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On The Pulse - February 2018

On The Pulse

Tertius Lydgate

Friday, 23 February 2018

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The dangers of drinking very hot tea
The hypothesis that hot beverages may lead to oesophageal cancer dates back as far as the 1930’s, but has never been firmly established. However, according to a recent Chinese study published in Annals of Internal Medicine, the regular consumption of very hot tea, when combined with cigarette smoking or alcohol intake, may lead to an increased risk of oesophageal cancer. The prospective cohort study, hailed as a significant addition to the literature by an accompanying editorial, included more than 450, 000 participants, with a long-term follow-up period of 9.2 years. Researchers collected information regarding peoples’ tea drinking habits, as well as other health-related variables. Over this period, 1,731 cases of oesophageal cancer were documented. High-temperature tea drinking combined with either alcohol consumption or smoking was associated with a greater risk for oesophageal cancer than hot tea drinking alone. Compared with participants who drank tea less than weekly and consumed fewer than 15g of alcohol daily (just under two units), those who drank burning-hot tea and 15g or more of alcohol daily had the greatest risk for oesophageal cancer (HR 5.00 [95% CI, 3.64 to 6.88]). The study authors concluded that abstinence from hot tea may be beneficial for people who drink alcohol excessively or smoke.

Diagnosing non-metastatic lung cancer
Late-stage diagnosis is a main reason for the high mortality of lung cancer (LC) and different risk assessment tools have been developed for GPs in order to detect LC earlier by clinical features. However, research published in BJGP Open has shown that patients with non-metastatic lung cancer (nMLC) cannot be easily identified by symptoms coded in medical records. Despite the lack of this specific data, GPs’ referrals for a chest X-ray resulted in a 40% detection rate of nMLC. The population-based case-control study included 373 patients diagnosed with LC in 2011 (of which 132 had nMLC) and 1,472 controls selected from the Swedish Cancer Register and regional healthcare database, respectively. The study identified 12 features that were associated with nMLC, of which eight were also in common with metastatic LC. Clinical features with the highest odd ratio (OR) were vitamin B12 deficiency anaemia (OR 6.7, 95% CI=1.6 to 27.9), dyspnoea (OR 5.0, 95% CI=2.0 to 12.7), and chronic bronchitis (OR 5.0, 95% CI=1.3 to 18.6). Clinical features used by GPs’ as reasons for requesting chest X-ray were almost three times more frequent in the request forms compared to the corresponding diagnostic codes in the medical records, thus suggesting difficulty in using pre-diagnostic codes in medical records to identify at risk patients.

Trimethoprim use for UTIs
Although we don’t know whether trimethoprim is linked to sudden death, it remains a first-line option for the treatment of uncomplicated urinary tract infections (UTIs) and over 3.7m prescriptions were dispensed in England in 2015. A study in The BMJ therefore investigated the association between the use of this antibiotic and acute kidney injury, hyperkalaemia, or sudden death in a cohort of patients aged 65 and over (n=1,191,905). The results show that trimethoprim is associated with a greater risk of acute kidney injury (adjusted OR 1.72, 95% CI 1.31 to 2.24) and hyperkalaemia (2.27, 1.49 to 3.45) compared with other antibiotics used to treat UTIs, but not a greater risk of death. The relative risk increase is similar across population groups, but the higher baseline risk among those taking renin-angiotensin system blockers and potassium-sparing diuretics translates into higher absolute risks of acute kidney injury and hyperkalaemia in these groups. The researchers recommended that, whenever possible, other antibiotics should be considered for high-risk groups, and that adequate monitoring should be performed when there is no other option.

Antibiotic prescribing for children
Last month, Dr Lydgate pointed out a study in the BJPG highlighting the mixed quality of antibiotic prescribing for common infections in young children attending primary care. This month, further research in the BJPG looks at interventions to reduce inappropriate antibiotic prescribing for non-severe acute infections. In this cluster randomised controlled trial, 2,227 non-severe acute infections in children were registered by 131 Family Physicians (FPs). The participants were allocated to one of four intervention groups according to whether the FPs performed: (1) a point-of-care C-reactive protein test (POC CRP); (2) a brief intervention to elicit parental concern combined with safety net advice (BISNA); (3) both POC CRP and BISNA; or (4) usual care (UC). In comparison with UC, POC CRP did not influence antibiotic prescribing, (adjusted odds ratio [AOR] 1.01, 95% CI=0.57 to 1.79) and BISNA increased antibiotic prescribing (AOR 2.04, 95% CI=1.19 to 3.50). In combination with POC CRP, this increase disappeared. The study concludes that systematic POC CRP testing without guidance is not an effective strategy and eliciting parental concern and providing a safety net without POC CRP testing conversely increased antibiotic prescribing. This prompts Dr Lydgate to think that parents do gain confidence from having a POC test, but only if their concerns are addressed and with safety netting. The authors suggest FPs may need more training in handling parental concern without inappropriately prescribing antibiotics.

