GP Research Review

ISSN 1178-6124
GP
Research Review
Making Education Easy
In this issue:
Issue 52 – 2011
Welcome to the fifty-second issue of GP Research Review.
Media usage can disrupt
child sleep
The first study in this issue of GP Research Review demonstrates how the use of media such as television, video games
and online content can affect a child’s sleep. The study found that each additional hour of daytime violent media content or
evening media use increased sleep problems in preschool-aged children. The study authors recommend that parents choose
non-violent media content and avoid media screentime entirely during the hour before the child’s bedtime.
Classic ‘red flag’ symptoms of
meningococcal disease
Telephone triage systems and primary care clinicians should be aware of the outcomes of a study from the UK that
confirms the diagnostic value of classic ‘red flag’ symptoms of meningococcal disease in children: neck stiffness, rash, and
photophobia, as well as two others – confusion or leg pain.
Childhood nonspecific
abdominal pain in family
practice
In our Natural Health section, green tea is reported as having beneficial oral health effects. Rinsing out the mouth with green
tea lowered Streptococcus mutans counts in saliva and plaque, improved salivary and plaque pH values, and lowered scores
on the Gingival Bleeding Index.
Cardiovascular risk
management: is medication
needed?
Link rapid antigen detection
testing to antibiotic prescribing?
Our final study is intriguing. It reports that a course of acupuncture, added to usual care, improved health status and wellbeing
in general practice ‘frequent attenders’ with medically unexplained physical symptoms. Moreover, this benefit was sustained
for up to 12 months.
Kind Regards,
Jim
Assoc Professor Jim Reid
[email protected]
Vitamin D of uncertain benefit
on cardiovascular outcomes
Media use and child sleep: the impact of content, timing,
and environment
Fluoxtine in chronic prostatitis/
pelvic pain syndrome
Authors: Garrison MM et al
Constipation raises risk of CVD
in postmenopausal women
Green tea: beneficial oral
effects
Acupuncture resolves
unexplained pain
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Summary: This study explored the joint influence of media content and time of day on child sleep in over 600 children
aged 3–5 years. On average, children consumed 72.9 minutes of media screen time daily, with 14.1 minutes occurring after
7:00 pm. Eighteen percent of parents reported at least 1 sleep problem; children with a bedroom television consumed more
media and were more likely to have a sleep problem. Each additional hour of evening media use (regardless of content type)
was associated with a significant increase in the sleep problem score on the Children’s Sleep Habits Questionnaire (0.743),
as was violent media content viewed during the day (0.398). No such effects were observed with nonviolent daytime media
use. There was a trend toward greater impact of daytime violent use in the context of a bedroom television (p=0.098) and in
low-income children (p=0.07).
Comment: The TV has a lot to answer for. An average of 72.9 minutes glued to the box daily seems to me a lot of time of
inactivity of both limbs and brain. Screen time and content is associated with increased sleep problems and the former is
also strongly associated with being overweight. There is a lesson here, and one does not need to be a rocket scientist to
come to that conclusion!
Reference: Pediatrics. 2011;128(1):29-35.
http://pediatrics.aappublications.org/content/128/1/29.abstract
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Which early ‘red flag’ symptoms identify children with
meningococcal disease in primary care?
Authors: Haj-Hassan TA et al
Summary: This UK-based study set out to determine the diagnostic value of presenting symptoms in primary care for children
with meningococcal disease, using data collected by a parental symptoms checklist at point of care for 1212 children aged
<16 years presenting to a GP with acute infection; 924 of the children had an acute self-limiting infection, including 407 who
were reported by parents to be febrile. Symptom frequencies were compared with those reported by parents of 345 children with
meningococcal disease. Five symptoms were identified as having clinically useful positive likelihood ratios (LR+) for meningococcal
disease: confusion (LR+ 24.2), leg pain (LR+ 7.6), photophobia (LR+ 6.5), rash (LR+ 5.5), and neck pain/stiffness (LR+ 5.3).
Cold hands and feet had limited diagnostic value (LR+ 2.3); headache (LR+ 1.0) and pale colour (LR+ 0.3) failed to discriminate
meningococcal disease in children.
