Alopecia, bariatric surgery and muscle relaxants for low back pain: journals update September 2016

Recent research of interest to GPs.

Male alopecia may be associated with raised cardiovascular risk

Alopecia in males and cardiovascular risk1

General practice is in a great position to offer preventive advice and early detection of asymptomatic risk factors or conditions in a wide, unfiltered selection of patients.

Therefore it can be important to consider any established associations between external or measurable features and potential subtle disease and act on them, if practical.

Study design
This cross-sectional study examined previous research suggestions that there could be an association between androgenic alopecia (AGA) and aortic stiffness, as well as impaired coronary microcirculation, in men who have untreated hypertension.

A total of 101 men with newly diagnosed and untreated hypertension and AGA at various levels of severity were checked for any impairment of their coronary flow reserve and 24-hour pulse.

Key findings
Coronary flow reserve was shown to be significantly impaired with severe AGA in comparison to moderate AGA (P=.007) or no AGA (P=.02). With the assumption that impaired coronary microcirculation and aortic stiffness precede the development of coronary stenosis, these findings suggest that there is an association of AGA with cardiovascular processes and risks, which are further increased by early onset and therefore overall duration of AGA.

Implications for GPs
Although the number of patients examined was small, the findings add evidence to previous proposals that there is a direct association between AGA and cardiovascular risk.

This means that alopecia may need to be redefined from a cosmetic problem to a potential prompt to opportunistically check BP, particularly in young patients, which a GP might not do routinely. GPs could also consider Read-coding AGA in patients as a condition, to allow audit, searches and further evaluation as these patients age and possibly acquire further cardiovascular risk factors.

Bariatric surgery and addictive behaviour2

This study aimed to review an established addiction screening tool and adjust it for application in post-bariatric surgery patients, who could be at risk of mental health problems and cross-addictions after the rapid weight loss period. Up to now, there has been no validated screening tool to assess the risk for possible cross-addictions in this context.

Study design
This qualitative study on a very small number of post-bariatric surgery patients (n = 12) was based on other related research into the topic, expert advice and the patients themselves.

Post-surgery, the following addictive behaviours emerged and were determined as significant and disruptive for the patient:

  • Alcohol
  • Gambling
  • Shopping
  • Excessive exercise
  • Abnormal eating behaviours
  • Problems regarding sexuality and relationships

Key findings
The findings were reasonably consistent that the risk of developing any of the above addictions increased following bariatric surgery, although there was less agreement regarding use of caffeine, tobacco and prescription or illicit drugs.

Implications for GPs
It could make sense that, when a patient ‘loses’ aspects of a condition, particularly if it is lifestyle related, they may respond with inner conflict and subsequent stress or undesired and even adverse compensatory behaviour.

It could be useful to address this risk early on and use targeted screening for the potential and early identification of such problem behaviours, in specialist services or primary care, so that appropriate support can be arranged to preserve the results achieved by surgery.

Hypertension and cognitive impairment3

There are concerns that treatment of hypertension may not only result in immediate risks of complications such as falls, but also potentially the development or acceleration of other conditions, such as dementia.

Study design
This cohort study of 1,408 older patients looked into the possible influence of orthostatic BP changes on the risk of developing cognitive impairment (CI) or cognitive decline (CD).

Cognitive function was as measured by Mini Mental State Examination scores. An absolute score of ≤24/30 was defined as CI and a three-point score decrease from the baseline to the follow-up examination was regarded as CD.

Key findings
Just over 18% of patients had orthostatic hypotension (a drop of 20mmHg in systolic or 10mmHg in diastolic BP) or orthostatic hypertension (a rise of 20mmHg in systolic BP) at baseline.

At the time of follow-up (4.4 ±1.2 years), 286 participants out of the 1,408 showed signs of CI and 138 had a measurable CD.

