Journals watch

Too busy to read all of the journals? Dr Bryan Palmer selects papers of interest to primary care.

Antihypertensives appeared to in crease the risk of hip fracture in elderly patients (SPL)
Antihypertensives appeared to in crease the risk of hip fracture in elderly patients (SPL)

Antihypertensives in the elderly and hip fracture risk

Arch Intern Med 2012; 172: 1739-44

More elderly people, more hypertension, more treatment, more falls. Does that lead to more hip fractures? This population-based, self-controlled case series was used to identify patients initiating an antihypertensive drug in Ontario, Canada, and their falls outcomes.

Among the 301,591 newly treated hypertensive community-dwelling elderly patients, 1,463 hip fractures were identified.

Hypertensive elderly patients who began receiving an antihypertensive drug had a 43% increased risk of having a hip fracture during the first 45 days following treatment initiation, relative to the control periods.

The authors note that caution is advised when initiating antihypertensive drugs in the elderly.

Non-benzodiazepine hypnotics for patients with insomnia

BMJ 2012; 345: e8343

This meta-analysis of randomised, double-blind, parallel placebo-controlled trials of 'Z' drugs (eszopiclone, zaleplon and zolpidem) was designed to assess their effectiveness and placebo response.

The researchers looked at 13 studies, including 4,378 participants from different countries, and various drug doses, lengths of treatment and study years.

'Z' drugs decreased polysomnographic sleep latency by 22 minutes compared with placebo and subjective latency by seven minutes.

The authors also noted a large placebo effect. Taking side-effects into consideration, they suggest that increased attention should be directed at psychological interventions.

Take heart from good news

JAMA 2012; 308: 2577-83

Heart disease is still the biggest killer in developed countries, but a recent autopsy-based US study suggests things are improving.

The first study to look at atherosclerosis in servicemen was carried out among those who fought in the Korean War. This showed 77% of servicemen killed in the war had atherosclerosis in their coronary arteries.

A second study on servicemen in the Vietnam War found a prevalence of 45% in the same vessels.

This current study on servicemen who died of combat or unintentional injuries between October 2001 and August 2011 reports that only 8.5% had any atherosclerosis in their heart vasculature at all, with greater than 50% occlusion in one or more vessels in 2.3%, moderate occlusion in 4.7% and minimal occlusion in 1.5%.

The total number of subjects for whom an autopsy was performed was 3,832, of whom 98.3% were male, with an age range of 18-59 years.

The authors suggest two main factors - improved modification of risk factors and the fact that modern recruits might also be a group of 'healthy warriors'.

Amoxicillin in the treatment of lower respiratory tract infection

Lancet Infect Dis 2012 doi:10.1016/S14 73-3099(12)70300-6

This study aimed to compare the benefits and harms of amoxicillin for acute lower respiratory tract infection with those of placebo, both overall and in patients aged 60 years or older.

A total of 1,038 patients were assigned to the amoxicillin group and 1,023 to the placebo group.

New or worsening symptoms were significantly less common in the amoxicillin group than in the placebo group (NNT = 30).

Cases of nausea, rash or diarrhoea were significantly more common in the amoxicillin group than in the placebo group (number needed to harm = 21). The authors conclude there was little benefit and a risk of slight harm.

Active management of patients with whiplash injury

Lancet 2012 doi:10.1016/S0140-6736 (12)61304-X

This study aimed to assess whether training staff in A&E to provide active management consultations was more effective than usual consultations, and to estimate whether a physiotherapy package was more effective than one additional physiotherapy advice session in patients with persisting symptoms after whiplash injury.

The results showed no benefit from the active management. The package of physiotherapy gave a modest acceleration to early recovery of persisting symptoms, but was not cost-effective from an NHS perspective.

Usual consultations in A&E and a single physiotherapy advice session for persistent whiplash symptoms are recommended.

  • 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.

  • Search for how many of your patients are on repeat prescriptions for 'Z' drugs and flag a medication review.
  • Hold a clinical meeting on antibiotic prescribing for lower respiratory tract infection. Measure prescribing rates before and after.
  • Audit physiotherapy referrals for whiplash from your practice.

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