Primary healthcare news, information & resources


What we've been reading - February 2018


Keeping up with medicine is made easier when we share clinical stories with our colleagues. On this page we share brief learnings and articles that have interested our GP liaison team during the month of February. If you come across an article, video or resource you think clinical and management teams should know about, send it to communications@pinnacle.health.nz.

DYNAMED PLUS evidence alert system - thoughts from Dr Jo Scott-Jones

One of the services DYNAMED PLUS provides is an Evidence alerts system you can sign up to. They filter over 35,000 articles published each year down to about 20 that are of high quality and relevant to your self-identified needs. If you find yourself feeling guilty about not keeping up with the latest reading, and comfort yourself with the thought that no-one possibly could keep up with it all, this is a way of helping you to relieve the guilt, and keep up with the latest thinking.

This month's alerts for me included a Cochrane review on the use of flu' vaccine in healthy adults.

Vaccines for preventing influenza in healthy adults. (Cochrane Database Syst Rev. 2018 Feb 1;2:CD001269. doi: 10.1002/14651858.CD001269.pub6 (Review)).

A 50 per cent risk reduction of flu like illness, but with a baseline risk of 2 per cent in this population, the authors question is it worth it? My considered answer to this was: YES if you have ever had the 'flu because it hurts, and YES if you are a health worker or someone else at high risk of getting it or at risk of passing the 'flu onto a vulnerable person, and YES if you are an employee and want to avoid sick days.

I found an article on probiotic use in infant colic more interesting. (Sung V, D'Amico F, Cabana MD, et al. Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis. Pediatrics. 2018 Jan;141(1). pii: peds.2017-1811. doi: 10.1542/peds.2017-1811. (Review) PMID: 29279326.)

Infant colic, or excessive crying of unknown cause, is a burdensome condition affecting 20 per cent of infants <3 months old. Defined as crying and/or fussing >3 hours per day for ≥3 days per week, it is more than a nuisance, and associated with abusive head trauma, maternal depression, and premature cessation of breastfeeding. Although it is believed to be a self-resolving condition, there is emerging evidence of its long-term adverse effects on child behavior, sleep, and allergy outcomes. Despite years of research, its etiology remains elusive, and management options are limited.

This group identified four high quality double-blind trials involving 345 infants with colic (174 probiotic and 171 placebo) were included. All 4 studies used the same probiotic (L reuteri DSM17398) manufactured by the same company (BioGaia, Stockholm, Sweden) in the same dose (0.2 × 108 colony-forming units per drop, 5 drops orally per day), The probiotic group averaged less crying and/or fussing time than the placebo group at all time points (day 21 adjusted mean difference in change from baseline [minutes] -25.4 [95% confidence interval (CI): -47.3 to -3.5]). The probiotic group was almost twice as likely as the placebo group to experience treatment success at all time points day 7 , 14 and 21.

Intervention effects were dramatic in breastfed infants (number needed to treat for day 21 success 2.6 [95% CI: 2.0 to 3.6]) but were insignificant in formula-fed infants.

Of interest was that during the study period ALL infants reduced their time crying / fussing - this may be the Hawthorn effect or a reflection of the fact that infant colic reduces over time and is usually settled by 5 months of age, but in the event of needing to suggest something to help - a probiotic drop may be actually useful. 

If you'd asked me 5 years ago, I'd have giggled. The drops are available in New Zealand online or via the local pharmacy.

Loneliness and social isolation as risk factors for coronary heart disease and stroke - thoughts from Dr Jo Scott-Jones.

We will all know them. Often an elderly person, who will arrive hours early for their appointment, brings baking for the staff, appears happy to wait for ages and then has a vague or trivial problem that needs to be solved. The chemist's staff know them well, they hang about the shop, chatting at the check-out. Loneliness underpins some of the "frequent fliers" we see in primary care.

We will all try and problem solve with the patient, find a card club or a kaumatua group for them to attend, talk about family relationships and how they can be repaired. Sometimes this can feel like rejection to the patient. It's worth considering, maybe you are a good enough solution. If there is an alternative, be careful about keeping your door open to this person. The danger of the frequent flier is both in under-servicing, and over-servicing. In the noise of the frequent trivial consultations, the significant weight loss and altered bowel habit can be missed. In an effort to address the frequent complaints we are tempted to add more and more investigations and referrals.

Sometimes, when it feels like your only function is to provide conversation, it's important to remember; that is your only function. Loneliness is associated with significant co-morbidities, and addressing it is an overlooked service general practices provide for the community.
Enjoy the baking.

The growing issue of the treatment of obesity in adults - thoughts from Dr Jo Scott-Jones

The treatment of obesity in adults is a growing issue for GPs. To be quite honest we have never been very good at behaviour change as individual GPs, people do a great deal better when we work as part of a multidisciplinary team - whether its smoking prevention or weight loss, post cardiac or COPD rehabilitation, or stress management.

After yet another set of New Year resolutions and a period of self-reflection, I decided to review the treatment of obesity again [see reference linked below] - and once again it's not rocket science - diet and exercise work, they work best if they are part of a planned programme delivered over a six month period, with the support of a trained professional in either a group or individual setting.

Loss of 5-15 per cent of weight improves outcomes and we should focus on weight loss to reduce complications rather than weight loss as the only goal, and a combination of diet and exercise works best - we can lose up to 1kg a week if we eat 500-1000kcal a day less than we expend in energy and sustained weight loss is possible, which I found quite heartening as there seems to have been a lot of talk about how useless it is to even try to lose weight over recent years.

We need to make available a weight loss-directed structured lifestyle intervention program consisting of a healthy meal plan, physical activity, and behavioral interventions that focus on the issues that are important to the patient. Interventions may include improved sleep patterns, relationship management, depression treatment, or dealing with addiction and others.

Now I just have time for another piece of that apple pie...

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. 115009, Obesity in adults; [updated 2017 Jun 27, cited Gisborne Pinnacle MHN office]; [about 59 screens]. Available from http://www.dynamed.com/login.aspx?direct=true&site=DynaMed&id=115009. Registration and login required.

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