Journals Watch - Diabetes, BP and pregnancy

Too busy to read all the latest journals? Let Dr Louise Newson bring you up to date with the research.

Blood glucose testing was part of a diabetes screening programme (Photograph: SPL)
Blood glucose testing was part of a diabetes screening programme (Photograph: SPL)

Who attends diabetes screening?
Diabet Med 2010; 27: 995-1003

There is some debate as to whether or not a national screening programme for type-2 diabetes should be introduced in the UK, especially in view of the rapidly increasing incidence of obesity. This study from the east of England examined factors which influenced diabetes screening in primary care.

The screening programme involved 135,825 people aged 40-69 years without known diabetes and initially identified those individuals at high risk from routinely available information such as sex, age and BMI. Those at high risk were offered both random blood glucose and HbA1c level testing.

Those who tested positive were then offered fasting blood glucose and oral glucose tolerance tests. In this study, 70 per cent of patients completed the screening programme.

Factors which increased the patients' likelihood of attending for screening included female sex and having a lower BMI. Those living in more deprived areas were less likely to attend.

Therefore, it seems to me that those patients most in need of screening are not attending.

Effectiveness of ACE inhibitors versus beta-blockers for hypertension
Circ Cardiovasc Qual Outcomes 2010; 3: 453-8

There has been bad publicity about beta-blockers for the treatment of hypertension recently.

However, I have several patients who have been taking a beta-blocker to control their BP for years and who are reluctant to change their medication.

I was very interested to read this observational study which compared the effectiveness of either an ACE inhibitor or a beta-blocker when used as second-line agents when BP is not controlled on thiazide alone. BP control over the following six to 18 months was comparable in both groups of drugs.

Rates of cardiovascular events were similar in both groups over an average of 2.3 years follow up. Although this follow-up period is not long, I feel the results of this study are reassuring for those patients who continue to take beta-blockers.

Relationship between burnout and professional conduct in medical students
JAMA 2010; 304: 1173-80

Teaching medical students has made me think more about the skills (other than knowledge) that they need to acquire as part of their training.

This American study aimed to determine the relationship between measures of professionalism and burnout among medical students.

In this study, students were given a survey which assessed their quality of life, included a depression screening tool and explored their personal engagement in unprofessional conduct and attitudes to a doctor's responsibility to society. A total of 2,682 students responded to the survey.

The results showed 52.8 per cent of students had burnout and that burnout was associated with self-reported unprofessional conduct and also less altruistic professional values.

Perhaps we should be screening for burnout in our medical students or even junior doctors.

Association between pregnancy weight gain and birthweight
Lancet 2010; 376: 984-90

Many more women are overweight or obese when they are pregnant, and many women do not realise the detrimental effects their size may have on their developing baby.

This study was undertaken to examine the association between maternal weight gain and birthweight. They examined how differences in weight gain that occurred during two or more pregnancies for each woman predicted the birthweight of her baby. The analysis included 513,501 women. Their results found that maternal weight gain during pregnancy increases birthweight independently of genetic factors.

Infants of women who gained more than 24kg during pregnancy were approximately 148.9g heavier at birth than infants of women who gained 8-10kg.

Although it is difficult to know whether or not this leads to an increase in obesity in later life, the authors state that as there is an association between birthweight and adult weight, obesity prevention targets aimed at women during pregnancy might well be beneficial for their babies.

How easy this is to implement into our practice remains to be seen.

Risk of bleeding with aspirin, warfarin and clopidogrel in patients with AF
Arch Intern Med 2010; 170: 1433-41

The benefits of anticoagulation and also aspirin for people with AF have been established.

However, we have seen several patients over the past few years who have been discharged on triple therapy after a cardiovascular event; namely aspirin, warfarin and clopidogrel.

Our local cardiologists have not managed to agree as to whether the benefits of this combination actually outweigh the risks or not.

This Danish study looked at patients who had been admitted with AF and discharged on these medications, or a combination of these medications.

The results showed combinations of warfarin, aspirin and clopidrogel are associated with an increased risk of fatal and non-fatal bleeding. The bleeding rate was highest for patients taking dual therapy of clopidogrel and warfarin. Their results confirm we need to decide whether these drugs are going to be beneficial in combination.

  • Dr Newson is a GP in the West Midlands and a member of our team who regularly review the journals

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Undertake a search of your patients with a raised glucose who are not diabetic. Perform a fasting glucose or oral glucose tolerance test on these patients.
  • Remind yourself of the NICE guidelines for weight management before, during and after pregnancy. Liaise with your practice midwife regarding any interventions she uses to help overweight or obese women control their weight during pregnancy.
  • Perform a search of your patients with AF who are taking warfarin with aspirin and/or clopidrogel. Look at the indication for these drugs and consider stopping them if the risks outweigh the benefits.

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