GP Research Review Issue 97 - New Zealand Association of

ISSN 1178-6124
GP
Research Review
Making Education Easy
In this issue:
Adjunct prednisone beneficial
in CAP
Statins benefit men and women
equally
Excessive BP lowering may
be harmful in dementia
Acid-lowering agents linked
to vitamin B12 deficiency
Use of shorthand in clinical notation
Increased risk of AMD with higher
FT4 levels
A printed decision aid deters men
from PSA screening
Spirometry underutilised in newly
diagnosed asthma?
Mindfulness meditation improves
sleep quality
Does sauna bathing reduce CVD
and all-cause mortality?
Abbreviations used in this issue
AMD = age-related macular degeneration
CAP = community-acquired pneumonia
CVD = cardiovascular disease
FT4 = free thyroxine
PSA = prostate-specific antigen
TSH = thyroid-stimulating hormone
TM
Issue 97 – 2015
Welcome to issue 97 of GP Research Review.
Italian research suggests that strict control of systolic blood pressure (SBP) may hasten cognitive decline among older adults
with pre-existing dementia or mild cognitive impairment. Patients whose daytime SBP was lowered to ≤128 mmHg had greater
declines in Mini-Mental State Examination score compared with those with higher SBP. Associations were significant only among
patients on antihypertensive medications and were unrelated to age, vascular comorbidity score, or baseline cognitive level.
Abbreviations and acronyms are ubiquitous in medicine. When a group of clinicians from the Royal Melbourne Hospital examined
electronic discharge summaries generated in their workplace, they found numerous instances of inappropriate, ambiguous or
unknown shorthand. They caution that this has implications for safe and effective patient care and they emphasise the need for
better awareness and education regarding use of shorthand in clinical notation.
Structured mindfulness meditation training appears to improve sleep problems and sleep-related daytime impairment among
older adults (≥55 years) in the general community, according to a study conducted in Los Angeles, and described in our Natural
Health section. The mindful awareness practices (MAPs) for daily living is a weekly 2-hour, 6-session group-based course
in mindfulness meditation that is available for residents to take in person within the Los Angeles area or to anyone online
(http://marc.ucla.edu).
I hope you enjoy this edition and I welcome your comments and feedback.
Kind Regards
Jim
Associate Professor Jim Reid
[email protected]
Adjunct prednisone therapy for patients with communityacquired pneumonia: a multicentre, double-blind, randomised,
placebo-controlled trial
Authors: Blum CA et al.
Summary: 785 patients aged ≥18 years admitted to hospital with community-acquired pneumonia (CAP) within 24 hours
of presentation were randomly assigned to receive either prednisone 50 mg/day (n=392) or placebo (n=393) for 7 days.
The primary endpoint was time (days) to clinical stability (defined as stable vital signs for at least 24 hours). The median time
to clinical stability was significantly reduced in the prednisone group (3.0 days) compared with the placebo group (4.4 days;
hazard ratio [HR] 1.33; 95% CI, 1.15 to 1.50; p<0.0001). Pneumonia-associated complications until day 30 did not differ
between groups (11 [3%] in the prednisone group and 22 [6%] in the placebo group; odds ratio [OR] 0.49; 95% CI, 0.23 to
1.02; p=0.056). Prednisone-treated patients were more likely than placebo-treated patients to require insulin treatment for
in-hospital hyperglycaemia (19% vs 11%; OR 1.96; 95% CI, 1.31 to 2.93; p=0.0010). Other adverse events that could be
attributed to corticosteroid use were infrequent and similar in both groups.
Comment: Maybe this is another sacred cow that needs further examination. Traditionally, steroids have been regarded
as unnecessary in non-steroid-dependent patients with CAP. In this study, which was of reasonable size, those patients
with CAP were randomly allocated to 50 mg of prednisone daily, or placebo. The group on prednisone took on average 1.5
fewer days (3 vs 4.4) to reach clinical stability, and thus had equivalent shorter hospital stays. This reflects considerable
cost savings.
Reference: Lancet. 2015;385(9977):1511-8
Abstract
Once Daily
SPIRIVA
®
(tiotropium 18 mcg)
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Efficacy and safety of LDL-lowering therapy among men
and women: meta-analysis of individual data from 174,000
participants in 27 randomised trials
Authors: Cholesterol Treatment Trialists’ Collaboration et al.
