Bear's Grease and Soda Water

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2 Bear's Grease and Soda Water Frank Sullivan GP Mill Practice, Dundee Director, Scottish School of Primary Care NHSTayside Professor Of R&D in Primary Care Galway 08 ICGP Foundation

3 Prescriptions and family medicines accurately compounded. Teeth extracted at one shilling each. Women attended in labour, two shillings and sixpence each. Patent medicines and perfumery. Best London pickles. Fish sauces. Bear's grease. Soda water Manchester Apothecary s shop 1838

4 Management of chronic cough Prof Kian Fan Chung DSc a, b,and Prof Ian D Pavord FRCPc aexperimental Studies, Airway Disease Section, National Heart and Lung Institute, Imperial College London, London, UK broyal Brompton Hospital, London, UK cinstitute for Lung Health, Department of Respiratory Medicine, Allergy and Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK

5 Polyclinics will mean the end of family medicine as we know it, and I'm not sure that our patients fully realise this. Professor Steve Field Chairman of RCGP Council

6 Number of practices The percentage of patients with CHD whose last total cholesterol is <5 mmol/l Year 1 Year Percentage achievement

7 Is the enigmatic smile of Mona Lisa due to incomplete recovery from Bell s palsy? Galway 08 ICGP Foundation

8 A GP perspective on Bell s Palsy 0-1 patients per annum 80-85% improve untreated 36% treated with oral steroids 19% referred to hospital Increasing use of antivirals Rowlands S, Hooper R, Hughes R, Burney P. The epidemiology and treatment of Bell's palsy Pickles W 1935 in the UK. Eur J Neurol 2002;91:63-7

9 Importance of Early Rx

10 We failed Galway 08 ICGP Foundation

11 The Howie Report 1988 For Research to succeed there needs to be: A Climate Of opinion in which R&D is expected, valued and rewarded Infrastructure Resources and advice Skills to support R&D Methodological, interpersonal and organisational

12 The First National School of Primary Care EMGO NIVEL EBP ExTra HEALTH

13 Galway 04 Extern assessor feedback MICGP 2004

14 Scottish School of Primary Care 888 GPs 259 Nurses 42 Dentists 10 Universities

15 Pump-priming research 750 for a proposed research idea Literature Searches Research Training Steering meetings for the development of the project - Pilot Studies Leading to a grant application

16 1 High quality research 2 External grants 5 Study success 6 Research Culture 4 Enhanced Research Infrastructure & Participation 3 NHS R&D Support Funds

17 Health Technology Assessment Board of the NHS Commissioning Brief: 02/09 What is the costeffectiveness of early treatment of Bell s Palsy with acyclovir (with or without steroids) versus natural resolution? 1M

18 Cochrane reviews Salinas, R.A., Alvarez, G., Alvarez, M.I. and Ferreira, J. Corticosteroids for Bell s Palsy October 2001 Three trials, 117 patients. Findings inconclusive Sipe, J. and Dunn, L. Aciclovir for Bell s Palsy August 2001 Two trials, 200 patients. Data sparsely reported. Findings contradictory

19 A patient s experience

20 Randomised Controlled Trial Factorial Design Aciclovir 2g/day 10 days Placebo Prednisolone 50 mg/day 10 days Both (AB) Prednisolone only (B) Placebo Aciclovir only (A) Neither(O)

21 Power Main effect = ½ (A + AB) ½ (B + O) Trt 1 Trt 2 % incomplete recovery % incomplete recovery Difference Relative Risk N per group Total 22% 32% 10% % 34% 12% % 37% 15% Galway 08 ICGP Foundation

22 Source of referral GP and OOH 414 Scottish Primary Care Research Network, MRC GP Research Framework, Teaching/Training networks A/E 41 Dentist 1 NHS24 26 Others/Unknown 69

23 Finding patients

24 Recruitment and completion to target Meetings Mail Media McKinstry B, Hammersley V, Daly F, Sullivan F Recruitment and retention in a multicentre randomised controlled trial in Bells palsy: A case study BMC Medical Research Methodology 2007, 7:15 doi: /

25 Time (hrs) after onset by Treatment Group 263/496 Galway 08 ICGP Foundation

26 Outcome measures House Brackmann Scale I-VI Derriford Appearance Scale Brief Pain Inventory Health Utilities Index NHS costs Process evaluation Patients GPs

27 I II House Brackman Scale Normal symmetrical function in all areas Slight weakness noticeable only on close inspection Complete eye closure with minimal effort Slight asymmetry of smile with maximal effort Synkinesis barely noticeable, contracture, or spasm absent III Obvious weakness, but not disfiguring May not be able to lift eyebrow Complete eye closure and strong but asymmetrical mouth movement with maximal effort Obvious, but not disfiguring synkinesis, mass movement or spasm IV Obvious disfiguring weakness Inability to lift brow Incomplete eye closure and asymmetry of mouth with maximal effort Severe synkinesis, mass movement, spasm V Motion barely perceptible Incomplete eye closure, slight movement corner mouth Synkinesis, contracture, and spasm usually absent VI No movement, loss of tone, no synkinesis, contracture, or spasm

28 What HB grade is he? I Normal II Slight Weakness III Obvious Weakness IV Disfiguring V Barely Perceptible VI No Movement eyebrows raised eyes tightly closed smiling

29 I II House Brackman Scale Normal symmetrical function in all areas Slight weakness noticeable only on close inspection Complete eye closure with minimal effort Slight asymmetry of smile with maximal effort Synkinesis barely noticeable, contracture, or spasm absent III Obvious weakness, but not disfiguring May not be able to lift eyebrow Complete eye closure and strong but asymmetrical mouth movement with maximal effort Obvious, but not disfiguring synkinesis, mass movement or spasm IV Obvious disfiguring weakness Inability to lift brow Incomplete eye closure and asymmetry of mouth with maximal effort Severe synkinesis, mass movement, spasm V Motion barely perceptible Incomplete eye closure, slight movement corner mouth Synkinesis, contracture, and spasm usually absent VI No movement, loss of tone, no synkinesis, contracture, or spasm

30 Disease Severity at onset No House Brackmann grading

31 Logistics Study measuring instruments Patient Case Record Forms Questionnaires Photographs, tapes, and film Transcripts Data trail collection, transfer, storage, backup processing and analysis archiving

32 Study detail- Randomisation

33 Follow up - 496/551

34 Main Results

35 Summary Recovery at 9 months 96% Prednisolone recover 78% Aciclovir 84% Placebo Absolute Risk Reduction (ARR) for Prednisolone compared to Placebo 96-84=12% Number needed to treat (NNT) 1/ARR 8 at 9 months

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37 The Mant Report Recommendations 3. Commission research on a small number of clearly focused programmes. 4. Encourage collaboration with overseas centres of excellence. Galway 08 ICGP Foundation

38 HRB Centre for Primary Care Research

39 Centre for Primary Care Research Work packages 1. Management of medicines in vulnerable groups Elderly, children, pregnant women, drug users 2. Evidence-Based Diagnosis Clinical prediction rules 3. Information & Communication Technology Computerized clinical decision support systems Comparative clinical data

40 SAPC THE SOCIETY FOR ACADEMIC PRIMARY CARE Galway 08 Extern ICGP Foundation

41 Galway 08 Extern ICGP Foundation