Comment: This is an important study for New Zealand, because over the last few weeks we have had another fatality from
meningitis. At this time of the year, wilh “flu like illnesses” abounding, there is a real danger of missing a case of meningitis,
especially in the early stages of the disease. Telephone triage by receptionists, practice nurses, and doctors needs to consider
identifiable red flags, and this paper adds two to the list. With febrile illness ask about neck stiffness, rash, photophobia and
confusion and leg pain. If in doubt – see the patient, and if still in doubt – admit to hospital, even for observation.
Reference: Br J Gen Pract. 2011;61(584):97-104.
http://rcgp.publisher.ingentaconnect.com/content/rcgp/bjgp/2011/00000061/00000584/art00001
Childhood nonspecific abdominal pain in family practice:
incidence, associated factors, and management
Authors: Gieteling MJ et al
Summary: Outcomes are reported of an analysis of data from 91 family practices that participated in the Second Dutch National
Survey of General Practice (2001). The study researchers calculated the incidence and factors associated with childhood
nonspecific abdominal pain (NSAP; children aged 4–17 years), referrals, and prescriptions. The incidence of childhood NSAP was
25.0 per 1,000 person-years. Of the 1,480 children with newly diagnosed NSAP, most (92.7%) consulted their doctor for this
condition once or twice. Factors independently associated with NSAP were female sex (OR 1.4), nongastrointestinal-nonspecific
somatic symptoms (OR 1.3), and health care use (OR 1.04). When NSAP was diagnosed at the first visit, very few of the patients
(3%) were referred to specialist care, and even fewer (1%) received additional testing. Family physicians prescribed medication
in 21.3% of NSAP diagnoses.
Comment: I agree, non specific abdominal pain in children is a common presentation and seldom has underlying pathology.
This is the problem which is presented by a parent stating that the child is always complaining of “tummy ache”. There is
nothing to find on examination, and it is easy to embark on a raft of investigations which basically leave the doctor at square
one. I am not talking about abdominal pain that has specific characteristics (abdominal migraine, constipation) but the low grade
pain that is often prompted by parents’ questions – “have you got tummy pain?” It does not take the child long to learn…….
Reference: Ann Fam Med. 2011;9(4):337-43.
http://www.annfammed.org/cgi/content/abstract/9/4/337
Revised guidelines for
cardiovascular risk
management — time to stop
medication? A practicebased intervention study
Authors: van Duijn HJ et al
Summary: Six general practices participated in this
Dutch investigation into the benefit of medication in
patients without target organ damage receiving
treatment for hypertension and/or hypercholesterolaemia.
A total of 833 such patients were invited to re-evaluate
their cardiovascular risk. Of around the two-thirds of
patients who accepted, 61% had a low calculated risk,
especially younger patients, females, and non-smokers.
Forty-two percent of these were advised to stop
medication, especially younger patients and nonsmokers. Of those who discontinued medication, 40%
had restarted within 6 months. After 6 months, 80 of
the 833 patients (9.6%) had not restarted medication.
Treatment discontinuation was not associated with any
important side effects.
Comment: Sticking my neck out, there has been
almost blind “progress” in the prescribing of medication
for cardiovascular risk. This “progress” has often been
promoted by industry. Aspirin has already been shown
not to be of any use in primary prevention (but is of
benefit in established disease), and in assessment of
risk factors in mild hypertension and hyperlipidaemia
the lowering of overall risk in mild disease may be very
small. The take home message is to include the patient
in the decision making process – demonstrate the risk
reduction that can be achieved by taking medication,
and balance that against medication risk itself.
Reference: Br J Gen Pract.
2011;61(587):347-52.
http://tiny.cc/ue03p
s.
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Impact on antibiotic
prescription of rapid antigen
detection testing in acute
pharyngitis in adults: a
randomised clinical trial
Authors: Llor C et al
Summary: This study was conducted in primary care
centres in Catalonia, Spain, and enrolled 557 adults
with acute pharyngitis with at least one Centor criterion
(fever, tonsillar exudate, tender enlarged anterior cervical
lymph nodes, or absence of cough). The study aimed to
determine the impact of rapid antigen detection testing
(RADT) to identify group A beta haemolytic streptococcus
in acute pharyngitis on the utilisation of antibiotics and
appropriateness of their use. Participant physicians were
randomly assigned to one of two study arms: an intervention
group assigned to RADT and a control group that followed
usual care, without RADT. Data were evaluable from
543 patients (281 in the intervention group and 262 in the
control group). GPs without access to RADT were more
likely to prescribe antibiotics compared with those who
performed rapid tests (64.1% vs 43.8%; p<0.001). The
more Centor criteria the patients presented, the greater
the number of antibiotics prescribed, regardless of whether
RADT was available (p<0.001). Antibiotics were prescribed
in 30.7% of the cases with negative RADT results.
