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On The Pulse - July 2018

On The Pulse

Tertius Lydgate

Friday, 27 July 2018

Clinical features of testicular cancer
As the incidence of testicular cancer is rising, a study in the BJGP set out to identify clinical features of testicular cancer and to quantify their risk in primary care patients, with the aim of improving the selection of patients for investigation. 1,398 cases were available, with 4,956 age-, sex-, and practice-matched controls. Nine features were independently associated with testicular cancer, the top three being testicular swelling (OR 280, 95% CI=110 to 690), testicular lump (OR 270, 95% CI = 100 to 740), and scrotal swelling (OR 170, 95% CI = 35 to 800). The highest positive predictive values (PPV) for 17–49-year-olds was testicular lump, at 2.5% (95% CI = 1.1 to 5.6). Combining testicular lump with testicular swelling or testicular pain produced PPVs of 17% and 10%, respectively. The authors conclude that testicular enlargement carries a risk of cancer of 2.5% — close to the current 3% threshold in UK referral guidance. Contrary to traditional teaching, painful testicular enlargement may signify cancer. Some initial hydrocele diagnoses appear to be wrong, with missed cancers, suggesting an ultrasound may be useful when a hydrocele diagnosis is uncertain.

3D intervention in the management of multimorbidity
While there is an international consensus that care for multimorbidity should be patient-centred, there is little evidence that the so-called 3D approach (based on dimensions of health, depression, and drugs) improves the health-related quality of life of those patients. Researchers, writing in the Lancet, recruited 1,546 patients from 33 general practices in England and Scotland and randomly assigned them to receive either usual care (n=749) or six-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (n=797). The intention-to-treat analysis showed there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI −0·02 to 0·02;). The authors believe their trial is the largest investigation of the international consensus about optimal management of multimorbidity, and conclude that the 3D intervention did not improve patients' quality of life.

Gluten-free diet for chronic diarrhoea in CVID
Common variable immunodeficiency (CVID) is a primary immunodeficiency with reduced levels of immunoglobulins associated with a reduced antibody response. The most common presentation of this disease is recurrent infections and gastrointestinal disorders are frequent with chronic diarrhoea occurring in 20%–60% of patients. Clinical symptoms and histological alterations in CIVD can resemble celiac disease. But usually, patients with chronic diarrhoea associated with CVID do not improve with a gluten-free diet. However, authors writing in BMJ Case Reports present the case of a male patient who was diagnosed with CVID at age 33 and had chronic diarrhoea which resolved after initiating a gluten-free diet, despite the fact that coeliac disease markers were negative. Clinical relapse occurred after gluten reintroduction. With this case, the authors highlight that chronic refractory diarrhoea in patients with CVID can be associated to non-celiac gluten sensitivity and that significant improvement can be observed by implementing a gluten-free diet in patients with CVID.

Pharmacist-led hypertension interventions
Pharmacists can play a great role in taking some of the pressure off GPs, and the move earlier this year to increase the number of surgery-based pharmacists was welcome. Hypertension is one area that is a particular burden for primary care and researchers writing in the BJGP looked at the value of pharmacist management by identifying factors associated with referral of patients from pharmacies to general practice. Analyses were conducted on 131,419 patients (mean age: 65 years; 85% of white ethnicity). A total of 5,895 (4.5%) patients were referred by a pharmacist to a GP within the first two weeks of starting a new antihypertensive medication. Patients reporting side effects (adjusted OR 11.60, 95% CI=10.85 to 12.41) were most likely to be referred. Prescriptions for alpha-blockers were associated with referral (adjusted OR 1.28, 95% CI = 1.12 to 1.47), whereas patients receiving angiotensin-II receptor blockers were less likely to be referred (adjusted OR 0.89, 95% CI = 0.80 to 0.99). The authors conclude that the results are reassuring, in that additional pharmacist involvement does not increase medical workload appreciably, and support further development of pharmacist-led hypertension interventions.

