Patients with paroxysmal AF at risk of stroke are undertreated

23 Oct 2017Registered users

Patients with paroxysmal atrial fibrillation (AF) eligible for anticoagulation are still less likely to receive anticoagulants than those with persistent or permanent AF, a UK study has found. Both national and European guidelines recommend that anticoagulants are offered to all patients with AF at increased risk of stroke, irrespective of the type of AF. Even in 2015 patients with paroxysmal AF eligible for anticoagulation were still almost 20% less likely to have these drugs prescribed than those patients with persistent or permanent AF.

Does metformin lower CVD risk in type 2 diabetes?

28 Sep 2017Registered users

A recent meta-analysis to evaluate the impact of metformin on cardiovascular disease has been unable to demonstrate convincingly that it is associated with a reduction of risk. The investigators searched Medline, Embase and the Cochrane Library for relevant papers in all languages.  The final yield was ten articles, reporting 13 trials of metformin, virtually all carried out in Northern Europe or North America. In total, 2,079 patients with type 2 diabetes were allocated to metformin and a similar number to comparison groups. All the outcomes, with the exception of stroke, favoured metformin but none achieved statistical significance.

PPIs with aspirin in older patients lowers risk of major bleeds

28 Jul 2017Registered users

A UK prospective population-based cohort study assessed the risk, time course, and outcomes of bleeding on antiplatelet treatment for the secondary prevention of cardiovascular disease in patients of all ages. The authors concluded that in secondary prevention with aspirin-based antiplatelet treatment without routine PPI use, the long-term risk of bleeding at age 75 years or older is higher and more sustained than in the younger age groups included in previous trials, with particularly high risks of disabling or fatal upper GI bleeding. 'Given that half of the major bleeds in patients aged 75 years or older were upper GI, the estimated NNT for routine PPI use to prevent major upper GI bleed is low and co-prescription should be considered in future secondary prevention guidelines,' they say.

Cognitive deficits and awareness of hypoglycaemia in type 1 diabetes

22 Jun 2017Registered users

A study of patients with type 1 diabetes has shown an association between impaired awareness of hypoglycaemia and cognitive deficits such as diminished learning, memory and pattern separation. This study compared cognitive function in type 1 diabetes patients who had normal awareness of hypoglycaemia with patients who had impaired awareness of hypoglycaemia. The study authors state: ‘It is possible that people with impaired awareness of hypoglycaemia have a diminished ability to distinguish cues that are specifically associated with hypoglycaemia and hence are unable to take appropriate action to avoid severe hypoglycaemia.'

Job strain may precipitate clinical depression

23 May 2017Registered users

Job strain, a combination of high demand and low control, is associated with an increased risk of subsequent clinical depression, a meta-analysis has found. Patients who report stress at work are both more likely to be depressed and more likely to become depressed. In the UK in 2015/16, work-related stress accounted for 37% of work-related ill health and 45% of working days lost. When helping patients get back to work it is important to discuss ways of reducing job strain and the demand control support model provides a helpful framework.

Practice nurses can improve insulin uptake in type 2 diabetes

24 Apr 2017Registered users

Achieving and maintaining glycaemic targets early on in type 2 diabetes has been shown to improve long-term outcomes. Delay in stepping up treatment, especially initiating insulin therapy is known to be a problem in primary care. A primary care study from Australia, in which practice nurses were trained to have an enhanced role, has shown improved rates of safe and effective insulin initiation compared with usual care.

Depression in adults linked to maltreatment in childhood

22 Mar 2017Registered users

Almost one in two depressed adult patients report maltreatment in childhood and are at increased risk of early onset, chronic or treatment-resistant depression, a meta-analysis has found. Maltreated individuals were between 2.45 times (childhood physical neglect) and 3.73 times (childhood emotional abuse) more likely than those who had not been maltreated to become depressed as adults. Childhood emotional abuse and neglect were most strongly associated with both risk of depression and depression severity.

MP-MRI could improve the diagnosis of prostate cancer

22 Feb 2017Paid-up subscribers

Multi-parametric magnetic resonance imaging (MP-MRI) could play an important role in triaging men with a raised PSA for prostate biopsy and improve the detection of clinically significant prostate cancer, findings from a UK study suggest.

Risk of acute STEMI significantly increased in younger smokers

23 Jan 2017Registered users

Smoking is associated with an eight-fold increased risk of acute ST-segment elevation myocardial infarction (STEMI) in those under 50 compared with former and never smokers, a UK study has found. However, the incidence of acute STEMI in former smokers was similar to that in those who had never smoked, adding further evidence to the benefits of quitting smoking.

Does testosterone therapy raise the risk of VTE?

