Welcome to the Hot Topics podcast from NB Medical with Dr Neal Tucker. In this episode, we talk to Prof Hazel Everitt, a GP and lead author of a recent Lancet paper exploring whether amitriptyline is effective for IBS, and where it might fit in to general practice management.
We also look at research in the Lancet on treating hand osteoarthritis with methotrexate - what's the rationale and does it work? - plus a BMJ paper on using a patient information leaflet to improve lower urinary tract symptoms in men. Are PILS better than pills?
Resources
Lancet ATLANTIS paper on IBS & amitriptyline
ATLANTIS trial website with patient information
Gut journal CBT for IBS
National Institute for Health and Care Research - how to get involved
NIHR Local research groups - how to get involved
Lancet Methotrexate for hand OA with synovitis
BMJ Leaflets for LUTS
www.nbmedical.com/podcast
Welcome to the Hot Topics podcast from NB Medical with Dr Neal Tucker. In this episode, we talk to Prof Hazel Everitt, a GP and lead author of a recent Lancet paper exploring whether amitriptyline is effective for IBS, and where it might fit in to general practice management.
We also look at research in the Lancet on treating hand osteoarthritis with methotrexate - what's the rationale and does it work? - plus a BMJ paper on using a patient information leaflet to improve lower urinary tract symptoms in men. Are PILS better than pills?
Resources
Lancet ATLANTIS paper on IBS & amitriptyline
ATLANTIS trial website with patient information
Gut journal CBT for IBS
National Institute for Health and Care Research - how to get involved
NIHR Local research groups - how to get involved
Lancet Methotrexate for hand OA with synovitis
BMJ Leaflets for LUTS
www.nbmedical.com/podcast
It's Friday, the 1st of December 2023, and this is the Hot Topics Podcast. Welcome to the Hot Topics Podcast from NB Medical, neil Tucker here again to take you through what's been going on in the world of research relevant to us in primary care over the last few weeks. And I know what you're thinking. Yes, there's just two podcasts to go until Christmas, unless you're listening to this at any other point than the next three weeks. Weird things podcasts.
Speaker 1:So the start of the show today is my interview with Professor Hazel Everett, who's a GP down in Southampton and academic as well, and she was the lead author on a really important paper, that published in the Lancet a few weeks ago exploring the role of amitriptyline in the management of irritable bowel syndrome. So we're going to go into detail about that paper. We're also going to have a look at a new paper published in the Lancet on hand osteoarthritis and whether methotrexate might be helpful for that, and also a paper in the BMJ, moving away from medications, exploring the simple strategy of whether a patient information leaflet and a bit of directed counseling by a healthcare professional can help men troubled by lower urinary tract symptoms. Let's kick off with the news, though, and actually I wasn't really going to do a news section today because I wanted to keep the Christmas spirit alive, and it's pretty hard to do that with general practice news over the last few months, or indeed last few years. There's no kind of dog on a surfboard stories just floating around, but it would seem remiss not to mention two important things that have happened. So firstly, consultant doctors. So our friends, our colleagues, our consultants have got a new deal from the government and they seem to broadly be welcoming this. I'm sure there's pros and cons.
Speaker 1:The consequence of this, however, is that various other healthcare bodies are now looking at that, thinking well, we didn't get that. So the nurses are annoyed and they're thinking about new strikes. And of course there may be implications for general practice in this as well. And already we start seeing some of the rhetoric escalate around why more funding isn't coming into general practice, why is our pay not being improved more? These, of course, are fair and legitimate questions, but how you get to that endpoint is going to be a complicated process. I still can't picture GP striking. I still can't picture GPs coming together as a unified body because we're so diverse. Of course, a lot of this won't matter, particularly to GP partners in England because all lies there will be on the new contract, the renegotiated contract for next year. But given what's going on with the consultants, if there's not a favorable outcome for this, I suspect there will be a lot of discontent even more discontent within the profession.