Antibiotics were inappropriately prescribed in 226 cases
(43%); more so in the control than in the intervention group
(60% vs 26.9%; p<0.001).
Comment: New Zealand has to date never been big on
rapid antigen detection testing (RADT), even though it has
been available to identify both group A beta haemolytic
streptococcus, and both type A and B influenza. This
reviewer has not been impressed with RADT with reference
to influenza, having obtained numerous RADT negatives,
only to have cultures (done as part of a research study)
return as positive. With the prevalence of rheumatic fever
in some parts of New Zealand, I would like to see more
evidence of testing accuracy before making RADT the
sole decision maker as to whether to prescribe antibiotics
or not. It is interesting that in this study, the clinicians
tended to prescribe according to number and severity of
symptoms regardless of RADT result.
Reference: Br J Gen Pract.
2011;61(586):e244-51.
http://tiny.cc/j4yzx
Vitamin D and cardiovascular outcomes: a systematic review
and meta-analysis
Authors: Elamin MB et al
Summary: This systematic analysis of the literature identified 51 randomised controlled trials that explored the effect of
vitamin D on cardiovascular outcomes. All trials were of moderate quality. In a random-effects meta-analysis that pooled
the relative risks (RR) and the weighted mean differences across trials, vitamin D was associated with nonsignificant effects
on the patient-important outcomes of death (RR, 0.96; p=0.08), myocardial infarction (RR, 1.02; p=0.64), and stroke
(RR, 1.05; p=0.59). These analyses identified minimal heterogeneity across studies. No significant changes were observed in
the surrogate outcomes of lipid fractions, glucose, diastolic or systolic blood pressure; significant heterogeneity was observed
in these analyses, and the pooled estimates were trivial in absolute terms.
Comment: Vitamin D is developing a high profile in the medical literature at the moment, with it not only featuring in
osteoporosis and osteomalacia, but also in carcinoma of the colon, Alzheimer type dementia, and depression. This metaanalysis suggests that studies that have been done with reference to reduction in mortality and cardiovascular risk are only
of moderate quality, and the subject is probably worth revisiting. This would need to be a very large study and probably
would not interest the pharmaceutical industry – no profit in sunlight!
Reference: J Clin Endocrinol Metab. 2011;96(7):1931-42.
http://jcem.endojournals.org/content/96/7/1931.abstract
Fluoxetine ameliorates symptoms of refractory chronic
prostatitis/chronic pelvic pain syndrome
Authors: Xia D et al
Summary: This study from China enrolled 42 men with refractory chronic prostatitis/chronic pelvic pain syndrome
(CP/CPPS) that had failed to respond to standard therapy (including multiple antibiotic courses and α-blockers).
All participants were administered fluoxetine 20 mg/day for 3 months. At 12 weeks, significant decreases from baseline were
observed in the National Institutes of Health-chronic prostatitis symptom index (NIH-CPSI) total scores (from 28.55 to 9.29),
NIH-CPSI pain scores (from 14.69 to 5.19), NIH-CPSI urinary scores (from 4.95 to 1.88), NIH-CPSI quality of life scores (from
8.83 to 2.20), and Beck Depression Inventory (BDI) scores (from 34.67 to 13.95); all p-values were <0.05. Also at 12 weeks,
29 men (69.05%) reported marked improvement in subjective global assessment scores and 33 (78.57%) had a greater than
50% decrease in NIH-CPSI. A Pearson correlation coefficient analysis demonstrated a positive correlation between BDI score
and each CPSI score. No treatment-emergent adverse events were reported.
Comment: “Chronic” prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is not an uncommon presentation in general
practice. Patients complain of pain in their genitalia, supra pubic region, in the perineum, and within the pelvis itself. While it
is important to investigate and attempt to elicit the cause of the pain, frequently the search is fruitless. This paper provides
good evidence that fluoxetine is worth a try.
Reference: Chinese Med J. 2011;124(14):2158-61.
http://www.cmj.org/Periodical/AbstractList.asp?titleid=LW2011719346128807652
Independent commentary by Associate Professor Jim Reid.