Cardiovascular safety of canagliflozin
Cardiovascular disease is the leading cause of morbidity and mortality in patients with type 2 diabetes. A population based cohort study in the BMJ has evaluated the cardiovascular safety of canagliflozin, a sodium-glucose cotransporter 2 inhibitor for the treatment of type 2 diabetes mellitus, in direct comparisons with DPP-4 inhibitors (DPP-4i), GLP-1 receptor agonists (GLP-1RA), or sulfonylureas, as used in routine practice. The study involved three pairwise 1:1 propensity score matched cohorts of patients with type 2 diabetes 18 years and older who initiated canagliflozin or a or a comparator agent. During a 30-month period, the hazard ratio for heart failure admission to hospital associated with canagliflozin was 0.70 (95% CI 0.54 to 0.92) versus a DPP-4i (n=17,667 pairs), 0.61 (0.47 to 0.78) versus a GLP-1RA (20,539), and 0.51 (0.38 to 0.67) versus a sulfonylurea (17,354). The hazard ratio for the composite cardiovascular endpoint associated with canagliflozin was 0.89 (0.68 to 1.17) versus a DPP-4i, 1.03 (0.79 to 1.35) versus a GLP-1RA, and 0.86 (0.65 to 1.13) versus a sulfonylurea. Canagliflozin was therefore associated with a lower risk of heart failure admission to hospital and with a similar risk of myocardial infarction or stroke in direct comparisons with three different classes of non-gliflozin diabetes treatment alternatives as used in routine care.

Scaling up general practice
National policy makers are increasingly advocating collaboration between general practices in England to form new provider networks and large-scale organisations. The move prompted the RCGP chair to urge caution and a long-term evaluation of existing innovative schemes. A systematic review in the BJGP looked at the available evidence. Out of 1,782 publications screened, five studies met the inclusion criteria and four examined the same general practice networks, limiting generalisability. It found that substantial financial investment was required to establish the networks and the associated interventions that were targeted at four clinical areas. Quality improvements were achieved through standardised processes, incentives at network level, information technology-enabled performance dashboards, and local network management. The fifth study of a large-scale multisite general practice organisation showed that it may be better placed to implement safety and quality processes than conventional practices. However, unintended consequences may arise, such as perceptions of disenfranchisement among staff and reductions in continuity of care. The authors concluded that as more general practice collaborations emerge, evaluation of their impacts will be important to understand which work, in which settings, how, and why.

Tackling childhood obesity
Excess weight in children is a significant problem with around 25% of children in the UK being overweight at school entry age. A cluster randomised controlled trial in the BMJ assessed the effectiveness of a school and family based healthy lifestyle programme, compared with usual practice, in preventing childhood obesity. The 12-month intervention encouraged healthy eating and physical activity, including a daily additional 30min school time physical activity opportunity, a six-week interactive skill based programme in conjunction with Aston Villa football club, signposting of local family physical activity opportunities through mail-outs every six months, and termly school-led family workshops on healthy cooking skills. Data for primary outcome analyses were: baseline, 54 schools: 1,392 pupils (732 controls); 1st follow-up (15 months), 53 schools: 1,249 pupils (675 controls); 2nd follow-up (30 months), 53 schools: 1,145 pupils (621 controls). The mean BMI z score was non-significantly lower in the intervention arm compared with the control arm at 15 and 30 months in the baseline adjusted models (mean difference −0.075 and −0.027 respectively). And there was no statistically significant difference between groups for other anthropometric, dietary, physical activity, or psychological measurements. The research concludes that schools are unlikely to impact on the childhood obesity epidemic by incorporating such interventions without wider support across multiple sectors and environments. However, Dr Lydgate wonders what the actual uptake for the programme was and if making the activities compulsory would have made a difference.

Traumatic brain injury and dementia
As evidence is growing that traumatic brain injury (TBI) increases the risk of developing dementia, researchers writing in PLOS Medicine examined whether different types of dementia diagnoses are associated with previous TBI and whether any observed association is time dependent. They looked at all inhabitants living in Sweden above 50 years of age to form three cohorts: first cohort, 164,334 individuals with TBI matched with controls; second case-control cohort, 136,233 individuals with dementia matched with controls; and third cohort, 46,970 full sibling pairs discordant for TBI were evaluated for dementia during follow-up. Results from the retrospective and case-control cohorts showed that the risk of dementia was increased by four to six times the first year after TBI. Thereafter, the risk decreased rapidly but was still significant more than 30 years after the TBI (OR, 1.25; 95% CI, 1.11–1.41). The risk of dementia was higher for those with a severe TBI (OR, 2.06; 95% CI, 1.95–2.19) or multiple TBIs (OR, 2.81; 95% CI, 2.51–3.15), compared to those with one mild TBI (OR, 1.63; 95% CI, 1.57–1.70). The researchers cautioned that, given the observational study design, other factors may explain the observed associations, and this called for further studies.

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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