Speaker 1:The other big news for GPs this week was a report that published by the Health Services Safety Investigation's body, and their recommendation in this report was about continuity of care, calling it an essential requirement that could reduce the risk of delays in diagnosing serious health conditions, and the GP contract should be modified to explicitly include and support the need to deliver continuity of care. The example used in the report and in the media was of a male patient who had a history of breast cancer who then developed back pain and saw multiple different GPs and other healthcare professionals and eventually was diagnosed with metastatic disease. This diagnosis was late and they highlighted that there were many opportunities in his care to perhaps identify that much sooner and that could have affected the outcome for him, and it was out of. The lack of continuity significantly contributed to this late diagnosis. Surveys suggest that patients really want continuity. This is why various political parties have started talking about it. I suspect the vast majority of clinicians also want continuity, so why can't we deliver it? I'm sure you will all have your own ideas and your own experiences of why this is often very difficult.
Speaker 1:I personally think that successive governments have actually contributed to this problem quite substantially. The constant drive to increase the working hours of a practice, to extend accessibility to patients, is actually inversely affected continuity. You've got to be open early, you've got to be open late, you've got to be seeing more patients. Ultimately, something has to give, and what gives is clinicians ability to work on a more regular basis. That is the biggest barrier to continuity. If the government said GP practices could be open from nine to five and the vast majority of our work was nine to five, or maybe even within school hours for GPs who have got younger children then loads more people would do loads more work on a more regular basis and continuity could be restored. It's so easy, it's so basic. You would have to pay more because you're going to have to fund it, but ultimately it might be possible to actually reduce the number of different clinicians working within a practice, making continuity the norm rather than the exception. A recommendation to mandate continuity in a GP contract without addressing these other areas is, to be honest, just dumb.
Speaker 1:Okay, on to our first piece of research and paper. Number one is the Lancet methotrexate to treat hand osteoarthritis with synovitis, the method study theme for today's podcast good study acronyms. To be fair, this is probably something that works better if you could actually see it written down rather than me just saying it out loud. Anyway, we're looking at the method study Hand osteoarthritis. This is a miserable problem and a growing problem with an aging population, pain in the hand, restriction of activity. What can be done? Well, you can give people some hand exercises or some anti-inflammatory gel, but we know that for a lot of people this just doesn't cut it. So is there any other option that could be of use?
Speaker 1:A few years ago on the course, we were talking about prednisolone for osteoarthritis. So, particularly if someone had a flare, short courses of prednisolone may help settle down a flare. Everyone appreciates it's not a great option. It's for short term use, only in bad flares when everything else has failed. It's definitely not a long term treatment. But it did introduce the idea that there may be an inflammatory component to osteoarthritis. It could be amenable to anti-inflammatory agents, as the authors of this Lancet paper point out, hand osteoarthritis is a heterogeneous condition with multiple different phenotypes and one of those is inflammatory, which is characterized by synovitis. So you get swollen tender joints with it. Half of patients seen in the hospital with symptomatic hand o-way are found to have synovitis, so they've got inflammation. Well, perhaps methotrexate as an anti-inflammatory agent could be of use. Now there's already some data here.
Speaker 1:One randomized controlled trial failed to show benefit with this treatment. But it was an underpowered study Not very many participants and it didn't target specific phenotypes. Plus, it used a relatively low dose. So the authors were questioning whether, if they could target this population who do have synovitis, perhaps methotrexate could be shown to be of use. So this was a study conducted in Australia. It was a double blind, placebo, controlled, randomized controlled trial.
Speaker 1:The participants were patients were hand osteoarthritis and synovitis, aged 40 to 75. They had to have pain in their hand joints on most days for the last three months at least and at least a four out of 10 pain score over the last week. And then they had the condition confirmed by radiology and a radiologist and then they had the synovitis confirmed by an MRI scan. If you had existing inflammatory diseases or you couldn't take methotrexate, you were excluded. So the intervention was 20 milligrams per week of methotrexate for six months. They started on 10 for the first four weeks and then, assuming it was appropriate, they would be uptight, rated to the full dose. The comparator was placebo, so they had placebo tablets and both groups received five milligrams of Foley casted throughout the course of their treatment.
