Open toe sandals syndromeBMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6496 (Published 15 December 2016) Cite this as: BMJ 2016;355:i6496
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Borman and Johnson describe seasonal variation in GP requests for analysis on dermatophyte samples in the South West of England, peaking in July; and then argue that this may reflect the presence of “Open Toe Sandals Syndrome” (OTSS) in the UK. Data from our team’s explorer for NHS primary care prescribing data at OpenPrescribing.net shows a similar seasonal variation in prescribing of the most common treatments for tinea unguium (oral terbinafine and amorolfine nail laquer) with more in summer months.
In the same data we can also see a signal suggestive of guideline breaches. The national prescribing data shows a peak in July, and then a reduction in total prescriptions from August onwards; but the BNF states that treatment should last for three months for oral terbinafine and 9-12 months for amorolfine nail lacquer. To check whether long prescriptions were being given in summer, we have run a bespoke analysis on the underlying data, and found that the typical prescription duration is approximately 6 weeks: the mean number of tablets per terbinafine prescription was 41.1; while the mean number of “one month” amorolfine lacquer bottles per prescription was 1.24. Given this need for repeat prescriptions, one would expect the summer peak in diagnosis to give a peak in prescriptions that persists much later into the year. It is therefore likely that the management of many patients breaches the BNF guidance on duration of treatment.
We believe that this is a useful illustration of the value of prescribing data for monitoring variation in care; and we hope the BMJ will smile on the many papers we are submitting to them on this topic.
1 Borman AM, Johnson EM. Open toe sandals syndrome. BMJ 2016;355:i6496.
2 High-level prescribing trends for Terbinafine Hydrochloride (BNF code 0502050C0). OpenPrescribing.net. https://openprescribing.net/chemical/0502050C0/ (accessed 21 Dec 2016).
3 High-level prescribing trends for Amorolfine Hydrochloride (BNF code 1310020A0). OpenPrescribing.net. https://openprescribing.net/chemical/1310020A0/ (accessed 21 Dec 2016).
4 Joint Formulary Committee. British National Formulary. https://www.evidence.nhs.uk/formulary/bnf/current/ (accessed 21 Dec 2016).
Competing interests: RC is employed by a CCG to optimise prescribing, and has received income as a paid member of advisory boards for Galen Pharmaceuticals Ltd, Martindale Pharma, Galderma (UK) Ltd, ProStraken Group PLC, Menarini Farmaceutica Internazionale SRL and Stirling Anglian Pharmaceuticals Ltd. BG has produced free open websites offering insights into NHS prescribing data. BG receives income from speaking and writing for lay audiences on problems in science and medicine, including financial conflict of interest, but not dispensing practices or prescribing data. BG has received funding from West of England Academic Health Sciences Network for work on UK prescribing data. BG has received funding from the Health Foundation, NHS England, and NIHR for work on prescribing data, RC is employed partly on these grants. BG has received funding from the Wellcome Trust and the Laura and John Arnold Foundation to work on better use of data in medicine. BG and RC have all been employed by the NHS for a large part of their career.
Although it may be true that toe nail dystrophy sometimes accounts for the mistaken presumptive diagnosis of tinea ungium(1) it is important to emphasise that it is ethically indefensible to commence antifungal treatment without validating the diagnosis of tinea ungium by mycological analysis of toe nail clipping, given the fact that antifungal treatment is expensive and, in some instances, also fraught with the risk of liver damage. By the same token, in the event that empiric antifungal treatment may, in some cases, be inappropriate, it is a false economy to bypass the mycology lab in the beleif that one will, thereby, be saving the NHS money.. An analogous scenario occurs in the management of hypertension. In the light of the recognition that blood pressure readings using the technique recommended by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure(JNC7) are significantly lower than usual care(-12.4 mm Hg systolic and -6.0 mm Hg diastolic; p <0 001, respectively)(2), it is a false economy not to invest sufficient time in the correct measurement of blood pressure(BP) either in primary care or in secondary care. Indeed, "waiting a few extra minutes before measuring blood pressure has potentially important clinical......ramifications"(3). In fact, the most decisive strategy might be an investment in nurse practitioners specially trained to take time in the correct measurement of blood pressure, given the fact that nurse recorded blood pressure(using a strict protocol) is as efficacious as ambulatory blood pressure in predicting target organ changes (4). In that study blood pressure was recorded after a minimum of 5 minutes rest(as in the JNC 7 protocol), in a quiet room, and multiple blood pressure readings were taken(4).. In the era of automated oscillometric BP measurements the gold standard for multiple blood pressure readings is the average of three readings taken at one minute intervals. This has been found to be significantly closer to the awake ambulatory BP than the 10-second interval readings(5). The ideal, therefor, should be the average of three BP readings(at 1 minute intervals), in a quiet room, after a minimum of 5 minutes rest. If those conditions cannot be met in the doctor's consulting room, BP measurement should be performed by a specially trained nurse practitioner in the quiet environment of her own consulting room. To embark on antihypertensive medication(and its titration) without meeting those conditions would be ethically indefensible., and would ultimately not be a cost saving. When titrating antihypertensive therapy, It is also a false economy not to invest in ambulatory blood pressure monitoring, given the fact that . in the presence of masked hypertension, "office" blood pressure readings within the normal range may be falsely reassuring(6).These are examples where misguided cost saving proves either to be ethically indefensible or , ultimately, counterproductive.
(1)Borman A and Johnson E
Open toe sandals syndrome
(2) Burgess SE., MacLaughlin EJ., Smith PA., Salcido A., Benton TJ
Blood pressure rising: differences between current clinical and recommended measurement techniques
Journal of the American Society of Hypertension 2011;5:484-488
(3) Nikolic SB., Abhayaratna WP., Leano R., Stowasser M., Sharman JE
Waiting a few extra minutes before measuring blood pressure has potentially important clinical and research ramifications
J Human Hypertension 2014;28:56-61
(4)Woodwiss AJ., Molebatsi N., Maseko MJ et al
Nurse-recorded auscultatory blood pressure at a single visit predicts target organ changes as well as ambulatory blood pressure
Journal of Hypertension 2009:27;287-297
(5) Eguchi K., Kuruvilla S., Ogedegbe W et al
What is the optimal interval between successive home blood pressure readings using an automated oscillometric device
Journal of Hypertension 2009;27:1172-1177
(6)O'Brien E., Parati G., Stergiou G
European Society of Hypertension Position Paper on ambulatory blood pressure monitoring
J Hypertension 2013;31:1731-1768
Competing interests: No competing interests