Diabetes, otitis media and opioids

Short of time to catch up on the journals? Dr Alison Glenesk guides you through the latest research.

Coronary artery disease in type-2 diabetics
Heart 2008; 94: 290-5

This small study was very interesting, particularly in view of the present enthusiasm for putting everyone on statins, but somewhat marred for me by the fact that there did not seem to be a control group, or reference standard of any sort.

Multi-slice computed tomography, along with a calcium score (to assess vessel calcification) was used to evaluate the health of the coronary arteries in 70 patients with type-2 diabetes, with an average age of 54.

Even at this not particularly advanced age, 80 per cent were found to have coronary artery disease, 56 per cent had an elevated calcium score, and 26 per cent had at least one coronary artery significantly stenosed.

The authors state that these data fit with the known fact that the risk and mortality of those with type-2 diabetes is similar to MI survivors.

This should concentrate our minds on the statin question - and also on the necessity of picking up type-2 diabetes in the first place.

Pneumococcal vaccine and otitis media
Pediatrics 2008; 121: 253-60

This US study analysed databases for groups of children with medical insurance between 1997 and 2004.

Some time during this period (it was a little difficult to ascertain exactly when) routine immunisation for pneumococcus was introduced.

Figures for 1997 to 1999 were compared with 2004. There was a very large decrease from 2,173 to 1,244 consultations per 1,000 person years (42.7 per cent reduction) with antibiotic prescribing reduced from 1,244 to 722 per 1,000 person years (41.9 per cent). Total costs were reduced by 32.3 per cent.

Pneumococcal infection causes 30-50 per cent of otitis media, which is the most common reason for antibiotic prescribing in children in the USA.

Even so, the authors feel that the figures obtained cannot be accounted for by immunisation alone, and suggest that other factors, such as the published evidence on avoiding antibiotics for otitis media, may be relevant.

Outpatient DNAs
Scott Med J 2008; 53: 9-12

A disproportionately large number of letters in my e-intray nowadays seem to contain the news that my patient has not attended an outpatient clinic.

This, by implication, seems to be my fault, and there is usually an exhortation to find out what has happened and sort it out.

This article, based on a literature search, was especially interesting to me, because it comes from Aberdeen.

The study found that telephone reminders can be effective when delivered one to three days before the appointment, although difficulties were experienced in contacting the patient in about 50 per cent of cases.

Six studies looked at postal reminders: the most effective were those threatening dire consequences should the appointment be missed, and those offering some (unspecified) reward for attendance.

The author concedes that there are no data for the use of email or text-messaging (although these are not the prime means of communication in the hospital-going population yet), nor do we have 'Choose and Book' up here in Scotland.

With 11 per cent of outpatient appointments missed at a cost of £262 million per year to the NHS, we need to find an answer.

The use of opioids for non-cancer pain
J Pain Symptom Manage 2008; 35: 214-28

Until recently, prescribing opioids regularly for any condition other than cancer was frowned upon, mainly due to worries about addiction, misuse and escalating doses.

This meta-analysis looked at 17 studies that involved 3,079 patients who had been given long-term opioids by the oral, transdermal or intrathecal route for chronic non-cancer pain.

High withdrawal rates were found, mainly due to unacceptable side-effects (oral 32 per cent, intrathecal 6.3 per cent, transdermal 17.5 per cent), and lack of efficacy, for which the figures were lower.

Addiction and abuse, however, occurred in only 0.05 per cent and 0.43 per cent respectively.

After six months of use, pain scores were lower in the oral and intrathecal routes, but were not significant for the transdermal route.

The authors conclude that the evidence supporting the use of these drugs is present but weak, not because of our original concerns about addiction, but because of the lack of efficacy.

Varicella vaccine
Pediatric Infect Dis J 2008; 27: 119-24

We usually think of chickenpox as a mild disease of childhood, so this article from Germany made interesting reading.

A prospective nationwide surveillance of paediatric hospitals in Germany was carried out between January 2003 and December 2004 to detect children and adolescents up to and including the age of 16, who had been admitted with chickenpox.

Of the 918 cases found, complications occurred in 80 per cent, mainly neurological (25.4 per cent), skin infection (23.2 per cent) and GI complications (15 per cent).

Some 23 per cent of the children had predisposing conditions including immunosuppression and atopic dermatitis.

In all there were 10 deaths - some in previously healthy children.

Immunisation was widespread from 2004, so future studies are eagerly awaited.

Dr Glenesk is a GP trainer in Aberdeen and a member of our team who regularly review the journals.

The quick study

  • Coronary artery disease is common in patients with type-2 diabetes, and cardiovascular risk and mortality is similar to that in patients after MI.
  • Pneumococcal vaccination has reduced antibiotic prescribing for otitis media, but evidence for a lack of benefit of antibiotics in the condition may also have had an effect.
  • Outpatient appointments are kept by more patients if they are sent a written reminder one to three days before their appointment.
  • Opioids for non-cancer pain may be limited by side-effects and lack of efficacy.
  • Chickenpox complications are common, even in previously healthy children. It is hoped that the immunisation programme will help to reduce this burden.

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