Speaker 1:The primary outcome was reduction in pain scores. Now they actually used a 10 centimeter, or rather 100 millimeter, pain scale to do this. I've just said it's zero out of 10 because it's the same thing, but it's important to note that the minimum clinically important difference is meant to be a 1.5 reduction. They also had secondary outcomes of changes in pain and function. They recruited 97 patients, so about 50 in each group. Average age 61,. 70% were females. They'd on average had an OA for seven years and already half of them were taking regular paracetamol or anti-inflammatories. Now I really wanted this to really work. I guess so did the authors of the paper. At six months, the methotrexate group had a 1.5 reduction on that zero to 10 pain scale. The placebo group had an almost 0.8 reduction in pain scores.
Speaker 1:Giving the mean between group difference as basically one point To give you some important context. The baseline pain score was six to six and a half. Does a 20 to 25% difference in your pain scores represent a clinically meaningful improvement? A little bit hard to know. I think the authors class this as a moderate effect. Remember, we talked about this before on the podcast. When authors say moderate, what they mean is pretty rubbish, but they're keen to not give up on the idea, saying that there is potentially clinically meaningful reductions in pain and stiffness.
Speaker 1:There are a few points to pick up here. When you're looking at mean results, that can sometimes hide the fact that a number of patients will have a really good result and some will have just no result or a bad result. The average then looks pretty ropey. Perhaps there's still merit for those individuals who genuinely do respond very well. They also note that the benefits in pain reduction with methotrexate were not really seen until at least three months and more prominent at six months. So perhaps this is a treatment that requires a longer duration, and the initial study was meant to be for two years, but they had to reduce it in time due to COVID. Would there be more marked divergence in the outcomes at two years? Well, for now we just can't know.
Speaker 1:And then, lastly, is about compliance. So three quarters of the patients took the meds for over 80% of the time. The authors didn't really seem to question this. This must be kind of the normal, but my impression in day to day practice is that people are generally pretty good at taking their methotrexate. I guess the difference here is, if you've got a group of people where it's not really working very well, you're not getting that positive reinforcement from beneficial effects, then perhaps it's understandable that compliance may drop. The authors conclude, then, that there was a moderately beneficial effect of methotrexate compared with placebo, on hand osteoarthritis with associated sinusitis, and that the findings were consistent with the biological plausibility of a clinical response. And they went on to question whether there could also be a role in slowing disease progression. That, of course, would be very welcome, but I'm sure lots of us would question whether methotrexate, despite the positive safety profile that they demonstrated in this paper, methotrexate for hand osteoarthritis do the ends justify the means?
Speaker 1:Okay, on to paper number two. This was published in the BMJ a couple of weeks ago and this was the treatment of LUTs in primary care using conservative intervention, a cluster randomised controlled trial. In fact, the authors use a slightly different title than the BMJ does, so they called it the treating urinary symptoms in men in primary health care, which gives the acronym triumph. So was this a triumph or not? The question they were posing here was can a standardised and manualised intervention improve lower urinary tract symptoms compared with usual care? And it took me a little while to work out what on earth they meant by manualised. Initially I thought maybe someone was actually getting their hand right up there and maybe giving that bladder a good squeeze. But no, they just mean giving people a manual. So a patient information leaflet.
Speaker 1:In the medical world, where a lot of research is dominated by drugs that we could use for a problem, it would be lovely if there was a non pharmacological, simple treatment that could actually help. So the population here was adult men with bothersome lower urinary tract symptoms recruited from UK general practice. They pragmatically included all men, including those who just had one symptom, which might even be something just like nocturia. The intervention was a patient information leaflet that was pulled together from various specialist urological sources and contained various conservative and lifestyle information. So things like what to drink and when, salt intake, bladder training, pelvic floor exercises, urethral bulb pressure for post void dribbling. The leaflet has lots of information in, but it's very clear, it's easy to understand. It's a really good leaflet actually and, even better, it's freely available. I'll put the link in the podcast description, but you can also download it in the data supplement section of this BMJ paper.
