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On The Pulse - June 2019

On The Pulse

Tertius Lydgate

Friday, 28 June 2019

Best surgical interventions for women with urinary incontinence outlined
But research stresses need for better understanding of complications after surgery

In its recent guidance on the management of urinary incontinence and pelvic organ prolapse, NICE has highlighted the public concern about the use of mesh procedures and acknowledged that while there is evidence of benefit, evidence of long-term adverse effect is limited. A recent systematic review and network meta-analysis of randomised controlled trials in The BMJ, which sought to compare the effectiveness and safety of surgical interventions for women with stress urinary incontinence, reached a similar conclusion, calling for a better understanding of complications after surgery. Researchers however found that retropubic midurethral sling (MUS), transobturator MUS, traditional sling, and open colposuspension are more effective than other procedures for stress urinary incontinence in the short to medium term. The research, which included 175 randomised controlled trials assessing a total of 21,598 women showed that the interventions with highest cure rates were traditional sling, retropubic MUS, open colposuspension, and transobturator MUS, with rankings of 89.4%, 89.1%, 76.7%, and 64.1%, respectively. Women were also more likely to experience an improvement in their incontinence symptoms after receiving retropubic MUS or transobturator MUS compared with other surgical procedures. 

PPIs associated with excess mortality from CVD and CKD
Using PPIs only when indicated and for minimum duration necessary essential

Proton pump inhibitors (PPIs) are widely used drugs, yet research has linked them with serious adverse events and an increased risk of all-cause mortality. An observational cohort study in The BMJ, including 157,625 and 56,842 new users of PPIs and H2 blockers respectively, shows similar findings and suggests PPIs are also associated with a small excess of cause specific mortality. The results showed there were 45.20 excess deaths (95% CI 28.20 to 61.40) per 1,000 patients taking PPIs. There was a graded relation between cumulative duration of PPI exposure and the risk of all-cause mortality and death due to circulatory system diseases, neoplasms, and genitourinary system diseases. Analyses of subcauses of death suggested that taking PPIs was associated with an excess mortality due to cardiovascular disease (CVD) (15.48, 5.02 to 25.19) and chronic kidney disease (CKD) (4.19, 1.56 to 6.58). Among patients without documented indication for acid suppression drugs (n=116,377), taking PPIs was associated with an excess mortality due to CVD (22.91, 11.89 to 33.57), CKD (4.74, 1.53 to 8.05), and upper gastrointestinal cancer (3.12, 0.91 to 5.44). Authors conclude heightened vigilance in the use of PPI may be warranted.

Canagliflozin in type 2 diabetes and nephropathy
Reduced risk of kidney failure and cardiovascular events

Canagliflozin, an oral sodium–glucose cotransporter 2 (SGLT2) inhibitor indicated as monotherapy or in combination for the treatment of type 2 diabetes, could become a game changer in the improvement of renal outcomes in patients with type 2 diabetes. Researchers writing in the NEJM randomly assigned 4,401 eligible patients with type 2 diabetes and albuminuric chronic kidney disease (CKD) to receive canagliflozin at a dose of 100 mg daily or placebo. The trial was stopped early after a planned interim analysis (median follow-up 2.62 years) showed the relative risk of the primary outcome (end-stage kidney disease, a doubling of the serum creatinine level, or death from renal or cardiovascular causes) was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1,000 patient-years, respectively (HR, 0.70; 95% CI, 0.59 to 0.82). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (HR 0.66; 95% CI, 0.53 to 0.81), and the relative risk of end-stage kidney disease was lower by 32% (HR 0.68; 95% CI, 0.54 to 0.86). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (HR 0.80; 95% CI, 0.67 to 0.95) and hospitalisation for heart failure (HR 0.61; 95% CI, 0.47 to 0.80). There were no significant differences in rates of amputation or fracture.