16 Dec 2016Registered users

The evidence remains inconclusive as to whether testosterone increases the risk of VTE significantly. However, it would appear sensible, if initiating testosterone replacement, particularly in those with a past history of VTE or other significant risk factors, to mention the concern over this, and advise early reporting of any potential symptoms of VTE.

Take-home naloxone provision cuts opioid overdose deaths

23 Nov 2016Paid-up subscribers

Take-home naloxone programmes significantly reduce fatal outcomes of opioid overdose, a systematic review has found. In these programmes illicit opioid injectors, their peers, friends, relatives and carers are provided with overdose management training together with naloxone kits for emergency injection if someone they are with is suspected of having symptoms of opioid overdose, with a view to preventing death.

Active monitoring vs treatment for localised prostate cancer

24 Oct 2016

No significant difference in prostate cancer mortality was seen in men with localised prostate cancer who underwent active monitoring compared with surgery or radiotherapy at ten years’ follow-up in ProtecT, a large UK trial. However, both surgery and radiotherapy were associated with lower rates of metastasis and disease progression. ProtecT seems to support the use of active monitoring/surveillance in low-risk patients, but this does not mean that it is a sensible option for all men newly diagnosed with prostate cancer. Most men in ProtecT had low Gleason grade, low-risk disease and the findings must not be used to push men with more aggressive disease away from active treatment.

Abrupt smoking cessation more effective than cutting down

23 Sep 2016Paid-up subscribers

A large UK trial found clear evidence that quitting smoking abruptly was superior in both the short- and longer-term to gradual cessation. The researchers concluded that in clinical practice patients should be encouraged to stop smoking abruptly and not gradually. 

Chlamydia infection raises long-term risk of reproductive complications

01 Aug 2016Paid-up subscribers

Infection with chlamydia increases the risk of pelvic inflammatory disease (PID), ectopic pregnancy and tubal factor infertility by at least 30%, a nationwide study from Denmark has shown. The risk persisted throughout the 17 years of follow-up. Following a second infection the risk of PID was increased by a further 20%. Adjusted hazard ratio for each reproductive complication was 31-50% higher in women who tested positive for chlamydia compared with women who tested negative.

Does early introduction of foods protect against allergy?

23 Jun 2016Registered users

A UK study, published in the New England Journal of Medicine, set out to investigate whether introduction of six common dietary allergens from three months of age would prevent food allergies in breast-fed infants in the general population.

Antidepressants and cardiovascular risk

23 May 2016Registered users

Selective serotonin reuptake inhibitors (SSRIs) are not associated with an increased risk of cardiovascular events in younger adults with depression, a large UK cohort study has found. Compared with periods of no antidepressant treatment, periods of SSRI treatment were not associated with an increased risk of arrhythmia, stroke or TIA.

Sedentary behaviour associated with type 2 diabetes

25 Apr 2016Registered users

The findings of a large prospective cohort study suggest that sedentary behaviour increases the risk of developing metabolic syndrome and type 2 diabetes. When the data were analysed, increased sedentary time was associated with both metabolic syndrome and type 2 diabetes. An extra hour of sedentary time was associated with 22% increased odds of type 2 diabetes and 39% increased odds of metabolic syndrome, independent of high-intensity physical activity.

Women with bipolar disorder at high risk of relapse after childbirth

21 Mar 2016Registered users

One in three women with a previous diagnosis of bipolar disorder or postpartum psychosis will relapse during the postpartum period, a meta-analysis has found. Women with bipolar disorder or previous postpartum psychosis should be referred for specialist preconception advice.

Pill use before or during pregnancy does not raise risk of birth defects

22 Feb 2016Registered users

A study, using data from the Danish Medical Birth Register, confirms that oral contraceptive use does not significantly increase the risk of birth defects, whether just before or after the onset of pregnancy. The exposure to exogenous oestrogens is therefore unlikely to cause major birth defects in the developing fetus.

Active and passive smoking linked to infertility and early menopause

25 Jan 2016Registered users

Exposure to tobacco smoke through passive as well as active smoking is associated with an increased risk of infertility and menopause occurring before the age of 50, a large observational study has shown. This is the first study to assess the impact of second-hand smoking on infertility and age of menopause.

Sedentary behaviour is bad for your mental health

22 Dec 2015Registered users

The Christmas holidays are a time for sitting by an open fire to read or watch television. However, before we curl up with a good book we should consider the results of a recent crossover study which suggest that sitting down has a detrimental effect on our mental health.

How should GPs test for dementia?

25 Nov 2015Registered users

Most of the alternative dementia screening tests perform as well as the Mini-Mental State Examination (MMSE), a systematic review and meta-analysis has found. The Mini-Cog and Addenbrooke’s Cognitive Examination-Revised (ACE-R) were the most accurate tests with performances comparable with the MMSE.