Speaker 1:Men didn't have to read all of this, but they were signposted to certain sections by practice nurses, healthcare assistants or research nurses who'd all had some training in how to use the book and how to signpost people to the most relevant sections. The comparator group was just usual care and clinicians were recommended to follow standard local management for LUTs. So they don't really expand on that because that could range from literally absolutely nothing. But it doesn't explicitly state in the paper whether those men could be started on medications. Some clarity on that would be really welcome and it feels like a bit of an omission.
Speaker 1:The outcome that they was looking for was change in the international prostate symptoms score. That's a very commonly used questionnaire exploring a range of lower urinary tract symptoms and is scored out of 0 to 35. A change in 3 is normally considered the minimum important difference In this paper. They argued that a change in two points might be appropriate because they'd included those men who only had one symptom. So in that group you're never going to get a very large difference in that score.
Speaker 1:Patients were followed up at one week and then at four and 12 weeks, either by telephone, email or text, and that was the end of the intervention. But then they also looked at the men's international prostate symptoms score at 12 months. Quite a large study, this. They recruited 1,077 patients who were randomized in a one-to-one basis to the intervention or usual care, and at 12 months the mean difference between the two groups was minus 1.8 in favor of the intervention arm. As the paper says, this indicates less severe urinary symptoms in that group than in the usual care group and that, usefully, this difference had been sustained nine months after the intervention had ceased.
Speaker 1:The way the results are reported, everything sounds quite positive. But the reality is and the Hawkeyes amongst you will have already realised that minus 1.8 is less than their predefined target reduction of two points, which in itself is already lower than what's considered generally to be the minimally clinically important difference. With that in mind, the final conclusions from the authors, where they say future research will be directed at integrating the triumphant intervention into general practice infrastructure, does seem a little bit out of kilter with their own demonstrated findings. Do we really want to integrate a product which works a little bit for some people but less than everyone hoped? I'm not so convinced. Having said that, I genuinely do think that, as a patient information leaflet, this booklet is very good, and if what they mean by integrating this is actually allowing us to print it out or text the link to a patient and then pointing out which parts they should read, well, that sounds pretty sensible and achievable. All of us are always on the lookout for good patient information resources that can help patients and speed up our consultations a little bit, even if the research suggests that all the other stuff they did with it doesn't add very much.
Speaker 1:Our third paper published in the Lancet three weeks ago, and this hit the headlines because it's dealing with a very common problem of irritable bowel syndrome and exploring a very common intervention amortryptoline. Today, I'm lucky enough to be joined by Professor Hazel Everett. She is a GP in Southampton and also the lead author of this paper. Maybe to kick off, hazel, could you just introduce yourself to the audience and explain a little bit about what you do?
Speaker 2:Yes, of course, I've been a GP for over 25 years. I've worked in the same practice for a very long time. I'm also a professor of primary care research. Here in Southampton I lead the primary care research centre. I also happen to be author of the Oxford Handbook of General Practice, so very embedded in general practice. I've been doing research in general practice for a very long time. The reason that I've got involved in IBS research is that I see patients with IBS and we struggle to treat them in general practice and that's really driven me thinking of these research questions and trying to answer them with doing high quality research.
Speaker 1:Okay, so you've got an interest in how we manage IBS. I know you've done various bits of research over the years on this. Why did you then want to undertake work on amortryptoline?
Speaker 2:Nice IBS guidelines say that GPs should consider prescribing amortryptoline for people who have IBS symptoms that aren't responding to first line treatments. When nice says consider, it means that it's potentially an option, but there really isn't enough research evidence. There's been some small trials done in secondary care settings where they think amortryptoline might be helpful and that people do get prescribed amortryptoline for IBS when they go to gastroenterology clinics, but really we don't use it much in primary care at the moment. It's odd because we use amortryptoline at low dose for other conditions like chronic pain, but actually we don't think about it very often for IBS. So the point of this trial was to try and make a proper, strong evidence base.
