GP plans improve diabetes outcomes
PATIENTS with diabetes who have a GP management plan (GPMP) or a GPMP and team care arrangements (TCAs) have significant improvements in clinical outcomes, particularly when followed up by regular reviews, according to research published in the MJA. The before-and-after study analysed prospectively collected data between 2008 and 2012 for 577 patients with type 1 or 2 diabetes managed with a GPMP created using cdmNet, a web-based chronic disease management system. Significant improvements were seen after creation of a GPMP in the proportion of annual cycle of care (ACOC) clinical tests completed (57.9% v 74.8% in patients without a plan), total cholesterol level, low-density lipoprotein (LDL) cholesterol level and body mass index (BMI). Patients using GPMPs and TCAs also improved their glycated haemoglobin (HbA1c) level, with a mean decrease of 10.4 mmol/mol. In patients followed up with irregular reviews there were significant improvements in the proportion of ACOC clinical tests completed (59.2% v 77.6%), total cholesterol level and BMI. However, patients who had regular reviews had greater improvements in the proportion of ACOC clinical tests completed (58.9% v 85.0%), HbA1c level (57.7 v 53.0 mmol/mol), total cholesterol level (4.8 v 4.5 mmol/L), LDL cholesterol level (2.8 v 2.4 mmol/L) and diastolic blood pressure (76.0 v 74.0 mmHg). The researchers wrote that the study indicated that use of web-based tools to support collaborative care management for patients with diabetes “has the potential for transformative change in best-practice care”.

Dissatisfaction with psoriasis treatment
LACK of treatment and undertreatment of patients with psoriasis and psoriatic arthritis are a significant problem in the US, according to research published in JAMA Dermatology. The research involved 5604 patients with psoriasis or psoriatic arthritis who completed the National Psoriasis Foundation’s biannual surveys between 2003 and 2011. The researchers found that, during the research period, 36.6% to 49.2% of patients with mild psoriasis were not receiving treatment compared with 23.6% to 35.5% of patients with moderate psoriasis and 9.4% to 29.7% of patients with severe psoriasis. They also found that 52.3% of patients with psoriasis and 45.5% of patients with psoriatic arthritis were dissatisfied with their treatment. “Although various treatment modalities exist for psoriasis and psoriatic arthritis, widespread treatment dissatisfaction exists”, the researchers wrote. “As efficacious treatments are introduced to this patient population, concurrent efforts in advocacy and education are needed to ensure that these medications are accessible to those most likely to benefit and that patients are properly informed of the benefit-risk profiles.”

Briefings improve education for surgeons
MOTIVATING surgeons to adopt a preoperative and postoperative educational briefing/debriefing structure successfully reminded “surgeons that they needed to teach” and reminded residents “what they needed to learn”, according to research published in JAMA Surgery. The researchers combined a continuous improvement approach with confidential objective individualised feedback to improve the frequency of desirable preoperative and postoperative teaching behaviours and to improve behaviours during procedures. The three-phase observational study included university-based surgeons, general surgery residents and preclinical student observers, and involved elective cases at a large tertiary hospital. The first phase measured teaching behaviours by surgeons unaware of the study objectives, and was used to develop standardised preoperative briefings and postoperative debriefings. The second phase applied a deliberate teaching model, with continuous process improvement efforts (Plan, Do, Check, Act) and repeat observations. The final phase used resident prompts to enhance teaching behaviours. The researchers wrote that the progressive increase in these “theoretically desirable teaching behaviors was accompanied by a substantial and statistically significant improvement in resident perceptions of teaching”. An accompanying commentary said that in an era of limited resources, “this approach could be easily applied to all types of clinical training at essentially no cost”.

Climate change warning on gastro flares
A STUDY into the impact of climate change on diarrhoeal diseases has identified the effect of heatwaves on hospital admissions in urban areas because of inflammatory bowel disease (IBD) and infectious gastroenteritis (IG) flares. The retrospective controlled observational study, published in the American Journal of Gastroenterology, included data from 738 patients with IBD and 786 with IG admitted to hospital between 2001 and 2005, and 506 controls with other non-infectious chronic intestinal inflammations. After adjusting for temporal and seasonal trends, the researchers estimated that hospital admissions increased by 3.7% for IBD and 5% for IG for each additional day of a heatwave period. There was an even bigger increase of 7.7% for IG admissions when a 7-day delayed effect of heatwaves was considered. “This indicates that the effect of heat waves on IG flares occurs with a 1-week delay, whereas it is immediate with respect to flares of IBD”, the researchers wrote. They speculated that heat waves favoured the expansion of potential pathogenic bacteria and/or viruses. While conceding the limitations of the study, the researchers said the rate of heat waves was likely to increase with climate change and the possible impacts on health would become more important.

Vitamin D no help in BP control
VITAMIN D supplementation does not improve blood pressure (BP) or markers of vascular health in patients aged 70 years and older who have isolated systolic hypertension, according to the results of a randomised control trial published in JAMA Internal Medicine. The trial involved 159 patients with a mean age of 77 years with a mean office BP of 163/78 mmHg at the start of the trial. In the intervention group mean 25-hydroxyvitamin D levels increased from a baseline level of 18ng/mL to 28 ng/mL at 6 months before plateauing. There was a small (3 ng/mL) increase in vitamin D levels in the placebo group. The researchers found no significant treatment effect for mean office BP and no significant treatment effect was evident for any of the secondary outcomes (24-hour BP, arterial stiffness, endothelial function, cholesterol level, glucose level and walking distance). There was no excess of adverse events in the treatment group, and although the total number of falls in the treatment group was lower, it was not significant. The researchers said the results did not support the need to perform larger randomised controlled trials aimed specifically at BP reduction in older patients. An accompanying commentary said the overall health effect of vitamin D could be larger than reflected changes on BP alone. “Although the vitamin D hypertension story is incomplete, avoiding deficient levels (<20 ng/mL) is important for overall health”, it said.

Mystery of nodding syndrome
THOUSANDS of cases of a distressing disease in previously healthy children aged 5–15 years that causes repetitive head nodding and is variably associated with other seizure activity, neurologic and cognitive impairment, delayed puberty and growth retardation have been reported in parts of Africa. A report published in Emerging Infectious Diseases said the epidemic illness was characterised by head nodding associated with onchocerciasis and had been described in eastern Africa since the early 1960s. “The effect of the disease on families and communities can be devastating because previously healthy young children drop out of school, lose the ability to eat, and require constant oversight because they might fall into a cooking fire or wander off and drown”, the report says. However, the underlying cause of nodding syndrome is a mystery. “Reports from parents and clinicians regarding effectiveness of different anti-epileptic drugs are anecdotal with rare exceptions, and a controlled trial of treatment would be invaluable”, the authors wrote. “Affected families and communities will probably be coping with chronically dependent patients with nodding syndrome for many years with few resources and considerable pressure for effective management.”

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