Summary: This meta-analysis examined data from 22 trials of statin therapy versus control (n=134,537) and 5 trials of moreintensive versus less-intensive statin therapy (n=39,612), in this investigation into the effects of statin therapy in women and
men. Of all 174,149 participants, 46,675 (27%) were women. In these trials, women were generally at lower cardiovascular
risk than were men. Statin therapy had similar absolute effects on 1-year lipid concentrations in both sexes (LDL cholesterol
reduced by about 1.1 mmol/L in statin vs control trials and roughly 0.5 mmol/L for more-intensive vs less-intensive therapy).
In a Cox analysis adjusted for non-sex differences, the proportional reductions per 1.0 mmol/L reduction in LDL cholesterol
in major vascular events were similar overall for women (rate ratio [RR] 0.84; 99% CI, 0.78 to 0.91) and men (RR 0.78;
99% CI, 0.75 to 0.81, adjusted p value for heterogeneity by sex=0.33) and also for those women and men at less than 10%
predicted 5-year absolute cardiovascular risk (adjusted heterogeneity p=0.11). Similarly, sex did not significantly impact the
proportional reductions in major coronary events, coronary revascularisation, and stroke. No adverse effect on rates of cancer
incidence or non-cardiovascular mortality was noted for either sex. These net benefits translated into all-cause mortality
reductions with statin therapy for both women (RR 0.91; 99% CI, 0.84 to 0.99) and men (RR 0.90; 99% CI, 0.86 to 0.95;
adjusted heterogeneity p=0.43).
Comment: This is the first study that I have seen demonstrating equal efficacy of statins in lipid reduction extending into
positive outcomes for both men and women. Previously, there have been confounding factors including the protective
effect of oestrogen, but this study shows that both sexes of equivalent risk gained benefit with all-cause mortality.
Reference: Lancet. 2015;385(9976):1397-405
Abstract
Independent commentary by
Associate Professor Jim Reid.
11-14 June 2015 | Energy Events Centre | Rotorua
www.gpcme.co.nz
www.researchreview.co.nz
Jim Reid graduated in medicine at the
University of Otago Medical School in
Dunedin New Zealand. He had previously
trained as a pharmacist. He undertook his postgraduate work
at the University of Miami in Florida. Currently he is Head of
Rural Health and Deputy Dean of the School at the Dunedin
School of Medicine. He has a private family medicine
practice at the Caversham Medical Centre, Dunedin,
New Zealand. For full bio CLICK HERE.
Effects of low blood pressure
in cognitively impaired
elderly patients treated with
antihypertensive drugs
Authors: Mossello E et al.
Summary: This cohort study involved 172 elderly patients
(mean age 79 years) with overt dementia and mild cognitive
impairment (MCI) attending outpatient memory clinics.
At baseline, the mean Mini-Mental State Examination (MMSE)
score was 22.1, 68.0% had dementia, 32.0% had MCI,
and 69.8% were receiving antihypertensive medications.
Cognitive decline, defined as a change in MMSE score
between baseline and end of follow-up (mean 9 months),
was greater among patients in the lowest tertile of daytime
systolic blood pressure (SBP) (≤128 mm Hg) compared
with those in the intermediate tertile (129–144 mm Hg)
and the highest tertile (≥145 mm Hg) (mean −2.8 vs −0.7
and −0.7, respectively; p≤0.003 for both comparisons).
The associations were significant in the dementia and MCI
subgroups only among patients receiving antihypertensive
medications; these associations were independent of age,
baseline MMSE score and vascular comorbidity score.
A weaker association was observed between MMSE score
change and office SBP. No other ambulatory BP monitoring
variables were associated with MMSE score change.
Comment: This is a fascinating study that suggests
that low daytime SBP is associated with an increase
in cognitive decline in patients with mild cognitive
impairment and dementia. In the group studied,
nearly 70% were taking antihypertensive medication.
Physiologically, BP slowly increases with age, and it is
tempting to think that this could be the body’s adaptive
mechanism to resist a dementing process. It was
Hippocrates who said “primum nil nocere – first do no
harm”. This calls for just a little more research!
Reference: JAMA Intern Med. 2015;175(4):578-85
Abstract
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GP Research Review
Association between vitamin B12 deficiency
and long-term use of acid-lowering agents:
a systematic review and meta-analysis
Thyroid function and age-related macular
degeneration: a prospective populationbased cohort study - the Rotterdam Study
Authors: Jung SB et al.
