Journals Watch - HbA1c, proteinuria and obesity

Missed the latest research papers? Dr Jane Barnard brings you up to date with the current journals.

Testing for minimum HbA1c may be useful because low levels are also linked to an increase in mortality
Testing for minimum HbA1c may be useful because low levels are also linked to an increase in mortality

Minimum and maximum HbA1c targets Lancet 2010; 375: 481-9

This study questions the safety of aiming for a target HbA1c figure. Patients with type-2 diabetes were identified using the UK General Practice Research Database from November 1986 to November 2008. The primary outcome measurement was all-cause mortality.

The results demonstrated a general U-shaped pattern with the lowest HbA1c decile (6.1-6.6 per cent) and the highest HbA1c decile (10.1-11.2 per cent) - having the highest adjusted hazard ratios compared with the lowest hazard ratio seen in the median HbA1c decile of 7.5 per cent.

In other words, high and low HbA1c values appear to be associated with an increase in all-cause mortality and cardiac events. It may be that after further research we have another target to include - not only a maximum but a minimum HbA1c value.

Safety of venlafaxine compared with other antidepressants BMJ 2010; 340:c249

Venlafaxine has come in and out of favour as an antidepressant, but with cardiac side-effects as a worrying complication.

This research paper looked specifically at sudden cardiac death or near death in venlafaxine users compared with users of other commonly prescribed antidepressants.

The patients included had anxiety or depression and were on newly prescribed venlafaxine, fluoxetine, citalopram or dosulepin in 1995. They were followed up until 2005.

Key complications identified were non-fatal acute ventricular tachyarrhythmia, sudden death due to cardiac causes, or out of hospital deaths from acute ischaemiac cardiac events.

Interestingly, this large population-based study found no significant difference between venlafaxine compared with the other commonly prescribed antidepressants in rates of death or near death due to cardiac complications.

Effectiveness of different approaches in the management of UTI BMJ 2010; 340: c199

This study looked at some of the possible management options when faced with a patient with UTI symptoms and compared the outcome of each of these options.

The study was a small randomised controlled study with patients being randomised into five management approaches; empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on either a symptom score (two or more out of urine cloudiness, urine smell, nocturia or dysuria); a dipstick result (nitrite or both leucocytes and blood); or a positive result on MSU analysis.

All management strategies achieved similar symptom control. There was no advantage in sending an MSU for testing. Dipstick tests with a delayed prescription as backup, or empirical delayed prescription, helped to reduce antibiotic use.

Relationship between kidney function, proteinuria and adverse outcomes

JAMA 2010; 303(5): 423-9

When managing chronic kidney disease, a urine dipstick test is recommended. I found this particular article very interesting in terms of the importance of the dipstick test result and the likely patient outcome in terms of all-cause mortality, MI and progression to kidney disease.

This community-based cohort study found that adjusted mortality was twofold higher among individuals with heavy proteinuria on dipstick and an eGFR of 60ml/min/1.73m2 or greater, compared with those with an eGFR of 45-59.9ml/min/1.73m2 and normal protein excretion.

The risk of mortality and complications increases with a reduction in the level of eGFR but is also increased in patients with higher levels of proteinuria.

Dipstick testing is vital in truly getting a grasp of those patients with chronic kidney disease.

Non-surgical weight loss for extreme obesity in primary care Arch Intern Med 2010; 170: 146-54

Constantly hitting the headlines are the concerns over the increasing weight of our nation.

The Louisiana Obese Subjects Study (LOSS) tested whether with brief training, primary care practices could effectively implement weight loss for individuals with a BMI of 40-60.

It compared two groups of patients to either intensive medical intervention or usual care. Unsurprisingly, the intense intervention group involving a 900 kcal liquid diet for 12 weeks or less, group behavioural counselling, structured diet and choice of pharmacotherapy fared best.

The authors concluded that primary care practices can initiate effective management for extreme obesity and avoid the need for surgery.

That is all well and good, but the pharmocotherapeutic options are dwindling and intensive weight loss programmes seem few and far between in the NHS.

The role of a GP in back pain and work rehabilitation Fam Pract 2010 27: 31-7

Back pain continues to be one of the main causes of sickness absence and lower back pain can and does affect work ability.

The government continues to give responsibility to GPs for the issue of sickness certification and yet this study demonstrated that our knowledge of work rehabilitation is minimal and that effective communication between GPs, patients' employers and therapists is minimal.

A total of 76 per cent of GPs who answered this postal questionnaire reported that they did not take overall responsibility for managing a patient's work problems.

Only 2.5 per cent reported that they initiated communication with employers and 10 per cent initiated communication with therapists regarding their patient's work ability.

The conclusion of the authors was that the current expectations of a GP's role in work ability may be unrealistic and consideration on training or an alternative means of managing this problem is needed.

  • Dr Barnard is a GP in Yateley, Hampshire, and a member of our team who regularly review the journals

THE QUICK STUDY

  • HBA1c is associated with an increase in mortality if too low as well as too high.
  • Venlafaxine causes no significant increase in cardiac death compared with other commonly used antidepressants.
  • UTI management can be adapted to reduce antibiotic use.
  • Proteinuria assists in assessing long-term prognosis in patients with abnormal eGFR results.
  • Obesity management in primary care can achieve weight reduction in those with a BMI between 40 and 60.
  • Work rehabilitation in back pain patients is currently poorly managed.

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