Vol 1 - Sep 2024 Evidence for Primary Care
Evidence for Primary Care: the latest evidence from the Trip Database
A summary of some of the most important new documents for primary care that have recently been added to the Trip Database
Editorial: Cutting Through the Noise of Guidelines and Trials
It’s a busy world for clinicians, and as we dive into the latest guidance and studies, four stand-out articles this month could spark change in how we approach chronic disease management. Oral GLP-1 agonists for weight loss are finally bringing convenience into the mix, making life easier for patients who dread injections—if they can handle the side effects, that is. Meanwhile, the ESC’s hypertension guidelines serve as a reminder that individualized care is key—more blood pressure cuffs at home, less guessing in the clinic.
Over in the cancer screening department, we’re finally getting serious about prostate cancer detection—shared decision-making has emerged as the star player, steering us away from blanket PSA screening and towards more nuanced risk-based approaches. And if you're managing COPD, British Columbia’s focus on climate-related exacerbations might be the most relevant part of their new recommendations, given today’s environmental concerns.
Sprinkled throughout the rest of this issue are an assortment of equally thought-provoking studies and reviews: the latest ESC Atrial Fibrillation Guidelines, insights into testosterone replacement therapy, and a fresh look at how hearing loss and dementia might be connected. Want more? The RESET-BP trial could change how you counsel desk-bound patients on blood pressure management, and the LAMP trial takes telehealth mindfulness mainstream for chronic pain.
With so much to explore, it's worth taking a break from the clinic chaos to catch up on how these guidelines and trials can reshape our practice.
In This Edition
- Are oral GLP-1 agonists effective for weight loss?
- ESC Guidelines for the management of elevated blood pressure and hypertension
- Prostate Cancer Early Detection in the European Union and UK
- Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management
- Current evaluation of amenorrhea
- What Is the Efficacy of Antibiotic Treatment for Children Diagnosed With Acute Otitis Media?
- Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial
- Evaluation of glucose-lowering medications in older people: a comprehensive systematic review and network meta-analysis of randomized controlled trials
- Examining the association between hearing loss and dementia
- Genitourinary Syndrome of Menopause: A Systematic Review
- The role of the World Guidelines for Falls Prevention and Management's risk stratification algorithm in predicting falls: a retrospective analysis of the Osteoarthritis Initiative
- Clinical practice guidelines for influenza
- 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)
- The effects and safety of testosterone replacement therapy for men with hypogonadism: the TestES evidence synthesis and economic evaluation
- Primary Care Approaches to Addressing the Impacts of Trauma and Adverse Childhood Experiences (ACEs)
- Effects of Sedentary Behavior Reduction on Blood Pressure in Desk Workers: Results From the RESET-BP Randomized Clinical Trial
- What is the optimal initial insulin for patients with type 2 diabetes?
- Summary of the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome: an Australian perspective
- The Efficacy of Exercise Therapy for Rotator Cuff-Related Shoulder Pain According to the FITT Principle: A Systematic Review With Meta-analyses
Tools for Practice
Are oral GLP-1 agonists effective for weight loss?
Clinical Bottom Line: Oral GLP-1 agonists offer a significant weight loss option for patients, especially those who prefer oral medications, though side effects and costs may limit widespread use.
Summary: This article reviews the effectiveness of oral GLP-1 agonists, particularly semaglutide, for weight loss. It highlights that higher doses (50mg) show greater weight loss (~15% over 68 weeks), though only a 14mg dose is currently available in Canada. Common side effects include gastrointestinal disturbances and gallbladder issues, while costs remain high. The article also discusses patient preferences for oral over injectable treatments.
View ArticleEuropean Society of Cardiology
ESC Guidelines for the management of elevated blood pressure and hypertension
Clinical Bottom Line: Updated hypertension guidelines prioritize individualized treatment based on cardiovascular risk, with a focus on out-of-office monitoring and achieving optimal blood pressure control.
