Journals Watch - Hip dislocation and diabetes

A review of this week's medical research. By GP Dr Suzanne Hunter

Babies suspected of having congenital dislocation of the hip were included in ultrasound screening (Photograph: SPL)
Babies suspected of having congenital dislocation of the hip were included in ultrasound screening (Photograph: SPL)

Selective screening for congenital hip dislocation
Arch Dis Child 2012; 97: 423-9
Universal ultrasound screening for congenital dislocation of the hip (CDH) is generally recommended. This report covered 20 years of selective ultrasound screening from 1988 to 2008.

If there was a clinical suspicion of CDH at the neonatal examination, babies were ultrasound screened at two weeks, and if there were risk factors for CDH (breech, family history, foot deformity), at six weeks.

Overall, 18.9% of the babies were referred for ultrasound; of these, 3.8% were diagnosed with dysplasia.

Of the 19,570 infants discharged with normal hips, not one presented again with a hip problem. The authors noted year on year that more infants were referred to the service.

CKD and mortality risk in type 2 diabetes
Age Ageing 2012; 41: 345-50

This study examined the relationship between reduced eGFR, albuminuria and mortality in older patients with type 2 diabetes. The researchers divided the patients into those aged 65-75 years and those aged over 75, and divided eGFR levels into less than 45 and 45-60ml min 73m2.

The study found that in the 65-75 age group, there was an increased risk of mortality of 3.29 and 1.78 in eGFRs of less than 45 and 45-60ml min 73m2 espectively in the over-75s there was no excess mortality eGFRs but an increase of 42 when eGFR fell below 45ml.

Across the board, there was an increased risk of all-cause and cardiovascular mortality for any over-65-year-old in the presence of albuminuria.

This study fuels the suspicion that modestly decreased eGFR in over-75s is more physiological than pathological and we should be more concerned about the presence of albuminuria.

Proposed guidelines for diagnosing coeliac disease
Arch Dis Child 2012; 97: 393-4

This article is about updating the diagnostic criteria for coeliac disease. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition has suggested a new definition for coeliac disease: 'an immune-mediated systemic disorder elicited by gluten and related prolamines in genetically susceptible individuals, characterised by the presence of a variable combination of gluten-dependent clinical manifestation, coeliac disease specific antibodies, HLA-DQ2 and HLA-DQ8 haplotypes and enteropathy'.

This emphasises the autoimmune nature of the disease and the importance of serology testing for tissue transglutaminase (not antigliadin) when making a diagnosis.

The suggested definition also emphasises the strong genetic element to coeliac disease and the fact that this is a systemic disorder which may present with non-specific symptoms.

The strong genetic elements would make a case for screening all first-degree relatives of a patient with the condition but also asymptomatic individuals with a higher risk - Down's syndrome, autoimmune thyroid disease and type 1 diabetes.

Risk of falls in older patients who have diabetes
Age Ageing 2012; 41: 358-65

This study looked at whether older people with diabetes were at greater risk of recurrent falls compared with their peers.

Carried out in the Netherlands, the study compared the incidence of recurrent falls in people aged 65 years or over with and without diabetes in a three-year period. The researchers defined recurrent as at least two falls in six months.

They found that 30.6% of patients with diabetes and 19.4% of patients without diabetes had recurrent falls.

Factors identified to explain this increase were higher levels of musculoskeletal pain, the polypharmacy of preventive cardiovascular disease medicine, reduced physical activity and mental functioning.

Given the increase in the ageing population and the rise in the incidence of diabetes, this problem is going to become a significant one.

Acute renal problems on commencing fibrates
Ann Intern Med 2012; 156: 560-9

A rise in creatinine has been seen in fibrate use. The objective of this study was to assess renal outcomes in elderly adults within 90 days of a new fibrate prescription.

The researchers found that in the first 90 days, compared with ezetimibe, fibrate users were 1.3 times as likely to consult a nephrologist and 2.4 times as likely to be hospitalised for a rise in creatinine.

There was no difference in all-cause mortality, dialysis or severe acute kidney injury. In a smaller subgroup with baseline cholesterol and creatinine levels, 9.1% of fibrate users and 0.3% of ezetimibe users had a rise of 50% or more in creatinine level.

The researchers recommend close monitoring of renal function in patients commenced on a fibrate, especially in the presence of chronic renal disease.

Uptake of H1N1 vaccine in pregnant women
Am J Obstet Gynecol 2012; 206: 339e1-8

During the 2009-10 influenza epidemic, pregnant women were a priority for H1N1 vaccine. However, their concerns about safety, and the vaccine not being offered as standard, were cited as reasons for poor uptake.

In the summer of 2010, post-partum women at four New York hospitals were questioned. Of respondents, 42% felt the vaccine should be avoided in pregnancy and 35% felt it would hurt their unborn baby; 94% knew the virus could lead to hospitalisation or death. Almost all of the women indicated they would trust medical advice from someone looking after them.

Those most likely to take up the vaccine were women who had received previous flu vaccine or who felt it was safe for the fetus. The strongest influencing factor was provider recommendation, with 56% versus 6% vaccine uptake when providers did or did not recommend vaccination.

This study shows that the main way for uptake to increase in this group is for the midwife or GP to recommend and offer the vaccine.

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

  • Dr Hunter is a GP in Bishops Waltham, Hampshire, and a member of our team who regularly review the journals
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.

  • Invite a paediatric gastroenterologist to discuss recent updates in coeliac disease with the practice.
  • Incorporate a falls history into the routine diabetic clinic protocol.
  • Audit patients commenced on a fibrate in the past year to see how many of them had a baseline and post-commencement creatinine test.

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