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Constipation and risk of
cardiovascular disease among
postmenopausal women
Authors: Salmoirago-Blotcher E et al
Summary: These US-based researchers sought to
determine whether an association exists between
constipation and increased risk of cardiovascular (CV)
events in postmenopausal women, using data from
73,047 women enrolled in the observational arm of the
Women’s Health Initiative. Constipation was evaluated at
baseline by a self-administered questionnaire. The median
follow-up was 6.9 years. Constipation was associated with
increased age, African American and Hispanic descent,
smoking, diabetes, high cholesterol, family history of
myocardial infarction, hypertension, obesity, lower physical
activity levels, lower fibre intake, and depression. More
CV events occurred in women with moderate and severe
constipation (14.2 and 19.1 events/1000 person-years,
respectively) than in women with no constipation (9.6/1000
person-years). In an adjusted Cox proportional hazards
model, constipation was no longer associated with an
increased risk of cardiovascular events except for the
severe constipation group, which had a 23% higher risk of
cardiovascular events.
Comment: Interesting! From this study (73,047 women!!!!)
it seems that those with severe constipation had a higher
cardiovascular risk than those without, or with mild to
moderate symptoms. Cause is unknown, but it could be
well worthwhile reviewing CV risk factors in women afflicted
with severe constipation. A 23% higher risk is not to be
sneezed at.
Reference: Am J Med. 2011;124(8):
714-23.
http://tiny.cc/x7m8v
Evidence-based natural health by Dr Chris Tofield
A pilot study of the role of green tea use on oral health
Authors: Awadalla HI et al
Summary: This study from Egypt reports possible protective properties of green tea on oral health. Twenty-five subjects
rinsed with 2% green tea for 5 minutes. Significant pre- and post-rinsing scores were observed for Streptococcus mutans
count in saliva and plaque, pH values in saliva and plaque, and for scores on the Gingival Bleeding Index.
Comment: We have previously discussed green tea’s positive effects on warts, endometriosis, weight loss and
periodontal disease. Now this study enlightens us further on its beneficial oral health effects. The only downside I can
see is the fact that you have to swish the stuff around your mouth for a whole 5 minutes. Can we have a study looking
at maybe 30 seconds, please?
Reference: Int J Dent Hygiene. 2011;9(2):110-6.
http://onlinelibrary.wiley.com/doi/10.1111/j.1601-5037.2009.00440.x/abstract
Acupuncture for ‘frequent attenders’ with medically
unexplained symptoms: a randomised controlled trial
(CACTUS study)
Authors: Paterson C et al
Summary: This investigation was performed in four London general practices and involved 80 adults with medically
unexplained physical symptoms (MUPS), consulting GPs ≥8 times/year. The participants were randomised to receive
≥12 sessions of individualised five-element acupuncture, either immediately (acupuncture group) or after 26 weeks
(control group). Participants (80% female, mean age 50 years, mixed ethnicity) had high health-resource use. The majority
of problems (59%) were musculoskeletal and 65% had lasted for over a year. At 26 weeks, 80% of the participants
completed the Measure Yourself Medical Outcome Profile (MYMOP). Compared to baseline, the mean 26-week MYMOP
was improved by 1.0 in the acupuncture group and 0.6 in the control group (p=0.05). Other between-group adjusted
mean differences were: Well-Being Questionnaire (W-BQ12) score of 4.4 (p=0.002); EuroQol (EQ-5D) index of 0.03
(p=0.70); GP consultation rate ratio 0.90 (p=0.4); and number of medications 0.56 (p=0.28). All differences favoured
the acupuncture group. Imputation for missing values reduced the MYMOP adjusted mean difference to –0.4 (p=0.12).
Improvements in MYMOP and W-BQ12 were maintained at 52 weeks.
Comment: We all have one or two patients who experience unexplained symptoms, and who sometimes have been
investigated till the cows come home. Now this piece of research, aptly named the CACTUS study, throws the patient
(or us?) a lifeline. Exactly how the acupuncture achieved the good results is not clear to me, but there is enough
research on acupuncture now to make this a medically credible treatment option.
Reference: Br J Gen Pract. 2011;61(587):295-305.
http://rcgp.publisher.ingentaconnect.com/content/rcgp/bjgp/2011/00000061/00000587/art00001
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