Speaker 1:Can you tell me a little bit about your research then? What did it involve? How did you conduct it? Who was it in?
Speaker 2:The theory behind amortryptoline at low dose for IBS is not using it as an antidepressant for its mood changing properties, but for its actions that we potentially think it has on the gut as a neuromodulator. So we're talking about 10 to 30 milligrams one to three tablets of amortryptoline to be used at NICE for people with IBS. This was funded by the National Institute of Health Research and was a big team effort between three centres across England. So the clinical trials unit in Leeds helped run the study with us in Southampton and with researchers in Bristol. It's a large randomized controlled trial, so people were randomized either having amortryptoline tablets or an identical placebo.
Speaker 2:Now we really wanted this research to be useful and generalizable to everyday general practice and us GP sitting there and our patients. So we tried to make the inclusion criteria as wide and broad as possible so that the results would be generalizable. So we included all adults with a GP diagnosis of IBS. They had to also meet some IBS criteria and they had to have ongoing troublesome symptoms despite having tried first line treatments such as dietary changes or antispasmodics, those type of things. And we kept exclusion criteria to an absolute minimum. If people met NICE criteria for two week wait referral for suspected cancer or had celiac disease or inflammatory bowel disease or had any contraindications to taking amortryptoline, such as allergy or breastfeeding or pregnancy, then they had to be excluded. But really we could include nearly everybody who was potentially on people's list with a diagnosis of IBS.
Speaker 1:So people were randomized then to either have amortryptoline or placebo. How did you manage the uptitation?
Speaker 2:They got given six months worth of amortryptoline but split into divided doses so they didn't get a great big pile of tablets all in one go.
Speaker 2:The most important thing for this trial is that we tried to mimic how we would try and use amortryptoline in real life general practice. So patients were supported to self-titrate their dose of amortryptoline. So they started with one tablet, 10 milligrams of either amortryptoline or placebo, and we carefully developed a patient dose titration document with the help of patient input so that people could be in charge and help empower them to manage their titration. So the plan was that they totrated up from one tablet for one week to potentially two tablets for the second week and three tablets for the third week. But they were using their symptoms and side effects to help determine whether they went up or down, just like we would in normal general practice somebody starting amortryptoline at low dose at night, and the dose titration document helped them manage that. They did have the ability to ring on research nurses for a bit of support if they needed, but actually it worked very well, helping them to self-titrate.
Speaker 1:I think a patient information leaflet for this sounds fantastic. I know that I am often trying to counsel patients on how to up-titrate medications, but I'm probably not that systematic. I'm trying to impart a lot of information. You never know how much people actually retain. This then takes the time and the stress out of that and I know that clinicians if they're interested in this document, it's available, isn't it? You've put it on the Atlantis trial website.
Speaker 2:That's right. We've made the document available. It's freely available to download from the Atlantis trial website. It's really important for patients to understand the rationale for using amitriptyline for IBS and we've pulled together with patient input, a very accessible rationale document as well.
Speaker 1:That also sounds like a very good idea. I'm sure a lot of people will be thinking why are they giving me an antidepressant for IBS? I don't feel depressed. I've got a problem with my stomach. Doctor.
Speaker 2:Yes, and it's interesting. We did a lot of qualitative work alongside this big randomized controlled trial. We interviewed 16 GPs and 24 patients twice during the length of this trial and it was. It was great because actually it showed that both GPs and patients felt that amitriptyline was on the whole acceptable to try for for IBS. And it was interesting because the familiarity of people, having heard about amitriptyline as a drug before having been around for a long time, had sort of post hindered and helped its use for IBS in that because of its potential association with depression, patients might be a little bit concerned, gps might be a little bit concerned, but actually because it was so well known and people have heard of their friends having been prescribed it for chronic pain and other and other conditions actually, and that was seen as beneficial and potentially some beneficial side effects, so people actually quite like the idea that it might potentially help them with their sleep as well as their IBS symptoms.
Speaker 1:Can you describe what the results were?
