Journals watch - Gallstones, NSAIDs and diabetes

A research round-up for GPs by Dr Jonathan Holliday.

Gallstones: family history seemed a more relevant risk than age
Gallstones: family history seemed a more relevant risk than age

Gallstones: fair, fat and 40?

Postgrad Med J 2013; doi 10.1136/postgradmedj-2012-131341

This group of surgeons in Dublin looked at 398 patients admitted to hospital with upper abdominal pain over a one-year period to assess the accuracy of the 'five Fs' gallstones mnemonic.

The study split the patients into two groups: those with and those without sonographic evidence of cholelithiasis.

'Fair' was acceptable, with 63% of the cholelithiasis group versus 32% of the control group.

'Fat' was also acceptable, with 28% of the study group having a BMI >30, compared with 9.5% of the control group.

'Female' held true, with 75% versus 55%, as did 'fertile', with 68% versus 25%.

'Over 40' was not so accurate, at 41.5% versus 39.5%. In its place, the authors suggest 'family history', because 39.4% had a positive family history in at least one first-degree relative, compared with 13% of controls.

GPs' suspicion of cancer

Br J Gen Pract 2013; 63: 472-3

In this study, a one-page questionnaire was sent to all GPs registered in Norway. During 10 days, 396 (10%) GPs registered cancer suspicion that occurred when a patient presented with at least one of seven focal symptoms (such as lump/nodule, unusual bleeding, pigmented skin lesion) and three general symptoms (unintentional weight loss, unusual fatigue, unusual pain).

The study had a population of 51,073, of whom 6,321 had warning signs for cancer. A total of 263 patients had a subsequent cancer diagnosis; 106 of these had presented with warning signs.

GPs had assessed the possibility of cancer in 85% who presented with warning signs; 24% of those with warning signs assessed for cancer risk were considered 'cancer possible' and 61% 'cancer not likely'.

Overall, 3.8% of the positive suspicions proved correct, but 0.6% of patients previously assessed as 'cancer not likely' were subsequently diagnosed with cancer.

So they seemed to fail to assess cancer risk in 15% of patients with symptoms commonly considered to be warning signs of cancer, and get it wrong in 0.6% of patients with warning signs where such risk was considered. Coexisting multiple pathologies were shown to increase diagnostic delay.

Comorbidity and a consultation not being the first for that symptom should arouse more suspicion.

Side-effects of NSAIDs

Lancet 2013; 382: 769-79

This paper reported meta-analyses of 754 randomised trials examining the effects of NSAIDs, including COX-2 inhibitors, and comparing NSAIDs against placebo and against other NSAIDs. The main outcomes were major vascular events, major coronary events, stroke, mortality, heart failure and upper GI complications.

Major vascular events were increased by about a third by a coxib or diclofenac, mainly due to an increase in major coronary events.

Ibuprofen increased major coronary events but naproxen did not appear to do so. Compared with placebo, of 1,000 patients prescribed a coxib or diclofenac for a year, three more will have a major vascular event, one of whom will die. Heart failure risk was roughly doubled by all NSAIDs.

All NSAIDs increased the risk of upper GI complications, varying from coxibs at 1.81, through diclofenac at 1.89 and ibuprofen at 3.97, to naproxen at 4.22.

Cardiovascular outcomes of saxagliptin in diabetes

N Engl J Med 2013; DOI: 10.1056/NEJMoa1307684

In this study of 16,492 patients with type 2 diabetes who were at risk of, or had a history of, cardiovascular events, patients were randomly assigned to receive saxagliptin or placebo and were followed for a median of 2.1 years.

Physicians were allowed to adjust other medications, including other antihyperglycaemics. The endpoint was a combination of cardiovascular death, MI or ischaemic stroke.

A primary endpoint occurred in 613 patients in the saxagliptin group and in 609 in the placebo group (7.3% and 7.2% respectively).

Figures for acute and chronic pancreatitis were similar for both groups but more patients were hospitalised for heart failure in the saxagliptin group than in the placebo group (3.5% versus 2.8%).

The authors conclude that while saxagliptin improves glycaemic control, other approaches are required to reduce cardiovascular risk.

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

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

  • Review all cases of cholecystitis and cholecystectomy in your practice over the past 12 months and review the time to diagnosis and use of ultrasound in making the diagnosis.
  • Undertake a search to establish the relative use of coxibs, diclofenac, naproxen and ibuprofen in your practice. Discuss the results of this at a clinical practice meeting and agree a prescribing policy in relation to NSAIDs.
  • Consider how you discuss cardiovascular risk with diabetes patients and what approaches can be taken to reduce the risk.

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