Gastroenteritis in children, GP cancer care and pre-eclampsia risk: journals update June 2016

The latest clinical research of interest to GPs.


Evidence supporting the use of oral rehydration solution in gastroenteritis is primarily from low- and middle-income countries, and similar benefits may not arise where significant dehydration is uncommon. This study suggests a move away from this management strategy to reduce treatment failure.

Study design
This was a single-centre, randomised, single-blind non-inferiority trial conducted between 2010 and 2015 in Canada. A total of 647 children aged between six and 60 months, presenting with mild gastroenteritis and minimal dehydration based on an eight-point clinical dehydration scale, were included. The intervention group was given half-strength apple juice, followed by their drink of choice, while the control group received an electrolyte maintenance solution.

Key findings
In the intention to treat analysis, the treatment failure rate was 16.7% in the apple juice/preferred fluids group and 25% in the electrolyte maintenance solution group. This benefit was most notable in children aged 24 months or older. Dilute apple juice followed by desired fluids resulted in a reduction in the IV rehydration rate. Hospitalisation rates and diarrhoea and vomiting frequency were not significantly different between the two groups.

Implications for GPs
These results challenge the recommendation to routinely administer electrolyte solution when diarrhoea begins. Although it demonstrated a reduction in unscheduled follow-up care, no difference in hospitalisation or emergency department visits was shown.

Other studies have provided pragmatic evidence that in children with minimal dehydration, promoting fluid consumption is more important than the glucose load consumed, because the risk of osmotic diarrhoea is only at day one and therefore is outweighed. In high-income countries, the use of apple juice and preferred fluids may be an appropriate alternative to electrolyte maintenance solution use in children with mild gastro-enteritis and minimal dehydration.

  • JAMA 2016; 315: 1966-74


There are variations in cancer care in general practice geographically, and improved survival is leading to increased healthcare costs. This study supports a greater role for the GP at all stages of the journey, to improve the quality of patient care for cancer survivors.

Study design
This study aimed to explore the role of GPs in the provision of follow-up cancer care, focusing on patients’ and GPs’ perspectives of the GP role. It was a systematic literature review of 58 studies published globally, between January 1995 and September 2015.

Key findings
The analysis supported a greater GP role in all facets of care for cancer survivors. It suggests that primary care follow-up could result in lower costs to the healthcare system, with no difference in patient outcomes.

It found that the use of cancer care reviews was inconsistent and the GP role in palliative care was varied. Barriers identified were loss of contact with patients, uncertainty about the GP’s role, a lack of relevant training and knowledge, inadequate information from oncologists to GPs, and time and resource constraints. 

Implications for GPs
The most salient ways to improve GP involvement in follow-up care would be timely, accurate, individualised patient information from oncologists to GPs, and a continuing doctor/patient relationship.

GPs can potentially provide complex, holistic and long-term cancer care, encompassing the needs of a cancer survivor with appropriate training, facilitated by guidelines for follow-up cancer care with clearly defined roles. Time and resource restraints experienced by GPs, such as access to diagnostic facilities and appropriate remuneration, would need to be addressed for this to be put in place.

  • J Cancer Surviv 2016: online first


Although several well-defined risk factors for pre-eclampsia have largely been accepted in most clinical settings and guidelines, this study has systematically evaluated risk factors in early pregnancy that could lead to a timely intervention with aspirin prophylaxis.

Study design
This Canadian study aimed to develop a practical evidence-based list of clinical risk factors to estimate a woman’s risk of pre-eclampsia at less than 16 weeks' gestation to identify high-risk women who could="" benefit from aspirin prophylaxis. This systematic review and meta-analysis involved 92 large cohort studies. The absolute rate, pooled RR and population attributable fraction for pre-eclampsia for each risk factor was assessed.

Key findings
Each of 14 generally accepted risk factors, except a history of intrauterine growth restriction, was associated with a significantly heightened risk of pre-eclampsia. Antiphospholipid antibody syndrome, prior pre-eclampsia, chronic hypertension, pregestational diabetes, assisted reproductive technology and BMI >30 were most strongly associated with a high rate, suggesting that the presence of any one of these designates a woman as ‘high risk’, with a low number needed to prevent.

Implications for GPs
We already know that antiplatelet agents, especially aspirin, effectively and safely prevent pre-eclampsia among women who are at moderate or high risk of developing it. However, as the authors of this study point out, the list of risk factors in current guidelines has not been systematically derived. This study could help to develop a tool for estimating a woman’s risk and the need for heightened surveillance or aspirin prophylaxis. 

BMJ 2016; 353: i1753


Hypoglycaemia is the most common adverse reaction related to glucose-lowering drugs and is a serious clinical event, with an increased risk of mortality and morbidity. This study reinforces the importance of reducing sulfonylurea dose when combining a sulfonylurea with a dipeptidyl peptidase-4 (DPP-4) inhibitor, to reduce this risk.

Study design
This study aimed to quantify the risk of hypoglycaemia associated with the concomitant use of DPP-4 inhibitors and sulfonylureas compared with placebo and sulfonylureas. It was a systematic review and meta-analysis of 10 randomised, double-blinded studies, calculating the risk ratio and pooled risk ratio for each study.

Key findings
The addition of DPP-4 inhibitors to sulfonylureas to treat patients with type 2 diabetes is associated with a 50% increased risk of hypoglycaemia, leading to one excess case for every 17 patients in the first six months of treatment. The risk was confirmed for full doses of DPP-4 inhibitors, whereas it could not be excluded for lower doses.

Implications for GPs
Although the SPCs for DPP-4 inhibitors acknowledge the increased risk of combining them with a sulfonylurea and recommend a full-dose DPP-4 inhibitor and a reduced dose of sulfonylurea, the magnitude of the reduction is not stated.

This study has demonstrated a potentially huge number of cases worldwide and reinforces recommendations for a decrease in sulfonylurea dose when initiating DPP-4 inhibitors. It shows that urgent assessment is needed to determine the effectiveness of this risk minimisation strategy in preventing hypoglycaemia.

  • BMJ 2016; 353: i2231


Personalised support can improve patients’ ability to self-manage their condition

Encouraging self-management of health and disease is widely seen as a way to improve health outcomes and ultimately decrease healthcare costs. This study shows that questionnaire-based discussion could contribute to this.

Study design
The study aimed to assess the effect of providing personalised self-management support in clinical practice on patients’ activation and health-related behaviours. This cluster RCT was conducted in 15 primary care group practices in the Netherlands. It used a validated Self-Management Screening questionnaire (SeMaS) to discuss and tailor the self-management support, a 13-item Patient Activation Measure (PAM-13) and a lifestyle questionnaire at baseline and six months.

Key findings
The primary outcome measure, the PAM-13 score, did not differ significantly between the control and intervention arms at six months. In the intervention arm, 29.4% of the patients performed self-monitoring, versus 15.2% in the control arm. The study showed that discussing SeMaS and offering tailored support did not affect patient activation or lifestyle, but did stimulate patients to self-monitor and use individual care plans.

Implications for GPs
The SeMaS assesses individual capabilities or barriers for self-management and has been validated for patients with chronic disease. The effect of self-management support depends on individual characteristics, but many self-management interventions follow a one size fits all principle. By discussing the results of the validated SeMaS with the patient, we can provide personalised support.

  • BJGP May 2016. DOI: 10.3399/bjgp16X684985

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