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Making Education Easy
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 (. I hope you enjoy this edition and I welcome your comments and feedback. Associate Professor Jim Reid
Adjunct prednisone therapy for patients with community-
acquired pneumonia: a multicentre, double-blind, randomised,
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
Abbreviations used in this issue
to clinical stability was significantly reduced in the prednisone group (3.0 days) compared with the placebo group (4.4 days; AMD = age-related macular degeneration
hazard ratio [HR] 1.33; 95% CI, 1.15 to 1.50; p<0.0001). Pneumonia-associated complications until day 30 did not differ CAP = community-acquired pneumonia
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 CVD = cardiovascular disease
1.02; p=0.056). Prednisone-treated patients were more likely than placebo-treated patients to require insulin treatment for FT4 = free thyroxine
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 PSA = prostate-specific antigen
attributed to corticosteroid use were infrequent and similar in both groups.
TSH = thyroid-stimulating hormone
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.
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GP Research Review
Efficacy and safety of LDL-lowering therapy among men
Effects of low blood pressure
and women: meta-analysis of individual data from 174,000
in cognitively impaired
participants in 27 randomised trials
elderly patients treated with
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 more-
Authors: Mossello E et al.
intensive versus less-intensive statin therapy (n=39,612), in this investigation into the effects of statin therapy in women and Summary: This cohort study involved 172 elderly patients
men. Of all 174,149 participants, 46,675 (27%) were women. In these trials, women were generally at lower cardiovascular (mean age 79 years) with overt dementia and mild cognitive risk than were men. Statin therapy had similar absolute effects on 1-year lipid concentrations in both sexes (LDL cholesterol impairment (MCI) attending outpatient memory clinics. 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). At baseline, the mean Mini-Mental State Examination (MMSE) In a Cox analysis adjusted for non-sex differences, the proportional reductions per 1.0 mmol/L reduction in LDL cholesterol score was 22.1, 68.0% had dementia, 32.0% had MCI, 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; and 69.8% were receiving antihypertensive medications. 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% Cognitive decline, defined as a change in MMSE score predicted 5-year absolute cardiovascular risk (adjusted heterogeneity p=0.11). Similarly, sex did not significantly impact the between baseline and end of follow-up (mean 9 months), proportional reductions in major coronary events, coronary revascularisation, and stroke. No adverse effect on rates of cancer was greater among patients in the lowest tertile of daytime incidence or non-cardiovascular mortality was noted for either sex. These net benefits translated into all-cause mortality systolic blood pressure (SBP) (≤128 mm Hg) compared 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; with those in the intermediate tertile (129–144 mm Hg) adjusted heterogeneity p=0.43).
and the highest tertile (≥145 mm Hg) (mean −2.8 vs −0.7 Comment: This is the first study that I have seen demonstrating equal efficacy of statins in lipid reduction extending into
and −0.7, respectively; p≤0.003 for both comparisons). positive outcomes for both men and women. Previously, there have been confounding factors including the protective The associations were significant in the dementia and MCI effect of oestrogen, but this study shows that both sexes of equivalent risk gained benefit with all-cause mortality.
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
Independent commentary by
that low daytime SBP is associated with an increase Associate Professor Jim Reid.
in cognitive decline in patients with mild cognitive Jim Reid graduated in medicine at the impairment and dementia. In the group studied, University of Otago Medical School in nearly 70% were taking antihypertensive medication. Dunedin New Zealand. He had previously Physiologically, BP slowly increases with age, and it is trained as a pharmacist. He undertook his postgraduate work tempting to think that this could be the body's adaptive mechanism to resist a dementing process. It was at the University of Miami in Florida. Currently he is Head of Hippocrates who said "primum nil nocere – first do no Rural Health and Deputy Dean of the School at the Dunedin harm". This calls for just a little more research! School of Medicine. He has a private family medicine practice at the Caversham Medical Centre, Dunedin, Reference: JAMA Intern Med. 2015;175(4):578-85
New Zealand. For full bio .