Authors: Chaker L et al.
Summary: This meta-analysis reviewed data from 4 case-control studies (4254 cases and
19,228 controls) and 1 observational study to analyse the effects of long-term use of acidlowering agents on vitamin B12 concentration. A significant association was found between
long-term use of acid-lowering agents and the development of vitamin B12 deficiency (HR 1.83;
95% CI, 1.36 to 2.46; p=0.00).
Summary: These researchers examined the association between thyroidstimulating hormone (TSH), free thyroxine (FT4) and the risk of incident
age-related macular degeneration (AMD) among 5573 participants aged
≥55 years from the Rotterdam Study with TSH and/or FT4 measurements
and AMD assessment. During a median follow-up of 6.9 years, 805 people
developed AMD. Whereas TSH levels (normal range 0.4–4.0 mIU/L) were not
associated with increased risk of AMD, when FT4 values within normal range
(11–25 pmol/L) were categorised into quintiles, participants in the highest FT4
quintile (17.5–24.9 pmol/L) had a 1.34-fold increased risk of developing AMD
compared with people in the middle quintile (15.1–16.2 pmol/L) (95% CI, 1.07
to 1.66; p=0.066). Higher FT4 values in the full range were associated with
a higher risk of AMD (HR 1.04; 95% CI, 1.01 to 1.06 per 1 pmol/L increase).
Higher FT4 levels were similarly associated with a higher risk of retinal pigment
alterations. The association remained unchanged when analyses were limited to
euthyroid individuals, when multivariable analyses made additional adjustments
for confounding variables (smoking, diabetes, hypertension, cholesterol, body
mass index, and thyroid peroxidase antibody positivity), and stratification for age
and sex. One single nucleotide polymorphism (SNP rs943080) in the vascular
endothelial growth factor A (VEGF-A) gene that is associated with AMD was
found to be significantly associated with TSH genome-wide association study
(GWAS) data (p=1.2 x 10−4) but with not the FT4 GWAS. Adding SNP rs943080
to multivariable models did not change estimates.
Comment: This has been commented on previously in this column. Omeprazole is currently
the most common medication prescribed in New Zealand. It is widely believed to be without
significant side effects, but this is not so. One can now add possible B12 deficiency to necessary
surveillance, which includes renal function including serum magnesium and sodium, and full
blood count (leucopenia and thrombocytopenia). There is no question that omeprazole and
other protein pump inhibitors are effective, but as doctors we should ask ourselves if the
patients are taking the minimum required dose, if continuous therapy is necessary, and are
there other measures that could control the reflux.
Reference: Intern Med J. 2015;45(4):409-16
Abstract
Overview of shorthand medical glossary (OMG)
study
Authors: Politis J et al.
Summary: This group of clinicians reviewed 80 electronic discharge summaries issued by the
General Medical Units at the Royal Melbourne Hospital between July 2012 and June 2013.
They sought to describe the frequency of inappropriate and ambiguous shorthand used in the
summaries. All abbreviations were categorised according to appropriateness: 1. ‘Universally
accepted and understood even without context’; 2. ‘Understood when in context’; 3. ‘Understood
but inappropriate and/or ambiguous’; and 4. ‘Unknown’. These categories were determined by
the authors, which included junior and senior medical staff. The discharge summaries contained
840 different abbreviations used on 6269 occasions. Of all words, 20.1% were abbreviations.
Of the 6269 occasions of shorthand, 6.8% were categorised as ‘Understood but inappropriate and/
or ambiguous’ or ‘Unknown’ (category 3 or 4), equating to 1.4% of all words, and an average of
5.4 words per discharge summary.
