Journals Watch - Diabetes and smoking cessation

Not had time to read the journals? Dr Jonathan Holliday brings you up to date on the latest research.

Thirty-nine per cent of GPs reported having a protocol for the management of gestational diabetes (Photograph: SPL)
Thirty-nine per cent of GPs reported having a protocol for the management of gestational diabetes (Photograph: SPL)

Missed opportunities for diabetes prevention
Br J Gen Pract 2011; 61: 609-10

The link between gestational diabetes mellitus (GDM) and later diabetes is well known and as a consequence, NICE recommends testing fasting plasma glucose (FPG) at six weeks postpartum and annually thereafter. But how many of us have systems in place?

This paper examined practice in primary and secondary care and perceptions of where responsibility lies. The study found that 39% of GP respondents had a protocol for managing GDM. Most GPs (79%) were informed by hospital letter that women had GDM and 80% reported women having tests to exclude continuing diabetes.

Forty-five per cent of GPs thought they had the responsibility for short-term follow-up (six weeks postpartum), while 26% thought secondary care had the responsibility.

Thirty-nine per cent of GPs recalled women for long-term follow-up, while another 35% advised women with GDM to attend for future annual follow-up with FPG. This highlights the difficulties many GPs have in knowing whether responsibility lies with them or the hospital, and the difficulty that many GPs have ensuring that annual blood tests are performed.

Comparing bivalent and quadrivalent HPV vaccines
BMJ 2011; 343: d5775

This study aimed to compare the effect and cost-effectiveness of bivalent and quadrivalent HPV vaccination, taking into account differences in licensed indications, protection against non-vaccine type disease (for example, penile, oropharyngeal and anal cancers), protection against disease related to HPV types 6 and 11, and reported long-term immunogenicity.

The bivalent vaccine needs to be cheaper than the quadrivalent to be equally cost-effective, largely because of its lack of protection against anogenital warts. The study concluded that the quadrivalent vaccine may have advantages in reducing healthcare costs and quality adjusted life years (QALYs) lost, while the bivalent vaccine may have advantages in preventing death due to cancer. But considerable uncertainty remains about the differential benefit of the two.

Point-of-care CD4 cell counts and antiretroviral therapy
Lancet 2011. doi:10.1016/S0140-6736(11)61052-0

Loss to follow-up of HIV-positive patients can exceed 50% in low-income settings. This trial of point-of-care CD4 cell counting at four clinics in Mozambique assessed the effect on loss to follow-up before immunological staging and treatment initiation.

After the introduction of point-of-care CD4 testing, the proportion of patients lost to follow-up before CD4 staging fell from 57 to 21%, while the loss to follow-up before initiation of treatment fell from 64 to 33%. Furthermore, the median time from enrolment to initiation of antiretroviral reduced from 48 to 20 days. Not only does point-of-care CD4 staging reduce pretreatment loss to follow-up, it also reduces the time HIV-positive patients go without treatment.

Saw palmetto extract for lower urinary tract symptoms
JAMA 2011; 306(12): 1344-51

Saw palmetto fruit extracts are widely used for treating lower urinary tract symptoms attributed to benign prostatic hypertrophy. Recent clinical trials questioned its efficacy, so this RCT of 369 North American men assessed its efficacy at three times the standard dose.

The trial was conducted over 72 weeks with increases in dose at 24 and 48 weeks. Outcomes were measured using the American Urological Association symptom index score. Saw palmetto achieved a reduction in the score from 14.4 to 12.2 points, but placebo did rather better, reducing it from 14.7 to 11.7. The authors concluded that increasing doses of saw palmetto did not reduce lower urinary tract symptoms more than placebo.

The role of cytisine in smoking cessation
N Engl J Med 2011; 365: 1193-1200

Cytisine is a partial agonist that binds with high affinity to nicotinic acetylcholine receptors. It is a low-cost treatment and this study was designed to assess its efficacy and safety compared with placebo.

In this trial, subjects were randomly assigned to receive cytisine or matching placebo for 25 days. Subjects in both groups received a minimal amount of counselling. There were 370 people in each group.

After 12 months the rate of sustained, biochemically verified abstinence was compared for the two groups. The cytisine group rate was 8.4%, while the placebo group was 2.4%. GI adverse events were reported more frequently in the cytisine group.

While not achieving particularly high figures for success, the low cost of cytisine may make it suitable for advancing smoking cessation globally.

BMI at the age of 25 years and all-cause mortality
J Adolesc Health doi:10.1016/j.jadohealth.2011.06.006

About 20% of young adults in the US are obese and most gain weight in young to middle adulthood. This study examined the association between elevated BMI in early adulthood and later mortality.

The study used data from 13,941 adults who self-reported their weight at age 25 years and had their weight and height measured when they were 45-64 years old (1987-1989). Date of death was ascertained between 1987 and 2005. In the combined ethnic-gender groups, the hazard ratio associated with a 5kg/m2 increase in BMI at age 25 was 1.28 and the hazard difference was 2.75 deaths per 1,000 person-years. This increased death rate is independent of changes in weight later in life.

  • Dr Holliday is a GP in Berkshire and a member of our team who regularly review the journals

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Run an audit searching for all cases of GDM and establishing the proportion who have had follow-up as in NICE guidelines.
  • Review the practice arrangements for annual follow-up of blood tests such as FPG in GDM patients and serial PSA in men at risk.
  • Consider auditing smoking cessation, including the success of interventions your practice employs.

 

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