NB Hot Topics Podcast
NB Hot Topics Podcast
S5 E1: GP motivations; morning after pill & NSAIDs; cancer risk with non-erosive GORD
Welcome to Season 5 of the Hot Topics podcast from NB Medical with Dr Neal Tucker. Despite celebrating our 25th birthday (don't forget to check out our NB Plus birthday special here) the world of medical news and research never stops.
In this episode we look at research in the BJGP about the motivations behind being a GP, whether adding NSAIDs may improve efficacy of emergency contraception, and whether we should be worried about cancer in patients with reflux.
www.nbmedical.com
References
BJGP Mapping GP Motivations
Lancet Levonorgestrel + piroxicam for EC
BMJ Non-erosive reflux and oesophageal cancer risk
www.nbmedical.com/podcast
It's Friday, the 15th of September 2023, and this is the Hot Topics Podcast. Welcome back to the Hot Topics Podcast from NB Medical. This is season five. If I had a producer or any kind of budget to do any of this, I'd put in some kind of fancy jingle at this point, but all I've got is what I have in my house. So we're down to saucepins. It's like a metaphor for the NHS, but the good news is things could always be worse. I have friends working in hospitals which appear to be full of aerated concrete waiting to crumble on them. The money to fix it is now going to be delayed by another five years, so instead they get to practice evacuating the building In your practice. Wherever you're working, I hope at least that you have a roof above your head rather than a roof on your head.
Speaker 1:Okay, what can we expect from season five of the Hot Topics course? Well, more of me. I didn't introduce myself earlier. Hello everyone. I am Neil Tucker, if you have not met me before. I am a GP in Oxfordshire and a long-standing member of the NB Medical Education team, and we will be covering, as usual, our course, so the latest news and research that's come out relevant to us in primary care. We will have more songs assuming they make it past the lawyers and we will have lots more interviews, including and I'm very excited about this more interviews with authors of original research so they can come and have a chat with us about the implications of the new data that they're putting out there, what are the clinical implications and how it may improve things for us all and our patients.
Speaker 1:Now, before I forget, celebrations are in order, so it is our 25th year as a company. Nb Medical has been going for 25 years providing medical education to GPs and primary care clinicians. Were you there at the start with acetate sheets on the projector and scraggie handouts, and you're still here with NB listening to us on the podcast. I would love to know, do get in touch. Remember you can always get in touch Email hottopics at nbmedicalcom. You can find that on the nbmedicalcom website, or you can catch us on Twitter. Wow, so long since I've said that they've even changed their names X or Facebook as well. What do you prefer, the good old days or the modern NB?
Speaker 1:Now, in celebration of these 25 years, if you haven't signed up to NB Plus yet, that is our subscription service where you get to come on all of the online courses that we do live and on demand, for the whole year, get access to all the course booklets online and loads more stuff too all for just 320 pounds a year. Well, at the moment we're doing a happy birthday special offer where you can get 25 pounds off even that ridiculously cheap figure until the 30th of September. So do check out the website If you have any interesting coming on. More than one NB course this year and we do around a dozen different ones now, then this is an absolute bargain. On that note, check out the courses that we've got coming up over the next couple of weeks. Tomorrow morning that's only if you're listening to it on the day that it comes out, but tomorrow morning we'll be doing a mental health course, so Siobhan Becker is running that and I will be facilitating. Then, saturday, the 23rd, we have our new Hot Topics course. That's our Autumn, winter 2023 Hot Topics course, with loads of new topics and plenty more going on in the weeks after that. So it's a really busy, busy time during September, october and November. Take a look at the MBmedicalcom website.
Speaker 1:In other news, beyond crumbling concrete in happy birthdays, the NHS has managed to secure a batch of weight loss medications, we go via some semi-glutide. After multiple press releases from the government earlier in the year making our patients believe that they might actually be able to get this drug from their GPs, now we've got press releases making GPs believe that they might actually be able to get this drug for their patients. Unfortunately, searches by gangs of marauding PCN clinicians have proven as fruitless as a recent search for the Loch Ness Monster and a positive news story this week. I think it's positive that an English GP practice has successfully defended discrimination claims against them from a patient who abused staff and then they removed from their list. This all came about because there was a problem with the patient's prescription and that problem actually wasn't their fault. However, when they tried to then get it sorted out and they demanded for it to be sorted immediately and they were told that it couldn't be done right now they started threatening the staff and ultimately the police needed to be called because that threatening behaviour was so severe. This, of course, is an unacceptable way to be treating anyone, irrespective of whether there has been a problem that was not your fault, and there is no excuse for treating anyone in a practice like that. After complaining to the practice and NHS England, this patient then took the practice to court on discrimination grounds and suing for a large amount of money. Good to see, then, that the judge felt that the action of the practice was proportionate given the effects of the threatening behaviour, and good to see. The practices don't have to put up with patients being arseholes who claim that they're arseholes because they're sick.
