Early identification of at-risk children: service improvement study using immunisation status.

BACKGROUND: Children who have adverse childhood experiences (ACEs) tend to have more physical and mental health problems when they are adults compared with people who do not have ACEs. Evidence suggests that partial or no immunisation status can be associated with factors (including ACEs) that make children at higher risk of poor outcomes than immunised children. AIM: To explore the idea that 'missed immunisations' could be used as a proxy indicator in identifying children at risk of worse outcomes. DESIGN & SETTING: Service improvement study in seven GP practices in south London, UK. METHOD: Children aged 0-3 years who were ≥3 months late for immunisations were identified; their computer notes were reviewed during interdisciplinary meetings between health visitors (HVs) and GP practice staff. A bespoke template was used to guide discussions and to record action plans. Evaluation methods included a survey of practitioners and anonymised questionnaires about care management for a sample of children. RESULTS: Issues of concern, including some ACEs (for example, domestic abuse, mental health concerns in parent), were identified in 57% of children. Ninety-four per cent of practitioners found multidisciplinary meetings useful; 62% of practitioners changed the way they thought about providing care to very young children and their families. Of the children discussed during multidisciplinary meetings, 38% subsequently caught up on immunisations. CONCLUSION: 'Late for immunisations' appears to be a useful indicator for proactively identifying children with issues that make them at risk of poorer outcomes. Integrated working between GPs and HVs is important for ensuring targeted care is provided to families.

Two-year effectiveness of erenumab in resistant chronic migraine: a prospective real-world analysis.

BACKGROUND: Controlled and real-world evidence have demonstrated the efficacy of calcitonin gene related peptide (CGRP) monoclonal antibodies (MABs) in migraine. However, data on the over-one-year sustained effectiveness of CGRP MABs in resistant chronic migraine (CM) is sparse.  METHODS: This is a two-year real-world prospective analysis of an ongoing single centre audit conducted in patients with resistant CM. Patients received monthly erenumab for six months before assessing its effectiveness. Responders were considered those who achieved at least 30% reduction in monthly migraine days (MMD) by month 6, compared to baseline. Secondary outcomes were also analysed, including changes of the Headache Impact Test version 6 (HIT-6). RESULTS: One hundred sixty-four patients [135 (82.3%) females; mean age 46 SD 14) years] were included in the audit and 160 patients analysed. Patients had failed a mean of 8.4 preventive treatments at baseline. At month 6, 76 patients (48%) were 30% responders to erenumab, 50 patients (31%) were 50% responders and 25 (15%) were 75% responders. The mean reduction in MMD at month 6 was 7.5 days compared to baseline (P < 0.001). At month 12 and month 18, 61 patients (38%) and 52 patients (33%) remained 30% responders respectively. At month 24, 36 patients (23%) remained 30% responders, 25 patients (16%) and 13 patients (8%) were respectively 50% and 75% responders. Compared to 95% of patients at baseline, at months 6, 12 and 24, 46%, 29% and 16% of responders respectively had severe disability. At least one adverse event at month 6, 12, 18 and 24 was reported by 49%, 19%, 11% and 3% of patients. By month 6, 13% of patients discontinued the treatment because of side effects, often constipation. CONCLUSIONS: Long-term sustained effectiveness of erenumab was reported only by a minority of resistant CM patients. Although more research in resistant migraine is needed, Erenumab can provide long-term meaningful reduction in migraine load and migraine-related disability in some patients.

Should GPs have direct access to imaging for headache? A qualitative study of patients' views in the UK.

OBJECTIVE: We aimed to describe patients' views of a new referral pathway of general practitioner (GP) direct access to MRI, versus imaging after referral to a specialist. DESIGN: This qualitative study involved 20 semistructured interviews. Twenty patients (10 from each pathway) were purposively recruited and interviewed to describe their attitudes. SETTING: A neurology headache clinic and neuroradiology services from the boroughs of Southwark and Lambeth in South London, UK. PARTICIPANTS: Twenty patients were involved in this study. RESULTS: Over half of the participants felt relieved once they received their scan results, while some remained uncertain about the underlying cause of their symptoms. Some participants described a long wait to see a specialist. Others described a long wait time to receive scan results, especially from their GP. Spontaneous reduction in headache symptoms occurred for some participants and for others, normal imaging results allowed them to focus more on symptom management. CONCLUSION: Relief was reported especially when scan results had been explained clearly and without too much delay. Those with continuing pain focused on how to get relief from symptoms. Patient experience might be improved with clearer information from GPs about how patients can access results, standard reporting procedures and closer liaison between neuroradiology and GPs.

Primary care management of headaches and how direct-access MRI fits: a qualitative study of UK general practitioners' views.

OBJECTIVES: To develop a better understanding of general practitioners' (GPs) views and experiences of the management of patients with headaches and use of direct-access MRI scans, and observe outcomes of an educational session offered by a GP with a special interest (GPwSI) to GPs. DESIGN: A qualitative study using semistructured interviews, analysed using thematic analysis. A GPwSI in headaches visited practices delivering a talk on headache medication, diagnosis and management. SETTING: Sixteen (16) primary care family practices in South London, UK. PARTICIPANTS: Twenty (20) GPs. RESULTS: Not all GPs were aware of the availability of direct-access MRI, but all acknowledged having used referral or direct scans to manage patients' concern about their headaches. A normal scan result helped resolve uncertainty for patient and GP and helped management towards discussion of preventative treatment. However, patients with psychological and/or severe headache symptoms could not necessarily be reassured. GPs reported difficulty interpreting radiology reports, particularly incidental abnormalities. Those who received the educational talk gained knowledge in diagnosis and medication, improving their confidence in management. CONCLUSIONS: Increased access to imaging, training in headache management, addressing physical and psychological symptoms and standardised reporting of scans may improve GPs' use of direct-access MRI in the future.

Arthropod larvae misidentified as parasitic worm infection.

A healthy, asymptomatic man living in London, presented with seeing 'worms' in his toilet for two successive summer seasons. Repeated microscopic examination and cultures of both his faeces and urine were normal. He was empirically treated with multiple courses of antihelminthics without resolution of this problem. A sample of the worms was obtained, and positively identified as arthropod larvae under microscopic examination. These larvae do not parasitically colonise humans. It was subsequently deduced that a flying arthropod (most likely Culex pipiens mosquito) had laid eggs in standing toilet water, and the hatched larvae had been mistaken for parasitic worms. The patient was declared free of parasites and remains healthy. This case illustrates the dangers of starting empirical treatment without positive confirmation of causative organisms, which can result in unnecessary and potentially harmful treatment.