The findings suggested that participants with orthostatic hypertension were at significantly higher risk of CD (OR 1.5) and to some degree, also with orthostatic hypotension. There was no apparent association between orthostatic BP changes and CI.

Implications for GPs
Although it remains important to conduct regular medication reviews, particularly in the elderly with possible multipharmacy and an increased risk of side-effects or complications caused by medication, this study suggests that orthostatic hypertension resulting from reasonably robust antihypertensive treatment is not likely to have a significant impact on cognitive function.

However, this is only one aspect of the potential implications of long-term medication, particularly if there is a possibility of increased frailty in the patient. It remains essential to conduct a holistic, pragmatic discussion and appraisal of the expected or perceived benefit, as well as problems, with long-term medication in elderly patients.

Muscle relaxants for patients with lower back pain4

Muscle relaxants are frequently prescribed in primary and secondary care for low back pain (LBP). However, there is not much published evidence regarding the tolerability, safety and efficiency of this practice, which therefore relies more on commonsense than on facts.

Study design
This systematic review and meta-analysis evaluated the efficacy and tolerability of muscle relaxants, such as benzodiazepines, in patients with LBP by searching a number of medical databases with citation tracking for eligible RCTs.

Key findings
The search method used found 15 trials (3,362 participants), out of which, five (496 participants) provided high-quality evidence to confirm clinically significant short-term pain reduction in LBP through use of muscle relaxants. The median adverse event rate for muscle relaxants was similar to placebo (about 15%).

Implications for GPs
It appears that (selected) patients with acute LBP can clinically benefit from muscle relaxants in the short term.

The long-term efficacy of these medications for chronic LBP is mostly unknown, but cannot be recommended, because there could be a risk of implications, such as potential dependency.

The study was quite clear that there could be, in principle, variations in outcomes between different muscle-relaxant products, while the main body of available research relies mostly on data from a few specific muscle relaxant medicines.

High AUDIT-C scores and health risks5

Sometimes, scoring tools may feel academic and therefore somewhat irrelevant for practical medicine in primary care. However, this review examines a possible association of the simple AUDIT-C with immediate health risks.

Study design
This was a cohort study with the involvement of 486,115 male outpatients in the older age group (mean age 68 years).

The study participants had the AUDIT-C questionnaire administered on two occasions 12 months apart, with an evaluation of objective physical findings (HDL cholesterol measurement), as well as measurement of alcohol-related GI hospitalisations and general physical trauma.

Key findings
If the AUDIT-C score increased from low risk to severe misuse, the probability of physical trauma doubled and, for the highest score, the probability of hospitalisation for an alcohol-related GI condition increased threefold. A decreased AUDIT-C score was significantly associated with a decrease in HDL cholesterol.

Implications for GPs
It is interesting and probably important to acknowledge that the AUDIT-C screening questionnaire is not just a snapshot risk assessment tool, but appears to have some predictive validity for tangible, objective clinical outcomes in subsequent months.

Therefore it could be used as a stepping stone for discussion with a patient who may be at risk, to share concerns about short- and long-term outcomes of drinking behaviour on a fairly basic but practical level, which is probably quite relevant to the patient.

Unfortunately, the findings were inconsistent regarding patients who decreased their alcohol intake from higher to lower AUDIT-C risk groups at the follow-up evaluation, although one would expect a reduction of risks, but this should not stop clinicians promoting moderation of alcohol intake, when the opportunity arises.

  • Dr Jacobi, is a GP in York

Reflect on this article and add it to your CPD organiser on MIMS Learning


  1. J Clin Hypertens (Greenwich) 2016; Jul 1 doi: 10.1111/jch.12871
  2. J Am Assoc Nurse Pract 2016; Jul 11 doi: 10.1002/2327-6924.12390
  3. Hypertension 2016; 68(2): 427-35
  4. Eur J Pain 2016 Jun 2 doi: 10.1002/ejp.907
  5. Addiction 2016 Jun 27 doi: 10.1111/add.13505

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