Comment: Abbreviations drive me crazy. Acronyms are worse. This study demonstrates that
abbreviations occur in discharge letters at a frequency of one in five words. It is inappropriate
to require a glossary attached to each discharge letter but this is what, in many cases, is
necessary. In addition, each discipline has its own set, and those used by ophthalmology are
different to those coming from neurology. I could include a few from my own discipline of
general practice – for example NBG (no bl**dy good), TALOIA (there’s a lot of it around) and
GOK (God only knows)!!!! I have a few others that would get them going!
to read previous issues of GP Research Review
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Impact of a printed decision aid on
patients’ intention to undergo prostate
cancer screening: a multicentre,
pragmatic randomised controlled trial
in primary care
Summary: This trial was conducted in 86 general practices in urban and rural
areas in France and involved 1170 men aged 50–75 years who were randomised
to receive either a decision aid on patients’ intention to undergo prostate cancer
screening (intervention group; n=588) or usual care (control group; n=582). When
assessed immediately after reading the decision aid, significantly fewer men in
the intervention arm compared with those in the control arm decided to be tested
for prostate cancer (123 patients [20.9%] vs 57 patients [9.8%]; p<0.0001). In
the intervention group, fewer men expressed that cancer screening would protect
them from the disease, compared with controls (p<0.0001), while a greater
number stated that prostate cancer screening would not benefit their health
(p<0.0001) and may involve procedures with harmful side effects (p=0.0005).
Comment: Screening for prostate cancer is very controversial, and
never a month goes by without a plethora of material appearing in the
literature both for and against! The American Urological Society has now
abandoned the prostate-specific antigen (PSA) test in their screening
recommendations, using it now only for postoperative surveillance. What
is needed is a useful tool so men can make an informed choice, and this
work is currently being undertaken in New Zealand. But what we really,
really need is a reliable test that does not give the false positives and
negatives as does PSA.
T
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(N
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AS
H
A F
ON
O U N D AT I
SENS ITIVE
CHOICE
www.researchreview.co.nz
Reference: BMC Medicine. 2015;13:94
Abstract
Authors: Tran VT et al.
Reference: Intern Med J. 2015;45(4):423-7
Abstract
CLICK HERE
Comment: While TSH level seems not to be an enhancing factor for the
development of AMD, the level of FT4 is. Even if FT4 is in the range of
“normality”, those patients with levels at the upper limits of the scale had
an increased risk of developing AMD. This is an interesting observation, and
merely demonstrates the association between FT4 and AMD, which may
or may not have clinical implications. It is a matter of watching for further
research!
Reference: Br J Gen Pract. 2015;65(634):e295-304
Abstract
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GP Research Review
Choosing wisely: adherence by
physicians to recommended
use of spirometry in the
diagnosis and management
of adult asthma
Authors: Sokol KC et al.
Summary: These US-based researchers retrospectively
analysed data from a privately insured adult population in
this examination of trends in spirometry use in subjects
newly diagnosed with asthma over a 10-year period
(2002–2011). Guidelines issued by the National Asthma
Education and Prevention Program (NAEPP) and the
American Thoracic Society state that physicians should use
spirometry in the diagnosis and management of asthma.
This study hypothesised that spirometry use would increase
in physicians who care for asthma patients, especially since
2007, after the release of the revised NAEPP guidelines.
Of 134,208 patients found to have a diagnosis of asthma,
only 47.6% had spirometry performed within 1 year (± 365
days) of the initial date of diagnosis. Younger patients, males,
and those residing in the Northeast were more likely to
receive spirometry. Spirometry use began to decline in 2007.
Patients cared for by specialists were more likely to receive
spirometry than those cared for by primary care physicians
(80.1% vs 23.3%, respectively). Even without spirometry, as
many as 78.3% of patients were prescribed asthma drugs.
Comment: Although I have no authoritative recent data
originating in New Zealand, it is my feeling that while
still underutilised, spirometry (or at least the interest in
spirometry) is on the increase in primary care. In some
instances it is imposed in order to get special approvals
for medications, and it is also used in differentiating
between COPD and asthma. The reviewer has delivered
a number of workshops / lectures around the country
and high-quality spirometry can be achieved in the
primary care setting. This study showed that fewer
than half of patients diagnosed with asthma had
confirmatory spirometry within 1 year of diagnosis, and
the use as a diagnostic aid (at least in the US) began to
decline from 2007. My gut feeling is that this not the
state in NZ, but it would be nice to show this objectively.
Reference: Am J Med. 2015;128(5):502-8
Abstract
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Disclaimer: This publication is not intended as a replacement for
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are a summarised interpretation of the published study and reflect
the opinion of the writer rather than those of the research group or
scientific journal. It is suggested readers review the full trial data
before forming a final conclusion on its merits.
Evidence-based natural health by Dr Chris Tofield
Mindfulness meditation and improvement in sleep quality
and daytime impairment among older adults with sleep
disturbances
Authors: Black DS et al.