Speaker 2:Yes, of course. Well, this was a big trial. It's the largest trial of amitriptyline for IBS worldwide, and we undertook it during COVID, so it was amazing that we managed to recruit everybody and get a result from this trial. So we recruited 463 participants from 55 GP surgeries and a big shout out to all those surgeries that participated, because we can't do this sort of research in primary care without their help, and we found that there really was an improvement over placebo for amitriptyline. So a low dose amitriptyline can improve IBS symptoms across a broad range of patients that we see in primary care, and the great news was that it wasn't just our primary outcome measure, which was the IBS symptoms severity score, but also a whole raft of other questions that we asked patients.
Speaker 2:People found taking amitriptyline more acceptable than taking a placebo tablet over the length of the trial. The interesting thing is, though, that it isn't working through changing anxiety and depression. We didn't see big changes in anxiety and depression at this dose. We really do believe it's working on the gut as a neuromodulator. The other great news is that we didn't find any safety concerns during the trial. We looked and collected all data on side effects and safety concerns, and we did find that people who were taking the active amitriptyline had slightly more amitriptyine type related side effects, so more of them got a dry mouth. But actually, when you look at it, more people continued on their amitriptyline for the length of the trial than continued on placebo. About 20 percent of people discontinued the amitriptyline and about 13 percent of that was due to side effects, whereas actually 25 percent of people discontinued placebo and 9 percent of that was due to side effects. So we're not concerned that there's any major safety concerns and actually it was really quite well tolerated, with most side effects being mild in nature.
Speaker 1:Is there any concern about different subtypes of IBS, particularly thinking constipation, predominant IBS? When you're giving amitriptyline, which constipation is a recognized side effect from?
Speaker 2:Well, it is interesting, isn't it, that we wanted to make this research as generalizable as possible, so we included everybody with all subtypes of IBS. So we do have people with constipation predominant IBS involved in this trial and, although we're not powered to look closely at subtypes, we haven't seen any major problems. There wasn't major problems with people dropping out who come in with IBS with constipation, so we think it's probably, at this low dose, quite acceptable to prescribe amitriptyline to each subtype.
Speaker 1:Lots of us have become concerned about treatment burden and polypharmacy in recent years, and a few people listening to this might be thinking well, what about the anticholinergic burden linked with amitriptyline? Is this something we need to be worried about?
Speaker 2:A lot of people with IBS have lots of other chronic conditions as well. A lot of them have multimorbidity and we were really keen in this trial to make sure that people with a broad range of multimorbidities came into the study. So we're dealing with the same patients in this trial as we see in regular in general practice. Anticholinergic burden needs to be thought of along with all the other things we think of when we're prescribing new medicines for people. But the problem with the algorithms at the moment for anticholinergic burden is that they're a little bit crude and that probably you get your point for anticholinergic burden for amitriptyline when they're thinking of it as a high dose, the old 150 milligram dose that we used to prescribe for depression, whereas we think that probably prescribing it at a lower dose 10 to 30 milligrams for something like this has less of an issue.
Speaker 1:Okay. So I think the clinical implications from the research are fairly obvious, but where do you see amitriptyline then fitting into our general practice IBS management pathway?
Speaker 2:We know the irritable bowel syndrome is a chronic, long-term condition and lots of people have it for many years. The people that came into our trial had had their IBS diagnosis for over 10 years on average and had really quite severe ongoing symptoms still. And we know that that's the case in general practice because a lot of the first line treatments don't work very effectively. This was done in this trial for refractory symptoms and we're trying this as a second line treatment and I think that's a good place to try it. So we should be talking to people about the IBS, explaining it carefully to them and signposting them to information on what IBS is and then trying the first line treatments, such as diet and antisposmotics and things like that. But if we're then struggling to get an effect, then this would be a next line option. Interestingly, we were seeing continued improvement over the six months, so the results were improved at six months compared to three months. So it's worth giving it a reasonable length of time as a trial and people can titrate the dose up and down.