GP Research Review
Association between vitamin B12 deficiency
Thyroid function and age-related macular
and long-term use of acid-lowering agents:
degeneration: a prospective population-
a systematic review and meta-analysis
based 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
Summary: These researchers examined the association between thyroid-
19,228 controls) and 1 observational study to analyse the effects of long-term use of acid- stimulating hormone (TSH), free thyroxine (FT4) and the risk of incident lowering agents on vitamin B concentration. A significant association was found between age-related macular degeneration (AMD) among 5573 participants aged long-term use of acid-lowering agents and the development of vitamin B deficiency (HR 1.83; ≥55 years from the Rotterdam Study with TSH and/or FT4 measurements 95% CI, 1.36 to 2.46; p=0.00). 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 Comment: This has been commented on previously in this column. Omeprazole is currently
associated with increased risk of AMD, when FT4 values within normal range the most common medication prescribed in New Zealand. It is widely believed to be without (11–25 pmol/L) were categorised into quintiles, participants in the highest FT4 significant side effects, but this is not so. One can now add possible B deficiency to necessary quintile (17.5–24.9 pmol/L) had a 1.34-fold increased risk of developing AMD surveillance, which includes renal function including serum magnesium and sodium, and full compared with people in the middle quintile (15.1–16.2 pmol/L) (95% CI, 1.07 blood count (leucopenia and thrombocytopenia). There is no question that omeprazole and to 1.66; p=0.066). Higher FT4 values in the full range were associated with other protein pump inhibitors are effective, but as doctors we should ask ourselves if the a higher risk of AMD (HR 1.04; 95% CI, 1.01 to 1.06 per 1 pmol/L increase). patients are taking the minimum required dose, if continuous therapy is necessary, and are Higher FT4 levels were similarly associated with a higher risk of retinal pigment there other measures that could control the reflux.
alterations. The association remained unchanged when analyses were limited to euthyroid individuals, when multivariable analyses made additional adjustments Reference: Intern Med J. 2015;45(4):409-16
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 Overview of shorthand medical glossary (OMG)
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.
Politis J et al. Summary: This group of clinicians reviewed 80 electronic discharge summaries issued by the
Comment: While TSH level seems not to be an enhancing factor for the
General Medical Units at the Royal Melbourne Hospital between July 2012 and June 2013. development of AMD, the level of FT4 is. Even if FT4 is in the range of They sought to describe the frequency of inappropriate and ambiguous shorthand used in the "normality", those patients with levels at the upper limits of the scale had summaries. All abbreviations were categorised according to appropriateness: 1. ‘Universally an increased risk of developing AMD. This is an interesting observation, and accepted and understood even without context'; 2. ‘Understood when in context'; 3. ‘Understood merely demonstrates the association between FT4 and AMD, which may but inappropriate and/or ambiguous'; and 4. ‘Unknown'. These categories were determined by or may not have clinical implications. It is a matter of watching for further 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/ Reference: BMC Medicine. 2015;13:94
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
Impact of a printed decision aid on
abbreviations occur in discharge letters at a frequency of one in five words. It is inappropriate patients' intention to undergo prostate
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 cancer screening: a multicentre,
different to those coming from neurology. I could include a few from my own discipline of pragmatic randomised controlled trial
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! in primary care
Authors: Tran VT et al.
Reference: Intern Med J. 2015;45(4):423-7
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
to read previous issues of GP Research Review 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 or prostate cancer (123 patients [20.9%] vs 57 patients [9.8%]; p<0.0001). In vention group, fewer men expressed that cancer screening would protect compared with controls (p<0.0001), while a greater ted that prostate cancer screening would not benefit their health y 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.
ence: Br J Gen Pract. 2015;65(634):e295-304
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GP Research Review
Choosing wisely: adherence by
Evidence-based natural health by Dr Chris Tofield
physicians to recommended
use of spirometry in the
Mindfulness meditation and improvement in sleep quality
diagnosis and management
and daytime impairment among older adults with sleep
of adult asthma
disturbances
Authors: Black DS et al.
Authors: Sokol KC et al.
Summary: This study was conducted at a medical research center with 49 older adults (aged ≥55 years) reporting
Summary: These US-based researchers retrospectively
moderate sleep disturbances (Pittsburgh Sleep Quality Index [PSQI] >5), who were randomised to receive either a analysed data from a privately insured adult population in standardised mindful awareness practices (MAPs) intervention (n=24) or a sleep hygiene education (SHE) intervention this examination of trends in spirometry use in subjects (n=25) for 6 weeks (2 hours per week) as well as assigned homework. In intent-to-treat analyses, PSQI scores were newly diagnosed with asthma over a 10-year period improved from 10.2 at baseline to 7.4 post-intervention in the MAPs group; corresponding values were 10.2 and 9.1, (2002–2011). Guidelines issued by the National Asthma respectively, in the SHE group. The between-group difference was significant and had an effect size of 0.89. The MAPs Education and Prevention Program (NAEPP) and the group also demonstrated significant improvement versus the SHE group on secondary health outcomes of insomnia American Thoracic Society state that physicians should use symptoms, depression symptoms, fatigue interference, and fatigue severity (p<0.05 for all comparisons). Between-group spirometry in the diagnosis and management of asthma. differences were not observed for anxiety, stress, or inflammatory signalling via nuclear factor (NF)-κB, although NF-κB This study hypothesised that spirometry use would increase concentrations declined significantly over time in both groups (p<0.05).
in physicians who care for asthma patients, especially since 2007, after the release of the revised NAEPP guidelines. Comment: Sleep disturbances are extremely common in our elderly population, and medication use is widespread.