Pharmacological treatment of adults with major depression
Antidepressants plus benzodiazepines versus antidepressants alone

As major depression often presents with anxiety, it is not uncommon for benzodiazepines to be prescribed with antidepressants. A systematic review in the Cochrane Library, including 10 studies and involving 731 participants, sought to compare the effects of this treatment combination with monotherapy. Researchers found that combined antidepressant plus benzodiazepine therapy was more effective than antidepressants alone in improving depression severity, response in depression and remission in depression in the early phase. However, these effects were not maintained in the acute or the continuous phase. Combined therapy resulted in fewer dropouts due to adverse events than antidepressants alone, but combined therapy was associated with a greater proportion of participants reporting at least one adverse effect. The authors highlight that where antidepressant monotherapy may be considered inadequate, the potential benefits of the combined antidepressant plus benzodiazepine therapy must be balanced judiciously and individually against the possible harms of using a benzodiazepine (including development of dependence and accident proneness) and full consideration should be given to other alternative treatment strategies.

Recurrent falls and transient states of confusion in the elderly
A diagnostic challenge – BMJ Case Reports

New-onset paroxysmal events in patients over 60 years of age are often diagnostically challenging owing to atypical presentation. Authors writing in BMJ Case Reports present the case of an elderly patient with newly occurring ‘blackouts’ without obvious triggers and transient states of confusion for which he was amnestic. All neurological exams including brain MRI scan and routine electroencephalography (EEG) were normal. Long-term ECG monitoring using an event recorder captured an asystole during a habitual episode, leading to the diagnosis of syncope and pacemaker implantation. A subsequent video EEG monitoring performed due to ongoing unexplained confusional states revealed both bradycardia and long-lasting confusional states to be caused by unrecognised temporal lobe seizures. Authors point out that ictal video EEG monitoring may play a crucial role in establishing a diagnosis of atypical temporal lobe seizures in the elderly.

Pneumothorax after acupuncture
Be aware of possible adverse events – BMJ Case Reports

Despite being a popular form of complementary medicine, acupuncture isn’t without risk, as demonstrated by a case in BMJ Case Reports. A 79-year-old woman was admitted to the emergency department with a pneumothorax two days after receiving acupuncture treatment for chronic back pain. She felt a sharp right shoulder pain as needles were inserted in the interscapular area. As the pain did not resolve, she consulted her general practitioner and had a chest radiography done, revealing a right-sided pneumothorax. At the hospital, a right chest tube was inserted with relief of the symptoms and lung expansion. The chest tube was removed on the second day of admission, and she was discharged on the third day. The authors highlight that both acupuncturists and clinicians need to be aware of the possibility of adverse events following acupuncture, especially in those who develop symptoms.

Inhaled corticosteroids in children with persistent asthma
Review of different drugs and delivery devices’ effect on growth

Although treatment with inhaled corticosteroid (ICS) is generally considered to be safe in children, the potential adverse effects of these drugs on growth remains a matter of concern for parents and physicians. To assess the impact of different ICS drugs, the Cochrane Library published a systematic review which included six randomised trials, of at least three month’s duration, involving 1,199 children aged from 4 to 12 years (per‐protocol population: 1008), with mild‐to‐moderate persistent asthma. It suggests the drug molecule and delivery device may impact the effect size of ICS on growth in children with persistent asthma. Fluticasone at an equivalent dose seems to inhibit growth less than beclomethasone and budesonide. Easyhaler is likely to have less adverse effect on growth than Turbohaler when used for delivery of budesonide. But the authors caution that the evidence from the review is not certain enough to inform the selection of ICS or inhalation device for the treatment of children with asthma. Further studies are needed and good communication between healthcare professionals and parents is essential to reduce concerns about using steroids and to improve treatment adherence.

Non-medical roles in primary care: changing the skill mix
Introducing new roles to general practice is not a simple process

As new roles may be part of the solution to alleviate the current workforce challenges in general practice in England, qualitative research in the BJGP compared how three non-medical roles – advanced practitioner, physician associate and practice pharmacist – were being established, and set out to understand common implementation barriers, and identify measurable impacts or unintended consequences. The final sample for the semi-structured interviews and focus groups contained 38 stakeholders comprising training/service leads, role holders, and host practice staff. Three key themes captured participants’ perspectives: purpose and place of new roles in general practice, involving unclear role definition and tension at professional boundaries; transition of new roles into general practice, involving risk management, closing training–practice gaps and managing expectations; and future of new roles in general practice, involving demonstrating impact and questions about sustainability. The authors suggest recognising the factors affecting the assimilation of roles may help to better align them with the goals of general practice and harness the commitment of individual practices to enable role sustainability.

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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