Speaker 1:It's interesting that you talk about duration, because we've talked a lot about low FODMAP diets on the Hot Topics course over the last decade or so. Really good research showing clear improvements for a substantial proportion of people if they can maintain a low FODMAP diet. But the limitations of those studies are that they tend to be quite short and I think most of them are around four weeks only. Maintaining a low FODMAP diet for four weeks may be quite achievable, but perhaps maintaining it for years would be much more difficult.
Speaker 2:That's right and that's the problem with a lot of the IBS trials over the years is that they're only for a short period of time and people need to live with this for a long period of time.
Speaker 2:We think that empowering patients to understand their illness and manage their illness makes a big difference in a whole load of chronic conditions and this is no different. And we do feel that developing this patient, those titration document for this trial really helped because it gave people power to be more in control of their illness and they could up and down their dose depending on whether their IBS was flowing. I have also done research on cognitive behavioural therapy for IBS and we showed that that was incredibly effective with a long-term outcome. So we had follow-up at 12 and 24 months. So that's another option for IBS. We have worked very hard to try and make that CBT available because when we started doing that trial it was almost impossible for me as a GP to refer anybody for CBT for IBS. But now we've managed to get access to CBT for IBS into the improving access to psychological therapy services the IAP services within the NHS.
Speaker 1:What next in research?
Speaker 2:here you do more work on ibs yes, we're working up some more ideas, is plenty more work to be done in ibs and we've got a team of us working to try and rationalize the guidelines. Maybe think about trying to get some of the Treatments that we know are effective for refractory or second line treatment where they're doing those earlier or better. So potentially cognitive behavioral therapy might be Effective much earlier in the disease process when people are diagnosed and potentially amynda triptlum too, could be used earlier rather than as a second line agent. The other thing that I'm really interested in is is good communication within the gp consultation. I've got a big trial going on at the moment about empathy and positive messages within the consultation To see whether actually we can harness the placebo effects and the good clinical skills that we have is gps to improve patient care and outcomes.
Speaker 1:I always love the idea that healthcare professionals, just by listening and being nice, can have such a huge difference On patients and their problems. So lots for me to link in the podcast description. I'll pop in the lancet paper for this atlantis trial. That's open access so everyone can have a good look at that. Also hazel's previous cbt trial. And then to the atlantis web page, to don't forget. There's lots and lots of useful resources on there, including information for clinicians and patients, stuff about tight trading, amynda triptling, which is really useful, and other aspects of self care. In the current gp Landscape where workload is ever increasing, actually self care's gotta be the way forward, right? It's good for us and it's really good for patients.
Speaker 2:Supporting patients to self manage their chronic conditions is so important. They spend a lot more time out there in the wild world than they do in with our gps surgeries. We really support working to try and improve self management for a whole range of conditions. Just to say to all the gps out there is that we can only do this sort of research and Change evidence based like this with support of amazing gps who help support these trials. So if you're at all interested in getting involved in research, please do Sign up and get involved. This is how we change practice and give you the evidence to help treat your patients and improve patient care.
Speaker 1:And if you're wondering how to get involved also in the podcast, description output links to the national institute for health and care research and the clinical research network, which allow you to find what's going on your local area and reach out to them if you're interested. Hazel, it's been fantastic to have you on the podcast. Thank you so much for talking to me today and I look forward to having you back on the podcast, maybe when you publish your next piece of major practice changing research really thank you very much.
Speaker 1:Well, I hope you found that interesting. I wonder if you're more likely to prescribe amitriptyling now that we've got data that shows it can be very helpful. Do let us know. Remember you can always get in touch, so email is hot topics at nbmedicalcom, or you can find us on twitter at gp hot topics and if you enjoy podcasts, maybe you should check out our nb hot topics takeouts on the mbmedicalcom website. So I've just finished recording this series. It's a podcast style of our hot topics course from autumn. Stay up to date whilst you are out, walking the dog, going for a run, driving home from work, and it's all included as part of nb plus. Thank you for joining us once again. We'll have one last podcast for 2023 just before Christmas. I hope that your patients bring you many boxes of biscuits and chocolates before that. See you soon, bye, bye.