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On The Pulse - January 2020

On The Pulse

Tertius Lydgate

Friday, 31 January 2020

GP burnout linked to complexity of patients
Absolute amount of multimorbidity increases risk of psychological problems

Within a primary care setting, patients are becoming increasingly complex, many with multiple medical problems. Burnout among GPs is increasingly being seen in European countries and coincides with a substantial increase in workload. A team of researchers in the BJGP examined whether patient multimorbidity was associated with GP burnout. They linked questionnaire data on 1,676 Danish GPs with patient data choosing those with ≥ 2 chronic physical diseases. Data were analysed with logistic regression and adjusted analyses included GPs’ age and sex, number of GPs in practice, and socioeconomic deprivation among patients as covariates. A high crude rate of patient multimorbidity increased GPs’ likelihood of burnout (OR 1.79, 95% CI= 1.13 to 2.82), and when adjusting for covariates the association remained significant when comparing GPs in the third highest quartile of the multimorbidity rate against GPs in the lowest quartile (OR 1.64, 95% CI = 1.02 to 2.64). This shows the absolute amount of multimorbidity, and not the relative, affects the GP’s burnout risk. The authors call for support for GPs with high numbers of patients with complex needs to prevent suboptimal care and GP burnout.

Greater functional problems for localised cancer with prostatectomy
When compared to other treatment options available at the five-year mark

Understanding the long-term adverse effects of treatments can have an impact on how clinicians counsel patients on their options. Researchers writing in JAMA compared functional outcomes associated with different prostate cancer treatments over five years after treatment. The prospective, population-based cohort study included 1,386 men with favourable-risk prostate cancer and 619 men with unfavourable-risk prostate cancer. The authors found that in this cohort of men with localised prostate cancer, most functional differences associated with contemporary management options attenuated by five years. However, men undergoing prostatectomy reported clinically meaningful worse incontinence through five years compared with all other options, and men undergoing prostatectomy for unfavourable-risk disease reported worse sexual function at five years compared with men who underwent external beam radiation therapy with androgen deprivation therapy.

Renal denervation reduces the recurrence of atrial fibrillation
When added to pulmonary vein isolation enhances long-term antiarrhythmic efficacy

It is known that renal denervation can reduce cardiac sympathetic activity that may result in an antiarrhythmic effect on atrial fibrillation. Researchers, writing in JAMA, looked at whether renal denervation when added to pulmonary vein isolation reduced the likelihood of atrial fibrillation at 12 months. Patients with paroxysmal atrial fibrillation were randomised to either pulmonary vein isolation alone (n= 148) or pulmonary vein isolation plus renal denervation (n= 154). Freedom from atrial fibrillation, flutter, or tachycardia at 12 months was observed in 56.5% of those undergoing pulmonary vein isolation alone and in 72.1% of those undergoing pulmonary vein isolation plus renal denervation (hazard ratio, 0.57; 95% CI, 0.38 to 0.85). In addition, mean systolic blood pressure from baseline to 12 months decreased from 151 mm Hg to 147 mm Hg in the isolation-only group and from 150 mm Hg to 135 mm Hg in the renal denervation group. The authors note that although there was a lack of a formal sham control renal denervation procedure, the results show promise to patients to be free from atrial fibrillation with the combined procedure at 12 months.

Sunscreen active ingredients are systemically absorbed
Additional research required to determine if this poses any health risks

Previous research has shown that the application of topical sunscreen products results in an increase in plasma concentrations of active ingredients. Researchers writing in JAMA looked at how quickly systemic exposure of six active ingredients (avobenzone, oxybenzone, octocrylene, homosalate, octisalate, and octinoxate) exceeds the US Food and Drug Administration threshold exposure level of 0.5 ng/ml. Participants were randomised to one of four sunscreen products, formulated as lotion (n= 12), aerosol spray (n= 12), non-aerosol spray (n= 12), and pump spray (n= 12). Sunscreen product was applied at 2 mg/cm2 to 75% of body surface area at zero hours on day one and four times on day two through day four at two-hour intervals, and 34 blood samples were collected over 21 days from each participant. Geometric mean maximum plasma concentrations of all six active ingredients were greater than 0.5 ng/mL, and this threshold was surpassed on day one after a single application for all active ingredients. While the authors say the findings do not indicate that individuals should refrain from the use of sunscreen, they call for further research to determine if systemic absorption poses any health risks.

Rapid diagnosis centres reduce time to cancer diagnosis in primary care
Cost-effectiveness modelling shows excellent value for money if run at ≥ 80% capacity

 Although there is a push for speedier cancer diagnoses when patients present to primary care, making a diagnosis can be difficult when patients present with vague and/or non-specific symptoms and do not meet criteria for urgent referral. A pilot rapid diagnosis centre (RDC) allows GPs to refer these patients to a multidisciplinary RDC clinic where they are seen within one week. Researchers, writing in the BJGP, used modelling to estimate the cost-effectiveness of the RDC compared with standard clinical practice. A cohort of 1,000 patients was simulated based on real-life data and control patients were those referred to an urgent suspected cancer (USC) pathway but then downgraded. Researchers found that the RDC reduces mean time to diagnosis from 84.2 days in usual care to 5.9 days if a diagnosis is made at clinic, or 40.8 days if further investigations are booked during RDC. The authors conclude the use of an RDC for patients with vague symptoms provides excellent value and reduces time to diagnosis, if run at ≥ 80% capacity.

Long-term exposure to particulate matter increases risk of stroke
Almost linear exposure-response relations between long-term exposure to PM2.5 and incident stroke

The authors of Chinese research, published in The BMJ, have highlighted the major public health concern that ambient air pollution, especially fine particulate matter (PM2.5, particles with an aerodynamic diameter of ≤2.5 μm) pollution, represent worldwide. Their prospective cohort study examined the effect of long-term exposure to these pollutants on the incidence of total, ischemic, and haemorrhagic stroke among 117,575 Chinese adults. For each increase of 10 μg/m3 in PM2.5 concentration, the increased risks of incident stroke, ischaemic stroke, and haemorrhagic stroke were 13% (1.13, 1.09 to 1.17), 20% (1.20, 1.15 to 1.25), and 12% (1.12, 1.05 to 1.20), respectively. The researchers also found an almost linear exposure-response relations between long term exposure to PM2.5 and incident stroke, overall and by its subtypes. The authors concluded the findings are meaningful for both environmental and health policy development related to air pollution and stroke prevention in low- and middle-income countries.

The relationship between a healthy lifestyle and life expectancy
Never too late to adopt healthier options even in mid-life

It is well known that life expectancy is increasing across the world but as people live longer this can result in higher prevalence of chronic conditions and those with chronic conditions are seen to have a shorter life expectancy. Researchers writing in The BMJ examined how a healthy lifestyle is related to life expectancy free from major chronic disease. They studied two patient cohorts (total n=111,562) and derived a healthy lifestyle score based on information on five lifestyle factors: diet, smoking, physical activity, alcohol consumption, and body mass index (BMI). For women who adopted no low risk lifestyle factors, the life expectancy free of diabetes, cardiovascular diseases, and cancer at age 50 was 23.7 years (95% CI 22.6 to 24.7), in contrast to 34.4 years (33.1 to 35.5) for women who adopted four or five low risk factors. For men, it was 23.5 (22.3 to 24.7) and 31.1 (29.5 to 32.5) years. Male smokers and male/female patients with a BMI ≥ 30 had the lowest life expectancy. The findings therefore show that a healthy lifestyle at mid-life is associated with a longer life expectancy free of chronic disease burden.

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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