Speaker 1:Okay, on to the research, and, as usual, we are going to look at three recent papers. We could have talked about oral semi-gluteide, which has got loads published about it, and similar medications. So the Lancet, the New England Journal and Medicine these drugs are everywhere at the moment. We are going to be talking about these types of medications on the new Hot Topics course, because, whether we like it or not, whether we think it's the right path for a population, for a country to be going, these medicines are going to be big, big news, but it's also dull if that's all that we talk about. So we're actually going to kick off with a paper from the BJGP on mapping GP's motivation why do you go to work in the morning? Then we're going to have a paper from the Lancet on oral emergency contraception with levonogestrel plus peroxacam, and then we're going to round up with a paper in the BMJ on non-erosive gastroesophageal reflux disease and the incidence of esophageal adenocarcinoma.
Speaker 1:So let's start with the BJGP and congratulations are in order. Not just NB's birthday, but is also the BJGP's birthday. They've been around 70 years, so this latest edition is in celebratory mode. I'm not quite sure when an organisation can legitimately celebrate a birthday. Is 70 okay as opposed to 75? Would you do 65, or is it just 50? And then the next stop is 75. I guess they make up their own minds and we just run with it. Regardless, this journal just keeps getting better and better, and it's also great that we have a place where we can get important qualitative research published, not just quantitative research, which is what most of the major general medical journals concentrate on. Sometimes you just have to sit down and talk to people if you want to understand what is going on on earth is going on.
Speaker 1:So this paper was from Denmark and this is all about understanding GP's motivation. Why do we do the job that we do? Denmark has a general practice system that's quite similar to the UK's. I think maybe their GP's earn a little bit more. If you have a GP in Denmark. Please email and tell me all about it. I would be very interested, but we all know that money isn't everything. Otherwise most of you would have quit and would have gone into banking.
Speaker 1:This paper sets out the results of a survey that was undertaken by 1,100 GP's, and it looked at four different areas which might motivate GP's. So extrinsic motivation, intrinsic motivation, user orientation and public service motivation. So extrinsic motivations would be things like financial incentives. Intrinsic motivations would be doing things because you genuinely are interested in it and you like it. User orientated motivation is where you really want to do good for other people, such as your patients. And then public service motivation is where you're wanting to do good for society in general.
Speaker 1:To give you an idea about some of the questions they asked under extrinsic motivation, they've asked questions such as it is important for me to have an external incentive to strive for in order to do a good job, and respondents could say whether they agreed or disagreed and to what degree they would agree or disagree. How would you respond to that question? Intrinsic motivation. So first question on the list I very much enjoy my daily work. How would you respond to that? User orientation the individual user is more important than formal rules. And then public service motivation. It is difficult for me to contain my feelings when I see people in distress. I'm often reminded by daily events about how dependent we are on one another, and so forth. There's almost 30 questions along these lines for the different groups.
Speaker 1:Based on the responses, the authors found that they could group people into one of five classes. So class one was it's less about the money, lots of intrinsic motivation, user orientation and public service motivation coming out top there. Class two, it is about everything. Class three, it's about helping others. Class four, it is about the work and class five it's about the money and the patient. The main conclusion here was that there are lots of different work motivations in GPs. We're a highly heterogeneous group, but one thing comes out and that's it's not all about the money. 53% of responders, in fact, were in class one. It's less about the money. The next biggest group was 27% in class two it is about everything. I haven't actually undertaken this survey myself. I'm really hoping that for me it's not all about the money, although I suspect maybe I'd be in that second class. It's about everything. I don't think I want to be doing it entirely for free Tumbleweed on the podcast.
Speaker 1:I think this is useful information for policymakers and for governments as well. If you're asking why a doctor is still striking, well, it's not just about the money. It's about conditions as well, I guess, as practices. If you're a partner in a practice and you are looking after employees, then also we need to be thinking well, it's not just about the money. That's probably a relief given the fact that there's not a lot of money around. Maybe there's something else that could be done to improve working lives and happiness. And don't discount qualitative research. Sitting down and talking to each other, it turns out, can be a very powerful thing to do.
Speaker 1:Okay, the next paper was published in the Lancet last week. This was about oral emergency contraception with levonorgesteril plus peroxacam, a randomized double-blind placebo-controlled trial. So the background to this is that levonorgesteril, the morning after pill, is our standard therapy for emergency contraception. We perhaps don't think about its limitations enough, because if you give it post-ovulation, it doesn't work. It's a progestin. You give it before ovulation. It provides negative feedback, suppressing the pituitary that interrupts ovulation and you prevent the pregnancy. But if ovulation's already happened, then you're stuffed. Now, I never knew this, but cox2 inhibitors like maloxicam or peroxicam have been shown to disrupt ovulation before they prevent the conversion of arachidonic acid to prostaglandins. For the record, I'm reading this off the associated editorial right now. I'm not just a genius in physiology. Those prostaglandins are important for the release of the oocyte. So if you lower those levels of prostaglandins then you might prevent that process happening.
