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- Page navigation anchor for Risk stratification for freeRisk stratification for freePredicting risk is the new mantra for modern medicine. In 'AFTER ACHILLES' the challenge is set - In the maelstrom that is primary care; we need all the risk stratification tools we can get to help us identify who’s more at risk than the next guy.QOF encouraged us to identify CKD, and now overburdened by its commonness, we are at risk of throwing away all we have achieved. Few diagnoses are predictably associated with such a dramatic increase in cardiovascular risk and none are so easily identified by a cheap and easily available blood test.1-2. The clustering of vascular pathologies with diabetes and hypertension makes this burden of disease the greatest challenge for the next generation of patients and doctors.In our study we investigated the reassurance given by NICE, that the previous decades’ CKD QOF initiative, had improved the identification and management of CKD. In a practice population of 10264, 9% of adults’ ≥ 18 years had a diagnosis of CKD on repeated testing. Despite this remarkable prevalence (usual estimates 3-6%), a total of 75% of these patients with CKD were unaware of the diagnosis, and in more than 25% both GP and patients were unaware of the condition. The results demonstrated that this lack of awareness was not limited to those with mild renal compromise but applied to 1/3 of patient with CKD stage 4. Our short intervention, either by phone...Competing Interests: None declared.
- Page navigation anchor for After AchillesAfter Achilles
Contrary to the view that ‘using time as a diagnostic tool’ is 'sloppy and idle' and that general practice has 'floundered' as a result of such unhelpful phrases, we consider that general practice has struggled to provide a robust evidence base to confirm or refute the value of time as a diagnostic strategy.1 One of the most important diagnostic tasks performed by the GP is discriminating between the majority of patients with minor, usually self-limiting, illness and the minority with serious disease. This was illustrated by a cohort of 2690 adults presenting with lower respiratory tract infections of whom 92% had recovered within 3 weeks and only 1.1% were hospitalized, none of whom died.2
In 2013 we proposed the hypothesis that the opportunity afforded by reviewing a patient over time substantially increases the total gain in certainty when making a diagnosis in low-prevalence settings (the ‘time-efficiency principle’) such as general practice.3. We argued that this approach safely and efficiently reduces the number of patients who need to be investigated in order to make a correct diagnosis for a single person. We predicted that the time efficiency principle operates most effectively at low prevalence, typically up to 10%. It has since been noted as a widely used strategy in primary care. The Lancet oncology commission on primary care noted that adequate diagnosis requires time for sy...
Competing Interests: None declared. - Page navigation anchor for HLA DQ2/8 genotyping should not be requested in primary care for screening/diagnosing coeliac diseaseHLA DQ2/8 genotyping should not be requested in primary care for screening/diagnosing coeliac diseaseWe read with interest the editorial briefing entitled ‘After Achilles‘ with its emphasis on early and correct diagnosis.1 Coeliac disease (CD) occurs in 1% of UK population but vast majority remains undiagnosed.2 Reliable diagnostic tools and guidelines are available but not well understood especially recently revised European (ESPGHAN) guidelines.3 These recommend that all children presenting with symptoms suggestive of CD and groups at risk such as all first-degree relatives, type-1 diabetes should have IgA-based anti-tissue transglutaminase (tTG) checked and if positive undergo diagnostic small-bowel biopsies while on gluten.3-4However in a small group of symptomatic children who have tTG-titre >10-times upper limit of normal (ULN) on two occasions and positive IgA-based anti-endomysial antibodies, diagnosis can be made by specialists (paediatric gastroenterologist or paediatrician with special interest in gastroenterology) without biopsies after reviewing the child provided HLA-DQ2/8 genotype is positive.3We have noted that ESPGHAN guidelines3 are being misunderstood and many children with suspected CD and/or positive tTG-titre of <10xULN are inappropriately getting HLA-DQ2/8 tested in primary care. Children have been diagnosed with CD by GPs based on positive HLA-DQ2/8 genotype alone or in conjunction with tTG-titres les...Show MoreCompeting Interests: None declared.