Clinical round-up: April
Top journal papers for April
Adding an intensive lifestyle change programme alongside drug therapy for patients with type 2 diabetes reduced their HbA1c levels back to the normal range, and induced remission in other patients.
A Canadian RCT found that, compared with standard care, an eight- or 16-week intervention, alongside drug management, saw 21% and 41% of patients achieve partial or complete remission at 12 weeks post-intervention, respectively, compared with 10% and 14% for the control group.
For glucose control, 50% and 70% of patients in the eight- and 16-week intervention groups, respectively, achieved normal glucose levels in the final week of treatment, compared with just 4% in a control groups.
Patients were assigned to an intensive diet and exercise programme while taking insulin glargine, metformin and acarbose.
Dr Natalie McInnes, lead author and endocrinologist at MacMaster University, Ontario, said: ‘The finding that up to 41% of the intervention group maintained partial or complete remission 12 weeks after stopping challenges the notion that type 2 diabetes is a permanent and progressive disease.’
J Clin Endocrinol Metab 2017, online 15 Mar
GPs should avoid prescribing oral and topical antibiotics for mildly infected eczema as they are of little benefit in clearing infection.
Researchers from the University of Cardiff found antibiotics provided little to no advantage over topical corticosteroids in clearing up mildly infected eczema. Eczema symptom scores in patients taking a topical or oral antibiotic plus placebo, or just two placebos, showed similar levels of improvement over the following weeks.
The study featured 113 children aged between three months and seven years. All were given a topical corticosteroid and emollients, alongside placebos or antibiotics.
GP and lead author Dr Nick Francis, clinical reader at the University, said: ‘Providing or stepping up the potency of topical corticosteroids and emollients should be the main focus in the care of milder clinically infected eczema flares.’
Ann Fam Med, online Mar 2017
Giving patients with type 2 diabetes more time with practice nurses leads to earlier insulin uptake and better outcomes, according to new research from the University of Melbourne, Australia.
Investigating a model of care whereby practices nurses lead on insulin treatment as part of routine care, the team found insulin initiation rates in primary care rose from 22% to 70%. As a result, patients were twice as likely to have better HbA1c levels compared with controls given usual care.
The Stepping Up care model sees practice nurses trained and mentored by a registered nurse certified as a diabetes educator. As part of the research, the practice nurses then examined 266 patients with diabetes.
Lead author Professor John Furler, a GP in Melbourne, said: ‘With appropriate support and redesign of the practice system, insulin initiation can become part of routine diabetes management in primary care.’
BMJ 2017, online 8 Mar
Antibiotics may be a safe alternative to surgery in children with appendicitis.
A meta-analysis from the University of Southampton found antibiotics to be effective in 97% of children treated for acute non-complicated appendicitis, with no adverse effects or events, compared with those undergoing surgery.
But the rate of recurrent appendicitis in children receiving non-surgical treatment was 14%. And despite the effectiveness, the team concluded that ‘longer-term clinical outcomes and cost-effectiveness of non-operative treatment require further evaluation’.
Paediatrics 2017, online Feb
GPs should pay more attention to gambling addiction, as one in 20 of their patients may have a problem.
Academics at the University of Bristol found that 4.5% of patients surveyed at GP surgeries in Bristol reported having a low to moderately severe gambling problem, while 7% reported a problem among their family members.
Gambling problems were higher among males aged 16-24, people who used drugs, those who had problems with alcohol and those with depression.
In total, more than 1,000 patients were surveyed across 11 GP practices. Patients completed anonymous questionnaires that included questions about possible addictive behaviours.
Lead author Dr Sean Cowlishaw, research fellow at the Centre for Academic Primary Care at the university, said: ‘In this study we wanted to measure the extent of the problem and identify who is most vulnerable so that we can start to think about how primary care services might be able to help.’
BJGP 2017, online 13 Mar
A new screening tool can help GPs identify which symptomatic patients under 50 are most likely to have bowel cancer, and help prioritise who to refer for colonoscopy.
Developed by researchers at the universities of Durham, Exeter and North Tees after a case control study, the tool is the first to quantify bowel cancer risk based on a combination of symptoms. Patients with a >3% risk should be sent for colonoscopy, while those whose risk falls between 1% and 3% should be referred for a faecal calprotectin test to rule out inflammatory bowel disease.
GP and professor of primary care diagnostics at the University of Exeter Professor Willie Hamilton said: ‘It doesn’t replace clinical judgement but provides information for a referral decision.’
BJGP 2017, online 28 Mar
CPD Tip of the month
How to treat chronic plaque psoriasis
If you have a patient with chronic plaque psoriasis, you can try the following treatments:
- Start with Dovobet gel – it’s easier to use across a wide surface area
- When the plaques are flat, swap to Dovonex
- If there are plaques on the genitals or face, Silkis is a good option as it is less of an irritant
- If the plaques are very scaly, try Diprosalic ointment
- Thinner plaques tend to respond well to Exorex lotion
If all the above fail, refer to secondary care for alternative therapies.
Video module: managing psoriasis (1 CPD hour)