Speaker 1:This study was conducted in Hong Kong in community sexual and reproductive health services. Women were recruited if they were within 72 hours of unprotected sexual intercourse, and then randomized one-to-one to either have levonorgestrel plus peroxicam 40 milligrams or levonorgestrel and placebo. They were then followed up one to two weeks after the date of their next expected period to be assessed for their pregnancy status. 860 women were recruited, so 430 in each arm. The good news for women in general is that the rate of pregnancies in both groups were relatively low, but they were much lower in the treatment arm. So in those having just levonorgestrel plus placebo there were seven pregnancies. In the levonorgestrel and peroxicam arm there was just one. This was a statistically significant difference. The authors then also reported the rate of expected pregnancies. This showed that levonorgestrel plus peroxicam prevented 95% of expected pregnancies, compared with 63% in the placebo group. It seems to me that this is quite a big difference, important to note, about the adverse event profile, but actually that seemed to be the same between both groups. There seems to be a safe intervention.
Speaker 1:With all this in mind, then this seems like a very worthwhile intervention. Should we be implementing this in practice? Well, there are a few sticking points that will need to be ironed out before I think this becomes common practice, in the UK at least. Firstly, this was a study done in Hong Kong, and over 95% of the population were Chinese origin. We will want to see this repeated in other populations to make sure that this is a universal finding, and part of the issue here is that if you're Chinese, the chances are that you're probably fairly small. So almost everyone in this study was under 70kg. This is important because levonorgestrel becomes less efficacious at higher weights, so, particularly over 70kg, I'm sure that there will be quite a few of our patients who will be over 70kg, and so we don't know that this treatment will be as efficacious in this group.
Speaker 1:And then there's the issue of oral peroxocam. I don't think I've ever seen any patient of mine be prescribed oral peroxocam in the UK. I looked it up in the BNF. It does exist, but I was having these images of having to prescribe patients tubes of peroxocam gel and just getting them to smother their whole bodies in it as they took a morning after pill. It goes without saying that I can't vouch for the efficacy of that approach, and you may get a rash. There are questions, then, that need to be addressed before we can adopt this approach in the UK, and that's before we even get to the issue of where were these women in their menstrual cycle, because the reality is, even if you're giving levonorgestrel with a cox2 inhibitor, if it's after ovulation, it's still very unlikely to be effective. Let's not forget the other options. So Ulapristol has a slightly broader window that it's meant to be effective in, but definitely don't discount the coil. It's going to be the most effective option by far if we're at that point of ovulation or beyond. Okay, moving on to our last study and we are with the BMJ Now this was published this week and this was research on non-erosive gastroesophageal reflux disease and the incidence of esophageal adenocarcinoma.
Speaker 1:This was performed in three Nordic countries, a population-based cohort study. So the premise here is that the biggest risk factor for esophageal cancer is gastroesophageal reflux disease. Many patients these days with persisting symptoms will get referred for a scope and the vast majority come back with a diagnosis of non-erosive gastroesophageal reflux disease. Basically, it means when they put the scope down, they couldn't see anything wrong.
Speaker 1:In the last hot topics, course, we were talking about the over-prescribing of PPI's, especially in this group. But here's the question Is this group still at increased risk of getting esophageal cancer, especially if we elect not to treat them with an anti-secretary medication? Is encouraging people down a more holistic approach actually safe? So this was a cohort study using patient data from Denmark, finland and Sweden, and they had almost 500,000 adults who had gone undergone endoscopy included in this research. They found 280,000 people with non-erosive reflux, and the good news for this group and for us is that the incident rate of esophageal adenocarcinoma in this group was no different from that of the general population, even over time. So with longer follow-up of 15 to 30 years, the rate still did not increase. To make sure that these findings were legitimate, they validated it by comparing it against those who are diagnosed with erosive esophagitis, and in that group they found a definite increase. The chance of cancer was almost two and a half times greater than the general population and got more pronounced with time. The authors concluded that patients with non-erosive reflux disease have a similar incidence of esophageal cancer as the general population.
Speaker 1:This is great news, then, for our patients with non-erosive reflux disease is good for us. We can all be a little bit more relaxed and reassured. The only caveat, of course, is that all of these patients, by very definition, have had an endoscopy, so we've already proven the diagnosis. That, then, is the limitation. We cannot say that our patients who have not had an endoscopy that everything is going to be absolutely fine. It probably will be, and it's probably fine to adopt our usual approach. Think lifestyle, maybe try some treatment, maybe refer for endoscopy those refractory cases. And if we do send them for a scope and if they do come back with non-erosive disease, at least we know then that, if symptoms continue in the future, doing lots more scopes is really unnecessary.
Speaker 1:Okay, that's it for the research. Thank you for joining us on the podcast today. Next time I will be interviewing Simon Curtis, the founder of MB Medical Education, finding out how research, general practice and medical education has changed over the last 25 years. Don't forget that MB Plus subscription offer until the 30th of September and by all means. Do get in touch. Hot topics at nbmedicalcom Send me an email, look after yourselves everyone. Keep up the good work. Bye-bye.