Of 134,208 patients found to have a diagnosis of asthma, Having a non-drug alternative may appeal to some, particularly with other proven health benefits of mindfulness/ only 47.6% had spirometry performed within 1 year (± 365 meditation becoming more and more evident in the recent literature.
days) of the initial date of diagnosis. Younger patients, males, and those residing in the Northeast were more likely to Reference: JAMA Intern Med. 2015;175(4):494-501
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 Association between sauna bathing and fatal cardiovascular
many as 78.3% of patients were prescribed asthma drugs.
and all-cause mortality events
Comment: Although I have no authoritative recent data
Authors: Laukkanen T et al.
originating in New Zealand, it is my feeling that while Summary: The Finnish Kuopio Ischemic Heart Disease Risk Factor Study, a prospective cohort study of a population-
still underutilised, spirometry (or at least the interest in based sample of 2315 middle-aged (42–60 years) men from Eastern Finland, investigated the association of frequency spirometry) is on the increase in primary care. In some and duration of sauna bathing with the risk of sudden cardiac death (SCD), fatal coronary heart disease (CHD), fatal instances it is imposed in order to get special approvals cardiovascular disease (CVD), and all-cause mortality. Baseline examinations were conducted from 1 March 1984 for medications, and it is also used in differentiating through 31 December 1989. During a median 20.7-year follow-up, 190 SCDs, 281 fatal CHDs, 407 fatal CVDs, and between COPD and asthma. The reviewer has delivered 929 all-cause mortality events occurred. 601, 1513, and 201 participants reported having a sauna bathing session a number of workshops / lectures around the country 1 time per week, 2–3 times per week, and 4–7 times per week, respectively. In these 3 groups, the numbers of SCDs and high-quality spirometry can be achieved in the were 61 (10.1%), 119 (7.8%), and 10 (5.0%), respectively. Corresponding values were 89 (14.9%), 175 (11.5%), and primary care setting. This study showed that fewer 17 (8.5%), respectively, for fatal CHDs; 134 (22.3%), 249 (16.4%), and 24 (12.0%), respectively, for fatal CVDs; and than half of patients diagnosed with asthma had 295 (49.1%), 572 (37.8%), and 62 (30.8%), respectively, for all-cause mortality events. In analyses adjusted for CVD confirmatory spirometry within 1 year of diagnosis, and risk factors, compared with men with 1 sauna bathing session per week, the HR of SCD was 0.78 (95% CI, 0.57 to the use as a diagnostic aid (at least in the US) began 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 decline from 2007. My gut feeling is that this not the (p for trend = 0.005). Similar associations were found with CHD, CVD, and all-cause mortality (p for trend ≤.005). state in NZ, but it would be nice to show this objectively.
Compared with men having a sauna bathing session of <11 minutes, the adjusted HR for SCD was 0.93 (95% CI, 0.67 Reference: Am J Med. 2015;128(5):502-8
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
Privacy Policy: Research Review will record your email details on a secure database and will not release them to anyone without your association between sauna-going frequency and reduced cardiovascular risk and all-cause mortality was clearly prior approval. Research Review and you have the right to inspect, shown here, causality has not been determined. There may well be confounding lifestyle factors in sauna-goers that update or delete your details at any time.
contributed to the positive outcomes.
Disclaimer: This publication is not intended as a replacement for regular medical education but to assist in the process. The reviews are a summarised interpretation of the published study and reflect Reference: JAMA Intern Med. 2015;175(4):542-8
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. Research Review publications are intended for New Zealand 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
Time spent reading this publication has been approved for CME for Royal New Zealand College of General Practitioners (RNZCGP) General Practice Educational Programme Stage 2 (GPEP2) and the Maintenance of Professional Standards (MOPS) purposes, provided that a Learning Reflection Form is completed. Please to download your CPD MOPS Learning Reflection Form. One form per review read would be required.
Time spent reading this publication has been approved for CNE by The College of Nurses Aotearoa (NZ) for RNs and NPs. For more informa.
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