Abstract
Website of the month
The Infant and Toddler Forum is an online training programme to support the ‘Making Every Contact Count’ initiative. It contains tests and information. I liked the downloadable fact sheet with ideas and suggestions about ‘Healthy Conversation Skills’.
www.infantandtoddlerforum.org/health-childcare-professionals/healthy-conversation.
Fibroids and pregnancy
A prospective study of over 5000 women in pre- or early pregnancy has shown that about 10% had at least one fibroid detectable by transvaginal ultrasound, but that there was no association between the presence of fibroids and risk of miscarriage.
Hartmann K, Velez Edwards D, Savitz D, et al. (2017) Prospective cohort study of uterine fibroids and miscarriage risk. American Journal of Epidemiology 186(10): 1140–1148. DOI: 10.1093/aje/kwx062.
Bariatric surgery
A large American study has shown that more than a third of patients undergoing bariatric surgery achieved a body mass index (BMI) of less than 30 within a year. The best predictor of this was a BMI less than 40 at the outset. Conversely, fewer than one in ten people with a BMI of more than 50 before surgery succeeded in reducing it below 30 after surgery. This adds to the debate about when people are ‘fat enough’ to be referred.
Varban O, Cassidy R, Bonham A, et al. (2017) Factors associated with achieving a body mass index of less than 30 after bariatric surgery. Journal of the American Medical Association of Surgery 152(11): 1058–1064. DOI: 10.1001/jamasurg.2017.2348.
Palliative care
The number of people who will need palliative care is set to rise by approximately 40% to 530 000 by 2040. This is thought to be as a result of the number of people diagnosed with dementia and cancer. Taking this into account, the National Institute for Health and Care Excellence (NICE) has produced updated guidelines for clinicians and key professionals to provide high-quality palliative and end-of-life care. The RCGP and the charity Mary Curie, have worked in partnership to develop the ‘Daffodil Standards’, a voluntary structured approach for practices to use quality improvement methodology to improve care for patients who are approaching end of life or may be approaching an advanced stage of serious illness. The Daffodil Standards, consisting of eight standards for the care of patients and the support of families and carers, are currently being piloted in selected GP practices throughout the UK, to evaluate their use in primary care. You might want to consider the implications for your own practice or area.
Millington-Sanders C and Noble B (2018) New UK General Practice Core Standards for Advanced Serious Illness and End of Life Care. British Journal of General Practice 68(668): 114–115. DOI: 10.3399/bjgp18X694913.
Exercising in old age
Exercise in older men can reduce mortality by 17%, a recent study in the British Journal of Sports Medicine has found. This prospective cohort study recruited men from United Kingdom general practice in 1978–1980 and followed them up 20 years later. The findings showed that men who accumulated more minutes of activity from light intensity upwards were associated with lower all-cause mortality. The results also showed that accumulating any intensity level of physical activity up to a target of 150 minutes per week, was linked to a lower risk of death. Each additional 30 minutes a day of light activity, such as walking the dog or gentle gardening, was associated with a 17% lower risk of death. This means that our current physical activity guidelines for older adults could be changed to make them more achievable for those with low activity levels and stressing the benefits of all activities, even very gentle ones.
Jefferis B, Parsons T, Sartini C, et al. (2018) Objectively measured physical activity, sedentary behaviour and all-cause mortality in older men: Does volume of activity matter more than pattern of accumulation? British Journal of Sports Medicine. Epub ahead of print 12 February 2018. DOI: 10.1136/bjsports-2017-098733.
Anticoagulants and surgery
One of my patients had a stroke when he was taken off his warfarin prior to a surgical procedure. We recently received a pre-printed hospital letter asking us to confirm that an elderly patient could come off the anticoagulant 3 days before a minor surgery procedure. The same letter also informed us that they would still go ahead with the surgery if she remained on her anticoagulant. This prompted me to do some reading.
There are no national guidelines on how such patients should be managed. An article in GM, written by clinicians from the Royal Wolverhampton NHS Trust, has created flow charts for the cessation of warfarin and antiplatelet medication, and DOACs (direct oral anticoagulants). The focus is on balancing risk of bleeding against the risk of an ischemic event, including suggesting deferring procedures if there is a short-term increased risk of ischaemia, for example recent myocardial infarction or stroke
McNeela N, Srinivasan M and Barker V (2017) Cessation of antiplatelets and anticoagulation peri-procedure. GM 47(11): 24–27.
Perinatal mental health
An interesting article by a woman who had post-partum depression describes how health professionals missed opportunities to find out about her illness. It also reminds us that women can be worried that if they say they are ill then their babies might be taken away from them.
Anonymous (2017) Maternal mental health: Handle with care. BMJ 359(8129): 248.
New options for sickle cell disease
One of our friends died in his 40 s from complications of his sickle cell disease, so I am probably more alert to advances in treatment. I found the article discussing the risks and benefits of haematopoietic stem cell transplantation to be thought-provoking. I have not yet been asked to discuss this with a patient.
De Montalembert M, Chakravorty S, Pagliuca A, et al. (2017) Too high a price to pay? Treating children with sickle disease. BMJ 359(8131): 318–320.
Anticoagulation
New findings from a UK primary care study have shown that there is an increased rate of ischaemic stroke and haemorrhage in patients over 65 years old who are given anticoagulants with atrial fibrillation (AF) and chronic kidney disease (CKD). However, there is a lowered rate of all-cause mortality. Clinicians should have a discussion with their patients before starting anticoagulants in older people with CKD who develop AF, as there is a lack of randomised controlled trials to provide clarity on correct clinical management for this subset of patients.
Kumar S, De Lusignan S, McGovern A, et al. (2018) Ischaemic stroke, haemorrhage, and mortality in older patients with chronic kidney disease newly started on anticoagulation for atrial fibrillation: a population based study from UK primary care. BMJ 360: k342. DOI: 10.1136/bmj.k342.
Evidence behind the headlines
There are multiple studies recommending different diets and activities to help people lose weight and reduce their blood sugars. NHS Choices publishes a ‘Behind the Headlines’ section. A recent one discusses the detailed evidence behind recent newspaper headlines ‘diet and exercise are better than drugs at controlling diabetes’. I think it is really helpful to have evidence discussed in easy-to-understand language. Browsing other topics, I found a helpful summary of the recent debate about the efficacy of prostate screening.
www.nhs.uk/news/diabetes/weight-management-may-reduce-need-type-2-diabetes-medication/.
www.nhs.uk/news/cancer/routine-blood-test-prostate-cancer-doesnt-save-lives/.
Surgery and BRCA
A large prospective study has shown that for at least the first 10 years, the survival after treatment for invasive breast cancer for women with and without BRCA (tumour suppressor genes) mutation is no different. This is likely to change the conversation about urgent double mastectomies for such women.
Copson E, Maishman T, Tapper W, et al. (2018) Germline BRCA mutation and outcome in young-onset breast cancer (POSH): A prospective cohort study. The Lancet Oncology 19(2): 169–180.