Heart failure in a biological parent
Heart failure (HF) is a major global health burden with an associated severe prognosis. Risks factors include hypertension, coronary heart disease, diabetes, obesity, and valvular heart disease. As it also aggregates in families, a case-control study and cohort study in JAMA set out to determine the heritability of HF. A Swedish study involving 21,643 adoptees (49.1% female), as well as 35,016 adoptive parents and 43,286 biological parents, showed that adoptees had an increased risk of heart failure (OR 1.45 [95% CI, 1.04-2.03]) if they had a biological parent with the condition, whereas an affected adoptive parent conferred no such risk. Heritability (h2) of heart failure per Falconer regression was 26%; and if cardiomyopathies were excluded, heritability was 34%. The increased heritability of HF therefore suggests that genetic factors are important in HF pathogenesis and the authors suggest a genetic susceptibility should be considered in clinical practice and should motivate further genetic studies.

Risks and benefits of DOACs versus warfarin
As oral anticoagulants (DOACs) have gradually replaced warfarin in the last eight years, research in The BMJ investigated their safety profile. The prospective open cohort study involved 132,231 warfarin, 7,744 dabigatran, 37,863 rivaroxaban, and 18,223 apixaban users without anticoagulant prescriptions for 12 months before study entry, subgrouped into 103,270 patients with atrial fibrillation and 92,791 without atrial fibrillation (AF). The results showed that, compared to warfarin: apixaban was associated with a decreased risk of major bleeding events in patients with and without AF (adjusted HR 0.66, 95% CI 0.54 to 0.79 and 0.60, 0.46 to 0.79, respectively), particularly for intracranial and gastrointestinal bleeds; rivaroxaban was associated with a decreased risk of intracranial bleeds in patients without AF (0.54, 0.35 to 0.82); rivaroxaban and low dose apixaban were associated with an increased risk of all-cause mortality in patients with and without AF.

Polypill-based care
The 2016 European Society of Cardiology (ESC) guideline on the prevention of cardiovascular disease (CVD) set targets for blood pressure (BP), low-density lipoprotein (LDL) cholesterol and antiplatelet therapy. A meta-analysis of three randomised clinical trials in Heart suggests that polypill-based therapy (a polypill containing aspirin, statin and antihypertensive therapy) can significantly improve the achievement of all three ESC targets. Out of the 3,140 patients included in the trials, those randomised to polypill-based care were more likely than those receiving usual care to achieve recommended targets for BP (62% vs 58%), LDL (39% vs 34%) and all three targets for BP, LDL and adherence to antiplatelet therapy simultaneously (24% vs 19%) at 12 months. There was no difference between groups in antiplatelet adherence (96% vs 96%). Treatment effects increased with the fewer the number of treatments being taken at baseline: for patients taking 3, 2 and 0–1 treatment modalities the risk ratios for reaching all three guideline goals simultaneously were 1.10 (22% vs 20%), 1.62 (27% vs 17%) and 3.07 (35% vs 11%), respectively.

The cost of air pollution to the NHS
Air pollution is the leading environmental cause of early death - contributing to the equivalent of 5% of all deaths globally and an estimated 40,000 premature deaths each year in the UK. The authors of a study in PLOS Medicine used a dynamic microsimulation model to predict the future health and economic impact of the air pollutants PM2.5 and NO2 to the year 2035. This microsimulation examined data on air pollution exposure by age and sex, making use of disease and population data collected from the literature and from publicly available databases. The results showed that between 2017 and 2025, the total cost to the NHS and social care of air pollution for diseases for which there is more robust evidence for an association is estimated to be £5.56bn, corresponding to 1.15m new cases of disease. Approximately 2.5m cases of non-communicable diseases attributable to air pollution are predicted by 2035 if PM2.5 and NO2 stay at current levels, making air pollution an important public health priority, particularly as the UK Government is due to publish a final clean air strategy by the end of the year.

Author's Image

Tertius Lydgate

Originally from Northumberland, Tertius Lydgate studied medicine in Edinburgh, London and Paris. There he developed a special interest in communicable diseases and hoped to make great advances in treating and preventing them. But, after a promising start in a provincial centre of excellence in middle England, he was forced by circumstances (please, don't inquire) to abandon his high ideals. He now scrapes a living by pouring cold water on the over-enthusiastic at his private cryohydrotherapy clinic. Dreaming of the contributions he once hoped to make himself, he finds consolation in the latest medical journals and is happy to share his discoveries with his readers. He thinks that his creator, George Eliot, would have approved.
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