Be vigilant for neonatal abstinence syndrome

21 Oct 2015Registered users

A large population-based study, involving 290,605 pregnant women, identified 1,705 cases of neonatal abstinence syndrome for women who had filled an opioid prescription while pregnant, representing an absolute risk of 5.9 cases per 1,000 deliveries. The risk was greater for long-term prescription opioid users. The majority (88%) took them short term. Babies of women who used prescription opioids during the last trimester had a significantly higher incidence of neonatal abstinence syndrome compared with those who used them in the first two trimesters only.

Androgen deprivation therapy and cardiovascular risk

24 Sep 2015Registered users

An awareness of CVD risk allows GPs to look proactively at modifiable risk factors in these men, to encourage smoking cessation, weight loss and increased exercise – all of which have been independently associated with improved prostate cancer outcomes in their own right – and to consider medical treatment for risk factors such as dyslipidaemia.

Bullying in adolescence linked to depression in young adults

05 Aug 2015Registered users

Children who are frequently bullied during adolescence are more than twice as likely to experience depression as young adults, a UK prospective cohort study has found.

Medical therapy ineffective for aiding passage of ureteric stones

22 Jun 2015Registered users

The findings from this large, well designed randomised controlled trial which showed no benefit for medical expulsive therapy in expectant management, together with the fact that both alpha-blockers and calcium channel blockers have a significant side-effect profile, make a case for changing clinical practice.

Risks vs benefits of paracetamol

21 May 2015Registered users

The safety of long-term paracetamol use has been called into question in a recent systematic review. However, until large scale well conducted trials of specific patient populations are available, the advice for the prescription of paracetamol should remain unchanged. The balance of risk and benefit to the individual patient has to be considered, and the subsequent efficacy and tolerability reviewed against the alternatives available.

Smoking-related deaths linked to a wider range of diseases

23 Apr 2015Registered users

Taking data from five large US cohort studies, the authors of this present study posed the question: ‘Do current official estimates underestimate the deaths caused by smoking?' Overall, the excess mortality for smokers within the study population was 2.8 times that of never smokers and 17% of excess mortality was related to diseases not formally associated with smoking.

Peanut allergy – is it time to change infant feeding practice?

23 Mar 2015Registered users

Early introduction of peanut into the diet of high-risk babies significantly decreases the frequency of peanut allergy at five years of age, a UK open label single-centre study has found. The present study was well designed and showed a strong effect in its primary outcome. The question many will ask is can these findings now be translated into advice for our patients? The answer is no.

Antipsychotics still prescribed inappropriately in primary care

23 Feb 2015Registered users

Less than half the patients prescribed antipsychotics have a diagnosis of severe mental illness, a UK primary care study has found. For patients without severe mental illness, the most commonly recorded mental health diagnoses were anxiety, depression, dementia, sleep disorder and personality disorder. Around 1 in 10 patients had no recorded mental health diagnosis.

DRE has vital role in early detection of prostate cancer

22 Jan 2015Registered users

Digital rectal examination is important, not just for reducing concern in men with urinary symptoms, large prostates and borderline PSA levels, but also because it is recognised that a significant number of men have clinically significant prostate cancer despite a normal PSA. [With external links to the evidence base]

Obesity, metformin and prostate cancer risk

15 Dec 2014Registered users

A total of 104 global studies were reviewed, examining nearly 10 million (9,855,000) men and 191,000 cases of prostate cancer. The analysis concluded that being overweight or obese significantly increases the risk of advanced prostate cancer. The link between obesity and advanced prostate cancer is important for primary care. In order to maximise the benefit from PSA testing of asymptomatic men, we should be trying to target higher-risk men and should now think of adding obesity to that list. [With external links to the evidence base]

Second-hand smoke in the home more harmful than air pollution

24 Nov 2014Registered users

Pollution caused by fine particulate matter (PM2.5) is around ten times higher in homes where people smoke indoors compared with non-smoking homes, a study from Scotland has found. Furthermore, home air pollution from smoking appears to dwarf that from outdoor sources. Approximately 20% of those living in smoking homes in Scotland will inhale a lifetime mass of PM2.5 greater than the median value predicted for a non-smoker living in a heavily polluted urban setting.

Collaborative care effective in cancer patients with depression

23 Oct 2014Registered users

Integrated collaborative care substantially improves outcomes for cancer patients with major depression, a UK study has found. GPs have an important role in recognising depression in cancer patients and should bear in mind the high prevalence of depression when carrying out QOF cancer reviews. This study suggests that treatment is unlikely to be effective unless it incorporates some form of enhanced care. GPs may not have access to collaborative care but can provide case management and liaise with local oncology teams.

Identifying at-risk drinkers in primary care

23 Sep 2014Registered users

It has been estimated that around 20% of patients attending their GP are at risk from their drinking or have an alcohol use disorder. Without using specific screening tools GPs may typically detect about 40% of cases they see, but miss the majority. The study authors suggest a single or two question approach to initial screening, followed by either the CAGE or AUDIT test for those who are positive, and onward referral for those who test positive on the more in-depth questionnaire.

