Top 20 Primary Care Research of the Year

Much of the FOAMed material of the past 2-3 years has been heavily biased towards the emergency medicine and critical care scene – not least I suspect because these specialties embrace technology, want to keep up to date with the literature and apply the latest to their patients. Plus the individuals have the attention-span of a meerkat on dexamphetamine!

There hasn’t been a huge amount of FOAMed relevant to primary care. I was disappointed at last year’s Rural Medicine Australia (RMA2012) with how slow and turgid the sessions were – the content was mostly on registrar training and supervision – not much clinical content for experienced rural docs. This was picked up by others who are also evangelical about FOAMed.

Let’s hope next week’s RMA2013 will be better, although it was concerning to hear a fellow rural GP (female, 30s) say that she wouldn’t bother going to RMA13 despite being in Cairns – as the sessions looked so boring and uninspiring! Meducationalists take note!

A small ray of sunshine will be the session on SoMe and FOAMed run by Minh le Cong and colleagues. Let’s hope it is interactive – my spies from the recent GPET13 say that the SoMe session there was not well-received. If I recall correctly, the comments included :

“GPET workshop ended up polarising the audience and putting off a lot of the senior GPs”

“Too much politics, and navel-gazing, not enough actual focus on clinical material, how to access it and why it might change/augment the current modes of teaching / learning”

A shame.

So we have a way to go yet in terms of FOAMed for GPs. There are some great blogs out there (see blog roll) and sites like FOAM4GP are aimed squarely at primary care physicians. My own bias, rural medicine is catered for in part by ruraldoctors.net. There are a host of other great sites out there – I love theNNT.com for evidence-based guidelines on prescribing and treatment – and of course the sites and blogs like lifeinthefastlane.com, BroomeDocs.com, resus.me and prehopsitalmed.com cater for my interest in all things rural and ED/critical care.

To encourage primary care physicians – whether ACRRMs, RACGPs or whatever ilk – they need to be aware how FOAMed can help shape their practice and improve it. Keeping up to date with the literature and interaction with colleagues is one reason to use tools such as twitter, follow blogs or subscribe to RSS feeds and podcasts from valued sources.

An irony of my College (ACRRM) is that our conferences have an academic program – yet frontline clinicians can;t even access journals as (a) they are out in clinics in the bush and (b) they don;t have access. Unlike the RACGP, ACRRM membership doesn’t allow access to online library facilities. A common workaround is to apply for academic status – somehow I managed to blag an ‘adjunct senior lecturer’ in rural medicine via the fact I occasionally teach medical students…many of my colleagues couldn’t be bothered with the form-filling and three month long application process needed.

So I was delighted to see a great paper on ‘top 20 research studies of 2012 for primary care‘. The paper can be accessed HERE, but a summary follows via Australian Doctor author David Brill. It’s good FOAMed and can be accessed at australiandoctor.com.au

TOP TWENTY RESEARCH STUDIES OF 2012 FOR PRIMARY CARE

Diabetes

1. Do patients benefit from intensive treatment of type 2 diabetes aiming for lower blood glucose values? Click here to read the study.

“Based on long-term trials, it can be said with good confidence that intensive control of blood glucose does not lengthen life or decrease nephropathy risk, but doubles the occurrence of hypoglycemia severe enough to warrant intervention. The risks of myocardial infarction and retinopathy are decreased with intensive control, but the sample size was not sufficient to confirm these benefits. Cardiovascular mortality is not decreased, but this result may change with future study.”

2. Does the tighter control of diabetes benefit older adult patients with functional or cognitive impairment? Click here to read the study. 

“Community-dwelling older persons with tightly controlled diabetes are at greater risk of functional decline than those with modestly controlled diabetes. Although this is not a randomised trial, the findings are consistent with other clinical trials showing that tight glycemic control in adults with diabetes does not improve outcomes.”

3. Does home monitoring of blood glucose improve the management on non-insulin-dependent type 2 diabetes? Click here to read the study.

“Home glucose monitoring does not appreciably improve control of blood glucose levels in patients with type 2 diabetes not treated with insulin, lowering HbA1C levels an average of 0.25 percentage points (i.e. from 8.30% to 8.05%) after six or 12 months of use. There does not seem to be a subgroup of patients for whom home monitoring works better. Glucose monitors should be reserved for patients who use insulin.”

Cardiovascular disease

4. Is regular aspirin useful for primary prevention of CVD? Click here to read the study.

“Based on nine studies of more than 100,000 patients, including three fairly recent studies, a total of 254 patients without cardiovascular disease must take aspirin for seven years to prevent one additional person from having a cardiovascular event (myocardial infarction or stroke). Also, there will be one additional major bleeding episode in the same group.”

5. Does treating mild hypertension improve outcomes in patients without CVD? Click here to read the study.

“The treatment of mild hypertension (defined as 140/90 mm Hg to 159/99 mm Hg) in patients without cardiovascular disease does not decrease mortality, coronary heart disease, stroke, or total cardiovascular events. It appears that patients who have mildly elevated blood pressure measurements without symptoms or signs of heart disease do not benefit from treatment.”

6. How effective are statins for primary prevention of CVD in people at low to moderate risk? Click here to read the study.

