Infective endocarditis (IE) is a severe bacterial infection of the endocardial surface of the heart; it usually involves damaged or synthetic heart valves. Improvement in surgical and medical therapeutics have been encouraging, however, if managed poorly it can still have a poor prognosis. In the developed world, rheumatic heart disease is an uncommon risk factor whereas intravenous drug use, degenerative valvular disease in the elderly population and use of prosthetic heart valves are becoming more common. In terms of the microbiological cause of IE, Staphylococcus aureus is the most common cause in the Western world. It is therefore important for GPs to be aware of and be able to identify these risk factors. This article aims to examine the pathophysiology, risk factors, changing trends in epidemiology and recent guidelines on the management of IE.

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Aim We aim to identify the diagnostic significance of ECGs and 24 h Holter monitoring in children with palpitations and chest pain. Methods We retrospectively analysed all children presenting with palpitations and chest pain to the emergency department and to out-patient clinics between 2008–2013. Data was collected through detailed review of case-notes. ECGs and Holter results were classified as abnormal if a significant cardiac arrhythmia was identified. Isolated ectopic beats (ventricular or supraventricular) were not considered as abnormal. Children with previously diagnosed heart conditions were excluded. Results Palpitation was the predominant symptom 71% (n = 42) with remainder 29%(n = 17) presenting with chest pain. 8% (n = 5) were infants, 46%(27) were aged between 4–12 years and 46% (n = 27) were over 12-years. 20% (n = 12) presented to the emergency department, whilst 80%(n = 47) were referred from the general practitioners. ECG was performed in 97% (n = 57) of cases during the initial assessment, of which 10% (n = 6) were noted to be abnormal. 86% (n = 49) of those who had ECGs underwent Holter monitor, of which, 18% (n = 9) were abnormal (the presenting history was palpitations in all these cases). ECG 24hrs Holter Sensitivity 28% 56% Specificity 97% 100% Positive predictive value 83% 100% Negative predictive value 74.5% 82.5% 43% (n = 18) of the children with palpitations were diagnosed with a significant cardiac arrhythmia (12 with SVT, 3 with WPW, 3 with heart block). 57%(n = 24) were non-significant sinus tachycardia. 88% (n = 15) of children with chest pain were diagnosed to have non-cardiac cause. However, 12% (n = 2) were closely monitored due to a strong family history of cardiac arrhythmia. Children with significant cardiac arrhythmias were referred to tertiary centre for further management. Conclusion Palpitations and chest pain are not uncommon symptoms of presentation in the paediatric age group. The study demonstrates that ECGs are less sensitive compared to the 24-hour Holter, but in combination they are useful non-invasive diagnostic tools. Chest pain in children is probably of little concern as compared to palpitations and further investigations should only be requested if clinically indicated.

BACKGROUND Digital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective. OBJECTIVE The aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending. METHODS A retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or “weight” the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20. RESULTS The NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was £1.6 billion and £1.65 billion (a currency exchange rate of £1=US $1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12%, 31%, and 54% (£93, <i>P</i>=.047; £223, <i>P</i>&lt;.001; and £389, <i>P</i>&lt;.001) lower than the regional average in FY18/19 for the 3 weighting methodologies used. In FY19/20, it was 15%, 35%, and 51% (£114, <i>P</i>=.006; £246, <i>P</i>&lt;.001; and £362, <i>P</i>&lt;.001) lower. This amounted to lower costs for the Babylon GP at Hand population of £1.37, £4.40 million, and £11.6 million, respectively, in FY18/19; and £3.26 million, £9.54 million, and £18.8 million, respectively, in FY19/20. CONCLUSIONS Patients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs.

Background Digital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective. Objective The aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending. Methods A retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or “weight” the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20. Results The NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was £1.6 billion and £1.65 billion (a currency exchange rate of £1=US $1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12%, 31%, and 54% (£93, P=.047; £223, P<.001; and £389, P<.001) lower than the regional average in FY18/19 for the 3 weighting methodologies used. In FY19/20, it was 15%, 35%, and 51% (£114, P=.006; £246, P<.001; and £362, P<.001) lower. This amounted to lower costs for the Babylon GP at Hand population of £1.37, £4.40 million, and £11.6 million, respectively, in FY18/19; and £3.26 million, £9.54 million, and £18.8 million, respectively, in FY19/20. Conclusions Patients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs.

Antimicrobial resistance is a local, national and global health priority. With the emergence of new infections as demonstrated by the COVID-19 pandemic, our ability to conserve the effectiveness of antimicrobials is crucial. Public Health England's (PHE) UK 20-year vision for antimicrobial stewardship states that one of the key objectives over the next 20 years is to demonstrate the optimal use of antimicrobials.A digital approach to the delivery of primary care services provides significant advantages regarding accessibility and patient satisfaction. This is beneficial for patients in obtaining medical care at the point of need. However, there are concerns that such accessibility may provide an opportunity for increased and inappropriate antimicrobial prescribing.As a digital GP practice with over 100,000 registered NHS patients and a multi-disciplinary workforce of approximately 300 clinicians comprising of General Practitioners (GPs), Prescribing Pharmacists (PPs) and Advanced Nurse Prescribers (ANPs), it is essential that appropriate systems and processes are in place to support good antimicrobial stewardship.Monitoring of prescribing is a significant aspect of antimicrobial stewardship. At Babylon, we review our antibiotic prescribing across our private and NHS services in the UK. The results from monthly broad-spectrum antibiotic prescribing audits between April 2020 -October 2020 showed an average appropriate prescribing rate of 76.4%. It was identified that further improvements could be made by incorporating regular feedback to prescribers as part of the interventions used to support prescribing. A quality improvement study was undertaken to review the impact of prescriber feedback on appropriate prescribing of broad-spectrum antibiotics and audit results observed within the practice.