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On The Pulse - March 2017

On The Pulse

Tertius Lydgate

Friday, 31 March 2017

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Intensive therapy can induce type 2 diabetes remission
Doctors regularly give out brief intervention lifestyle advice to patients with diabetes but does it have an impact on disease progression? According to a study published in the Journal of Clinical Endocrinology & Metabolism, a short course of intensive lifestyle and drug therapy achieves on-treatment normoglycemia, promotes sustained weight loss and can also achieve prolonged, drug-free diabetes remission. Participants with type 2 diabetes for up to three years (n=83) were randomised to either an 8-week intensive metabolic intervention, a 16-week intensive metabolic intervention, or standard diabetes care. Twelve weeks after completion of the intervention, 21.4% of the 8-week group compared to 10.7% of controls (RR 2.00, 0.55-7.22) and 40.7% of the 16-week group compared to 14.3% of controls (RR 2.85, 1.03-7.87) met HbA1C criteria for complete or partial diabetes remission. Findings could shift the paradigm of diabetes treatment from simple glucose control to an approach where remission is induced and signs of relapse monitored.

Reducing cancer-related fatigue
Systemic symptoms of tiredness are common in patients with a diagnosis of cancer. Exercise, psychological, combined exercise and psychological, and pharmaceutical therapy are the four most commonly recommended treatments for cancer-related fatigue (CRF). A meta-analysis of 113 studies (11,525 unique participants), published in JAMA Oncology, found that exercise (mean weighted effect size – WES –, 0.30; 95% CI, 0.25-0.36), psychological (WES, 0.27; 95% CI, 0.21-0.33), and exercise plus psychological interventions (WES, 0.26; 95% CI, 0.13-0.38) improved CRF during and after primary treatment, whereas pharmaceutical interventions did not (WES, 0.09; 95% CI, 0.00-0.19). Researchers conclude that clinicians should prescribe exercise or psychological interventions as first-line treatments for CRF.

Long-term effects of bisphosphonate therapy
Many patients are treated with bisphosphonates for osteoporosis protection and it forms part of the quality and outcomes framework for GPs, but the benefits are brought into question. A small study published in Scientific Reports set out to investigate and compare the morphology of microdamage in healthy, osteoporotic and bisphosphonate-treated bone using synchrotron X-ray micro-CT and image segmentation technology. Some 16 trabecular bone cores and 21 rectangular tensile samples were investigated. Bone from bisphosphonate-treated fracture patients exhibited fewer perforations but more numerous and larger microcracks than both fracture and non-fracture controls. Authors concluded that there may be a population of patients in whom bisphosphonate therapy does not confer protective effects in resisting fractures, but is associated with microstructural damage and increased bone fragility instead.

DHA supplementation in pregnancy
The increasing trend for women to buy docosahexaenoic acid (DHA) while pregnant in the belief that taking it is beneficial for their unborn baby’s neurodevelopment has been questioned by research published in JAMA. Pregnant women were randomised to receive 800 mg of DHA daily or a placebo during the last half of pregnancy. Of those eligible, 543 children (85%) participated in the seven-year follow-up. Average IQ of the DHA and control groups did not differ (98.31 vs 97.32 respectively). Direct assessments consistently demonstrated no significant differences in language, academic abilities, or executive functioning. Results also showed that although perceptual reasoning was slightly higher in the DHA group, parent-reported behavioural problems and executive dysfunction were worse with prenatal DHA supplementation.

Corticosteroids for women at risk of preterm birth
Current guidelines recommend giving corticosteroids to women at risk of preterm birth from 23 to 34 weeks of gestation, however, benefits during the 23rd week have been less clear. A prospective cohort study in The BMJ, including 117,941 infants born between 23 and 34 weeks of gestation, showed that antenatal exposure to corticosteroids compared with no exposure was associated with lower mortality and morbidity at most gestations. It also showed that the number needed to treat with antenatal corticosteroids to prevent one death before discharge increased from six at 23 and 24 weeks’ gestation to 798 at 34 weeks’ gestation, suggesting that infants born at the lowest gestational ages benefit most. A linked editorial points out that timing is critical to maximising benefits for very premature babies and corticosteroids should ideally be administered within approximately one week of birth, which remains the biggest challenge for clinicians.

Novel procedure for detecting Barrett's oesophagus
A qualitative study published in BMJ Open investigated the acceptability of the Cytosponge, an ingestible oesophageal sampling device to detect Barrett's oesophagus. For this 5-min procedure, which can be administered in primary care, patients are asked to swallow a gelatine capsule on a string, which dissolves in the stomach. As the capsule dissolves, a small sponge expands and is pulled out of the mouth, collecting cells from the oesophagus, which are then analysed. While participants, 33 adults aged 50–69 years with gastro-oesophageal reflux disease (GORD), had initial concerns about the physical experience of taking the test, overall acceptability was high and concerns alleviated through multimedia resources. The study concludes that the procedure, perceived as more comfortable than endoscopy, could be used as a first-line test to investigate GORD symptoms.

Computerised systems to assess VTE risk after surgery
Researchers looked at the role of computerised clinical decision support systems (CCDSSs) in decreasing the risk of venous thromboembolism (VTE) in surgical patients. Published in JAMA Surgery, their systematic review and meta-analysis of 11 articles comprising 156,366 individuals showed that the use of CCDSSs was associated with a significant increase in the rate of appropriate ordering of prophylaxis for VTE (odds ratio, 2.35; 95% CI, 1.78-3.10) and a significant decrease in the risk of VTE events (risk ratio, 0.78; 95% CI, 0.72-0.85). “We should not ignore the strength of computer science in medicine,” concluded the authors, adding that “successful implementation of a CCDSS and physician acceptance depend on further trials that lend support to the efficacy of CCDSSs, their cost utility, their user acceptability, and, most important, their ability to change patient outcomes.”

Low-dose rivaroxaban in dual antiplatelet therapy for ACS
Dual antiplatelet therapy (DAPT), aspirin plus a P2Y12 inhibitor, is the standard antithrombotic treatment following acute coronary syndromes (ACS). Previous studies showed that rivaroxaban reduced mortality and ischaemic events when added to DAPT, but caused increased bleeding. Researchers, writing in The Lancet, investigated the safety of a dual pathway antithrombotic therapy approach combining low-dose rivaroxaban with a P2Y12 inhibitor. Eligible patients with ACS (n=3,037) received a minimum of 180 days of double-blind treatment with rivaroxaban 2·5 mg twice daily or aspirin 100 mg daily and either clopidogrel or ticagrelor. Thrombolysis in myocardial infarction clinically significant bleeding, not related to coronary artery bypass grafting, was similar with rivaroxaban versus aspirin therapy (total 154 patients [5%]; 80 participants [5%] of 1519 vs 74 participants [5%] of 1518; HR 1·09 [95% CI 0·80–1·50]; p=0·5840). Further trials would be required to definitively assess the efficacy and safety of this approach.

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.

How would qualify the communication between primary and secondary care services? (See OnMedica News 20/04)

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