“This study is a report of patients who are at low to moderate cardiovascular risk (an average 10-year risk of cardiovascular death or myocardial infarction of 6.2%). An example of a patient with a 6% 10-year risk is a 50-year-old man who does not smoke, takes antihypertensives, and has a total cholesterol level of 5.44 mmol/L, an HDL cholesterol level of 1.29 mmol/L) and a systolic blood pressure of 130 mmHg. Physicians and patients should consider whether it is worth taking a medication for 10 years to hopefully be the one in 80 persons who will benefit from it. These fairly high numbers needed to treat for primary prevention in moderate-risk persons incorporate some of the biases of the underlying studies, so they are probably on the optimistic side.”

Infectious disease

7. Does honey ease cough and improve sleep in children with URTI? Click here to read the study.

“A teaspoonful of honey, given alone or with a non-caffeinated liquid before bed, decreases cough frequency and severity while improving the sleep of parents and the child with acute cough. Placebo also works, but not as well. Both honey and placebo give parents an active role in their child’s well-being while not exposing the child to potentially harmful medicines. The American Academy of Pediatrics recommends not giving honey to children younger than 12 months because of the rare risk of botulism.”

8. Are strep throat decision rules effective in ruling out group A beta-haemolytic stroptococcus as a cause of sore throat? Click here to read the study.

“Two commonly used strep scores are as effective as advertised for determining low likelihood of streptococcal pharyngitis in children and adults. Their proper use, advocated in the US by the CDC, can decrease costs by avoiding unnecessary testing.”

9. Does azithromycin increase the risk of cardiovascular death? Click here to read the study.

“For every 1 million courses of azithromycin that are prescribed to adults, there are an additional 49 deaths (number needed to harm = 20,400), mostly from sudden cardiac death. The increase in risk is even greater among those at high baseline risk of cardiovascular death (number needed to harm = 4,081). This is one more reason to avoid inappropriate use of antibiotics and to use amoxicillin instead of azithromycin when appropriate.”

Musculoskeletal disease and exercise

10. Does exercise alleviate depression in patients with chronic illness? Click here to read the study.

“Getting patients with chronic illness on their feet and into exercise programs decreases their depressive symptoms. The response is greater in patients with higher depression scores and in patients who exercise regularly. These results apply to patients with depressive symptoms in general, not just to patients with major depressive disorder.”

11. Does lifestyle intervention reduce the risk of disability in obese adults with type 2 diabetes? Click here to read the study.

“A fairly intensive lifestyle intervention had impressive results, with a significant reduction in disability and loss of mobility. The benefit was associated with the weight loss and the improved physical fitness. Mortality and morbidity data were not reported by the authors.”

12. What is the usual course of acute, and chronic, low back pain? Click here to read the study.

“Most patients with acute low back pain have significant improvement at six weeks, although some still have significant pain at one year after presentation.”

Cancer screening

13. What are the cancer yields, and acceptability, of colonoscopy and FOBT? Click here to read the study.

“FOBT every two years is more acceptable to patients than colonoscopy, and results in a similar cancer yield but a lower yield of advanced adenomas. Although at this point the weight of observational evidence and limited clinical trial evidence supports endoscopic screening every 10 years, for patients who are unwilling to undergo colonoscopy or who cannot afford it, FOBT with semiquantitative faecal immunochemical testing is a good option.”

14. Does prostate cancer screening in asymptomatic men save lives? Click here to read the study.

“After more than a decade of follow-up from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, there appears to be no mortality benefit to screening asymptomatic men for prostate cancer.”

15. Does PSA screening prevent deaths from prostate cancer? Click here to read the study.

“The authors of this evidence review concluded that PSA testing provides a small reduction or no reduction in prostate cancer—specific mortality and increases the risk of harm. If there is a benefit to PSA screening, it is very small. One in eight men has a false-positive result with regular testing, leading to more testing and treatment, which is likely to be harmful.”

Women’s health

16. What is the best interval for repeat BMD testing in older women? Click here to read the study.

“This study suggests that if the results of the initial screening test are normal or reveal only mild osteopenia in the femoral neck, the patient can wait 15 years before having a second examination. Women with moderate osteopenia should be retested five years after the initial screening, and those with severe osteopenia should consider annual testing until they are given a bisphosphonate.”

17. What is the optimal dosage of vitamin D for fracture prevention? Click here to read the study.

“A dosage of 800 IU/day is associated with a lower risk of hip and vertebral fracture among persons older than 65 years. A higher baseline vitamin D level is also associated with lower risk of fracture, but this may be because higher levels are a marker of better health and good health habits.”

18. How do the failure rates of long-acting contraceptives compare to the pill, patch and ring? Click here to read the study.

“The contraceptive failure rate with intrauterine devices and implants is much lower than failure rates with contraceptive pills, patches, and rings. The failure rate was similar to that of depot medroxyprogesterone acetate. The absolute difference in this study was approximately four pregnancies per 100 women-years of use.”

Miscellaneous

19. Do probiotics prevent antibiotic-associated diarrhoea? Click here to read the study.

“Probiotics, live organisms thought to reestablish gastrointestinal flora, are effective in decreasing the likelihood of antibiotic-associated diarrhoea in adults and children. This approach is also effective when using multiple antibiotics to eradicate Helicobacter pylori. It is not clear from this analysis whether one type of probiotic bacterium is better than another.”

20. Will patients experience more pain if they watch when undergoing painful procedures? Click here to read the study.

“Physicians should ask patients to look away or close their eyes before getting an injection or having blood drawn. In this experimental study, patients who received a mild electric shock experienced greater pain scores while simultaneously watching a video of a needle pricking a finger, even though they were fully aware that the video was not of their own hand.”

American Family Physician 2013; 88:380-386

 

FOAMed – it’s the way of the future for all doctors.

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