Journals Watch - Diabetes, eczema and cannabis use

Too busy to plough through a pile of journals? Dr Alison Glenesk rounds up the latest highlights.

Coronary artery stenosis: vascular death risk is higher in diabetics (Photograph: SPL)
Coronary artery stenosis: vascular death risk is higher in diabetics (Photograph: SPL)

Diabetes mellitus and risk of cause-specific death
N Engl J Med 2011; 364:829-41

Most of us associate diabetes with cardiovascular morbidity; however it appears that the situation is much more complex. Hazard ratios were studied for cause-specific death, according to baseline diabetes status or fasting glucose level for 123,205 deaths among 820,900 people in 97 studies.

After adjustment for age, smoking status and BMI, hazard ratios for people with diabetes compared with those without diabetes were 1.8 for death from any cause, 1.25 for death from cancer, 2.32 for vascular causes, and 1.73 from death from other causes. Diabetes was moderately associated with cancers of the liver, pancreas, ovary, colorectum, lung, bladder and breast, and a variety of other diseases including renal and liver disease, pneumonia, mental disorder and intentional self harm.

The authors found that a 50-year-old with diabetes died, on average, six years earlier than a non-diabetic counterpart, with about 40 per cent of the survival difference attributable to non-vascular deaths.

Internet-based CBT for health anxiety
Br J Psychiatry 2011; 198: 230-6

It is known that cognitive behavioural therapy (CBT) is an effective treatment for hypochondriasis, however trained therapists are scarce and treatment is labour-intensive. Internet resources, on the other hand are widely available. This Swedish RCT was conducted to compare internet-based CBT (n=40) with an attention-control condition (n=41) for patients with hypochondriasis.

Participants were recruited by referral from psychiatrists and primary care, and self-referred. After fulfilling eligibility criteria and assessment by a psychologist, participants were randomised. The internet group underwent CBT using a modular programme over 12 weeks and mindfulness training. The control group engaged in a computer-based discussion forum.

Internet CBT made large and superior improvements compared with the control group. This should increase the accessibility of treatment for this form of anxiety.

The two-thumb method in neonatal resuscitation
Arch Dis Child Fetal Neonatal 2011; 96: f99-f101

At present, resuscitation protocols allow chest compressions using either index fingers or thumbs in neonates. As manual compression achieves only a fraction of cardiac output compared with natural contraction, the correct technique is vital. This American trial involved 25 physicians and neonatal nurses. Using a manikin, they were filmed giving chest compressions for one minute, followed by two minutes of compressions using a 3:1 compression-to- ventilation ratio using one method followed by the other.

Using the thumb technique, greater depth of compression was achieved. The compression depth was more consistent and correct positioning was achieved more often using the thumb technique (21/25 versus 3/25).

It is important to have a clearly defined protocol using best practice, and this study has added valuable, potentially life-saving data.

Efficacy of treatment for atopic eczema
Br J Dermatol 2011; 164: 415-28

We are all aware of patients with eczema who go from one exacerbation to another, seemingly unresponsive to emollients. Current research suggests that intermittient treatment with a corticosteroid or tacrolimus may reduce exacerbations with less damage to the skin than constant application of a steroid.

This systematic review involved eight RCTs which reported on the efficacy of interval topical tacrolimus (3), fluticasone propionate (4) and methylprednisolone aceponate(1).

Meta-analysis of the data suggests all treatments are more effective than the vehicle (inactive components of the cream), and that fluticasone may be more effective than the others, though there are no long-term safety data for this approach.

Continued cannabis use and risk of psychotic symptoms
BMJ 2011; 342:d738

It is known that cannabis is associated with an increased risk of psychotic disorder.

This German study aimed to determine whether cannabis use is associated with the risk of later incident psychotic symptoms, and whether continued use increases the persistence of these symptoms.

The baseline cohort was 3,021 14- to 24-year-olds. Follow-up data collections were carried out at 1.6 years, 3.5 years and 8.4 years. Cannabis use and psychotic symptom prevalence were assessed using a validated method. A total of 1,923 participants were included in the analysis.

In participants who had no psychotic symptoms at the outset and never used cannabis, subsequent use increased the risk of psychotic symptoms later (odds ratio 1.9).

Continued use of cannabis increased the risk of persistence of these symptoms.

It appears, therefore, that we should continue to make strenuous efforts to discourage cannabis use, particularly in very young patients and those with mental health problems.

Diagnostic value of presenting symptoms for meningococcal disease
Br J Gen Pract 2011; 61 e97-e104

The aim of this study was to determine which symptoms might be useful in discriminating between meningococcal disease and other infections in primary care. The study population was 1,212 children under 16 presenting to their GP with acute illness, 407 with reported fever. Symptoms were determined by a point-of-contact symptom questionnaire. The symptom frequencies were then compared with the pre-admission symptoms of 345 children with meningococcal disease.

Symptoms strongly suggestive of meningitis were: confusion, leg pain, photophobia, rash and neck pain/stiffness. Headache and pale colour occurred but were not discriminatory.

Some of these symptoms are well known characteristics of meningitis, whereas leg pain is less well known. The authors make the point that these symptoms should be specifically asked about, particularly out-of-hours, and should prompt a face-to-face consultation.

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

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

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

  • Discuss neonatal resuscitation techniques at a practice meeting and consider arranging training for all staff.
  • Try using the twice-weekly steroid regime for patients with severe eczema, and survey patients' perceptions of this treatment.
  • Read up on the use of cannabis and psychotic symptoms, and develop a patient information leaflet.

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