Journals watch - Respiratory tract infections, diabetes and cognitive impairment

Research of interest to GPs, summarised by Dr Bryan Palmer

Steam in the management of respiratory tract infections

BMJ 2013; 347: f6041

I advise steam and simple analgesia for most respiratory tract infections (RTIs), explaining I have no evidence it works, but it is unlikely to do harm.

This Southampton research group sought to settle the matter with an RCT, in which 889 patients were randomised to advice on analgesia (take paracetamol, ibuprofen or both), dosing (as required versus regularly) and steam inhalation (no inhalation versus inhalation).

It seems I was wrong. Advice on dosing and steam inhalation was not significantly associated with changes in outcome. Compared with paracetamol, symptom severity was little different with ibuprofen. Four patients reported mild thermal injuries from the steam.

Antihypertensives in diabetes

BMJ 2013; 347: f6008

Guidelines suggest ACE inhibitors or ARBs as the first-line treatment in hypertensive patients with diabetes when cost is not a concern.

Clinical trials comparing an ACE inhibitor with an ARB are rare and the difference in protective effects between these drugs for patients with diabetes is inconclusive.

This study involved a systematic review of all RCTs of antihypertensive therapy (ACE inhibitors, ARBs, alpha-blockers, beta-blockers, calcium-channel blockers, diuretics and their combinations) in patients with diabetes, with a follow-up of at least 12 months. A total of 63 trials with 36,917 participants were identified.

The data suggest ACE inhibitors were superior on a cost basis when compared with ARBs and calcium-channel blockers might be the preferred treatment in combination with ACE inhibitors.

Flu vaccine and heart disease

JAMA 2013; 310(16): 1711-20

This meta-analysis of RCTs comprising almost 7,000 patients compared flu vaccine with placebo in patients at high risk for cardiovascular events.

Almost 40% of subjects had a previous history of cardiac problems. Mean follow-up time was almost eight months.

The analysis found that flu vaccination was associated with reduced risk of an acute cardiac event and the benefit was greatest in the highest-risk patients.

Cognitive impairment screening

Ann Intern Med 2013; 159(9): 601-12

This systematic review addressed the benefits, harms and diagnostic accuracy of brief screening instruments to detect cognitive impairment in community-dwelling older adults, and the benefits and harms of treatment and management options for older adults with mild cognitive impairment (MCI) or early dementia.

It included English language studies of fair to good quality, primary care feasible screening and treatments aimed at patients with MCI or mild to moderate dementia.

They concluded that although brief instruments to screen for cognitive impairment can detect dementia, there is no evidence this improves decision-making. Whether interventions have a significant effect in patients with earlier detected cognitive impairment remains unclear.

Combination therapy in patients with diabetic nephropathy

N Engl J Med 2013. DOI: 10.1056/NEJMoa1303154

Combination therapy with ACE inhibitors and ARBs decreases proteinuria, but its safety and effect on the progression of kidney disease are uncertain. This US study of diabetic veterans used an albumin-to-creatinine ratio of at least 300.

The veterans were started on losartan 100mg then randomised to receive lisinopril (10-40mg) or placebo. The primary endpoint was a decline in eGFR. The study was stopped early owing to safety concerns.

Among 1,448 patients with a median follow-up of 2.2 years, there were 152 primary endpoint events in the monotherapy group and 132 in the combination therapy group.

In this particular patient group, the combination therapy should be avoided.

  • Dr Palmer is a former Hampshire GP now working in Australia 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.

  • Hold an education session about the latest research on treatment of RTIs and audit antibiotic prescribing before and after the education session.
  • Perform a search of patients with diabetes on combined ARBs and ACE inhibitors and recall for a review.
  • Design a practice leaflet on the benefits of influenza vaccination and target persistent non-vaccinated heart disease patients.

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