decentralised model, results in high quality services that should be considered for adoption in the UK. Collaboration with professional medical bodies and governmental departments is necessary to expand services from secondary to primary care.

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Anticipatory care planning for older adults: a trans-jurisdictional feasibility study

British Journal of General Practice ◽

10.3399/bjgp20x711197 ◽

2020 ◽

Vol 70 (suppl 1) ◽

pp. bjgp20X711197

Author(s):

Dagmar Corry ◽

Julie Doherty ◽

Adrienne McCann ◽

Frank Doyle ◽

Christopher Cardwell ◽

...

Keyword(s):

Quality Of Life ◽

Older Adults ◽

Primary Care ◽

Action Plan ◽

Randomised Trial ◽

Cluster Randomised Trial ◽

Care Planning ◽

Healthcare Needs ◽

The Uk

BackgroundAs the population of older adults’ increases, the complexity of care required to support those who choose to remain in the community has also increased. Anticipatory Care Planning (ACP) through earlier identification of healthcare needs is evidenced to improve quality of life, decrease the number of aggressive futile interventions, and even to prolong life.AimTo determine the feasibility of a cluster randomised trial to evaluate the implementation and outcomes of Anticipatory Care Planning (ACP) in primary care to assist older adults identified as at risk for functional decline by developing a personalised support plan.MethodGP practices were randomised into control/intervention groups stratified by jurisdiction [Northern Ireland (UK) and the Republic of Ireland (RoI)], and by setting (urban and rural). Participants were included if they were a) aged ≥70 years, b) 2 or more chronic medical conditions, c) 4 or more prescribed medications. The Anticipatory Care Plan consisted of home visits where the study nurse discussed patients’ goals and plans. An action plan was put in place following consultation with patient’s GPs and study Pharmacist.ResultsEight primary care practices participated; four in the UK and four in the RoI. Sample n = 64. Data was collected pertaining to patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and the use of potentially inappropriate medication.ConclusionUnique insights relating to the trans-jurisdictional delivery of healthcare services in the UK and RoI were observed which has implications on service delivery for older adults.

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