Summary: This study was conducted at a medical research center with 49 older adults (aged ≥55 years) reporting
moderate sleep disturbances (Pittsburgh Sleep Quality Index [PSQI] >5), who were randomised to receive either a
standardised mindful awareness practices (MAPs) intervention (n=24) or a sleep hygiene education (SHE) intervention
(n=25) for 6 weeks (2 hours per week) as well as assigned homework. In intent-to-treat analyses, PSQI scores were
improved from 10.2 at baseline to 7.4 post-intervention in the MAPs group; corresponding values were 10.2 and 9.1,
respectively, in the SHE group. The between-group difference was significant and had an effect size of 0.89. The MAPs
group also demonstrated significant improvement versus the SHE group on secondary health outcomes of insomnia
symptoms, depression symptoms, fatigue interference, and fatigue severity (p<0.05 for all comparisons). Between-group
differences were not observed for anxiety, stress, or inflammatory signalling via nuclear factor (NF)-κB, although NF-κB
concentrations declined significantly over time in both groups (p<0.05).
Comment: Sleep disturbances are extremely common in our elderly population, and medication use is widespread.
Having a non-drug alternative may appeal to some, particularly with other proven health benefits of mindfulness/
meditation becoming more and more evident in the recent literature.
Reference: JAMA Intern Med. 2015;175(4):494-501
Abstract
Association between sauna bathing and fatal cardiovascular
and all-cause mortality events
Authors: Laukkanen T et al.
Summary: The Finnish Kuopio Ischemic Heart Disease Risk Factor Study, a prospective cohort study of a populationbased sample of 2315 middle-aged (42–60 years) men from Eastern Finland, investigated the association of frequency
and duration of sauna bathing with the risk of sudden cardiac death (SCD), fatal coronary heart disease (CHD), fatal
cardiovascular disease (CVD), and all-cause mortality. Baseline examinations were conducted from 1 March 1984
through 31 December 1989. During a median 20.7-year follow-up, 190 SCDs, 281 fatal CHDs, 407 fatal CVDs, and
929 all-cause mortality events occurred. 601, 1513, and 201 participants reported having a sauna bathing session
1 time per week, 2–3 times per week, and 4–7 times per week, respectively. In these 3 groups, the numbers of SCDs
were 61 (10.1%), 119 (7.8%), and 10 (5.0%), respectively. Corresponding values were 89 (14.9%), 175 (11.5%), and
17 (8.5%), respectively, for fatal CHDs; 134 (22.3%), 249 (16.4%), and 24 (12.0%), respectively, for fatal CVDs; and
295 (49.1%), 572 (37.8%), and 62 (30.8%), respectively, for all-cause mortality events. In analyses adjusted for CVD
risk factors, compared with men with 1 sauna bathing session per week, the HR of SCD was 0.78 (95% CI, 0.57 to
1.07) for 2–3 sauna bathing sessions per week and 0.37 (95% CI, 0.18-0.75) for 4–7 sauna bathing sessions per week
(p for trend = 0.005). Similar associations were found with CHD, CVD, and all-cause mortality (p for trend ≤.005).
Compared with men having a sauna bathing session of <11 minutes, the adjusted HR for SCD was 0.93 (95% CI, 0.67
to 1.28) for sauna bathing sessions of 11–19 minutes and 0.48 (95% CI, 0.31 to 0.75) for sessions lasting >19 minutes
(p for trend = 0.002); significant inverse associations were also observed for fatal CHDs and fatal CVDs (p for trend
≤0.03) but not for all-cause mortality events.
Comment: This study was undertaken in Finland, where sauna-going is a huge part of the culture. Although the
association between sauna-going frequency and reduced cardiovascular risk and all-cause mortality was clearly
shown here, causality has not been determined. There may well be confounding lifestyle factors in sauna-goers that
contributed to the positive outcomes.
Reference: JAMA Intern Med. 2015;175(4):542-8
Abstract
Research Review publications are intended for New Zealand
health professionals.
Dr Christopher Tofield
Dr Tofield completed his medical training at St Bartholomew’s and the Royal London Hospital in
London and is now a fulltime General Practitioner in Tauranga. Chris has extensive experience
in medical writing and editing and while at medical school published a medical textbook on
pharmacology. For full bio CLICK HERE.
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