Urgency urinary incontinence the most bothersome LUTS

25 Jul 2014Registered users

This study, from Finland, compared the impact of different lower urinary tract symptoms (LUTS). A total of 3,727 individuals took part, just over half were women. On an individual level, urgency urinary incontinence was the most likely symptom to be rated as bothersome by both men and women, with 30.7% reporting at least moderate bother. It is not the presence of symptoms but the bother they cause the patient that is vital to understand when assessing and managing LUTS. Storage symptoms, particularly urgency and urgency urinary incontinence, are the most likely to cause significant impairment of quality of life. [With external links to the current evidence base]

Women with diabetes at greater risk of CHD than men

23 Jun 2014Registered users

A recent large meta-analysis has confirmed that women with diabetes have more than a 40% higher risk of incident coronary heart disease (CHD) than men. For GPs this is a timely reminder to consider CHD as a high risk in women with diabetes, and to treat risk factors vigorously. This is especially important because routine screening in the healthy population accustoms us to women being generally at lower risk than men using the current CHD risk tools.

Weighing up the risks and benefits of androgen deprivation therapy

22 May 2014Registered users

The cardiovascular risks of androgen deprivation therapy (ADT) mean that a definite decision should be made regarding risk versus benefit for all men receiving this treatment. For men with high-risk prostate cancer, however, the oncological benefits of ADT are likely to outweigh the cardiovascular risks. Men receiving ADT should be 'medically optimised' in terms of cardiovascular risk and advice from their GP on exercise and diet is essential. [With external links to the current evidence base]

HPV vaccination uptake lowest in young women at greatest risk

22 Apr 2014Registered users

Teenage girls most at risk of cervical cancer are least likely to be offered HPV vaccination and, those who are, less likely to complete the course, a cross-sectional study of sexual health service users has found. [With external links to current evidence and summaries]

Smoking cessation improves anxiety and depression

20 Mar 2014Paid-up subscribers

Smokers with a history of anxiety, mood or alcohol use disorders are significantly more likely to be in remission three years later if they quit smoking, an American study has found. Smoking cessation may increase the likelihood of remission, but equally, those who recover may find it easier to quit smoking.

Identifying which patients are at risk of suicide

24 Feb 2014Registered users

Item 9 of the PHQ-9 can be used to identify patients with suicidal thoughts who are at increased risk of suicide. However, this is just one component of the comprehensive and ongoing risk assessment that should be made for all patients with major depression.

The prostatic urethral lift: a new treatment for LUTS

22 Jan 2014Registered users

The search continues for treatments for lower urinary tract symptoms (LUTS) to match the long-term effectiveness of surgical intervention but without the peri- and post-operative complications associated with these procedures. The first multicentre, blinded, randomised controlled study of the prostatic urethral lift has shown promising results.  [With external links to the current evidence base]

Weighing up the risks and benefits of smoking cessation therapies

05 Dec 2013Paid-up subscribers

A prospective cohort study from the UK has found no evidence that varenicline or bupropion raise the risk of depression, self harm or suicide.

Are 5-ARIs suitable for prevention of prostate cancer?

23 Oct 2013Registered users

As with the original Prostate Cancer Prevention Trial, the use of a 5-ARI, in this case finasteride, was seen to reduce the incidence of prostate cancer by about a third. Although high-grade cancer was more common in the 5-ARI group, after 18 years of follow-up there was no significant difference in rates of prostate cancer specific survival or overall survival between the two groups. Prescription of finasteride or dutasteride as a chemopreventive agent against prostate cancer cannot be justified on the available evidence. [With external links to current evidence and summaries]

PSA in men in their 40s predicts risk of prostate cancer death

23 Sep 2013Registered users

For many men, three lifetime PSA tests (mid to late 40s, early 50s and at age 60 years) would be sufficient screening to identify the small number of men developing clinically significant prostate cancer, allowing resources to be concentrated on those at higher risk, a study in the BMJ concludes. The European Association of Urology recommends that all men aged 40-45 years should be offered a baseline PSA to ‘initiate a risk-adapted follow-up approach with the purpose of reducing prostate cancer mortality and the incidence of advanced and metastatic cancer’.

Can radical lifestyle changes in diabetes improve CV outcomes?

25 Jul 2013Paid-up subscribers

A major trial to determine whether intensive lifestyle intervention would reduce cardiovascular (CV) morbidity and mortality in type 2 diabetes patients has been stopped early because of failure to show benefit in the intervention group. Nevertheless, clinicians may confidently advise patients that improvements in diet and activity will reduce weight, the need for medications and the incidence of sleep apnoea and will improve wellbeing.