Summary: This guideline provides a comprehensive overview of hypertension management, including pathophysiology, clinical consequences, and practical recommendations for measuring and treating elevated blood pressure. It covers new guidelines on blood pressure targets, cardiovascular risk assessment, and treatment strategies. The importance of both office and home monitoring, non-pharmacological interventions, and pharmacological approaches is emphasized, along with management for specific populations like pregnant women and older adults.
View ArticleEur Urol .
Prostate Cancer Early Detection in the European Union and UK
Clinical Bottom Line: Shared decision-making is preferred over population-based screening for prostate cancer, with PSA screening offering mortality benefits but posing risks of overdiagnosis, while future strategies aim to reduce harms through risk-adapted approaches.
Summary: This systematic review (SR) compiles insights from 26 SRs related to early detection of prostate cancer (PCa) in the European Union (EU) and the UK, identifying six key themes: invitation for screening, shared decision-making (SDM), screening acceptance, screening methods, potential harms and benefits, and the future of PCa screening. The review highlights the importance of SDM over population-based screening, notes the benefits of prostate-specific antigen (PSA) screening in reducing PCa-specific mortality, and acknowledges challenges like overdiagnosis and overtreatment. Future directions suggest risk-adapted screening to mitigate harms.
View ArticleBritish Columbia Guidelines
Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management
Clinical Bottom Line: COPD care should focus on early diagnosis, smoking cessation, tailored treatment, and addressing environmental factors like inhaler use and climate-related risks.
Summary: The guideline emphasize confirming diagnosis with spirometry, promoting smoking cessation, early management to slow progression, and referral for pulmonary rehabilitation. Immunizations are recommended to reduce exacerbation risks, and inhaler adherence should be regularly evaluated. Environmental impacts, such as inhaler choices and climate-related exacerbations, are also highlighted.
View Article
American Society for Reproductive Medicine
Current evaluation of amenorrhea
Clinical Bottom Line: The evaluation of amenorrhea should prioritize excluding pregnancy, conducting hormone tests (FSH, estradiol, prolactin, TSH), and considering common causes like PCOS, thyroid dysfunction, and hyperprolactinemia for proper diagnosis and management.
Summary: Amenorrhea is the absence of menstruation, categorized as primary or secondary. Common causes include polycystic ovary syndrome (PCOS), thyroid disorders, hyperprolactinemia, hypogonadotropic and hypergonadotropic hypogonadism, and anatomical abnormalities. The evaluation involves a detailed history, physical examination, and testing for serum FSH, estradiol, prolactin, TSH, and pregnancy. In primary amenorrhea, physical examination is more useful, while secondary amenorrhea requires additional diagnostic methods such as imaging and hormone testing.
View ArticleAnnals of Emergency Medicine
What Is the Efficacy of Antibiotic Treatment for Children Diagnosed With Acute Otitis Media?
Clinical Bottom Line: For children with acute otitis media in high-income countries, expectant observation is a reasonable approach, as antibiotics provide only slight pain reduction but increase the risk of side effects. Antibiotics should be reserved for select cases after shared decision-making, considering pain management and close follow-up.
Summary: This meta-analysis evaluated the efficacy of antibiotics in treating acute otitis media (AOM) in children in high-income countries. It found that antibiotics slightly reduce pain at 2 to 3 days and at 10 to 12 days but come with an increased risk of side effects such as diarrhea, vomiting, and rash. Immediate antibiotic use improved pain at 2 to 3 days compared to expectant management but had no significant impact on pain beyond that. The certainty of evidence varied, and heterogeneity in diagnostic criteria, treatments, and outcomes affected the consistency of the results.
View ArticleJAMA Intern Med.
Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial
Clinical Bottom Line: Scalable telehealth MBIs, whether group-based or self-paced, effectively improve pain-related function and overall quality of life in veterans with chronic pain, offering a promising nonpharmacological treatment option for chronic pain management in health care systems.
Summary: This randomized clinical trial compared two telehealth mindfulness-based interventions (MBIs), one group-based and one self-paced, to usual care in veterans with moderate to severe chronic pain. Over the course of a year, both MBIs significantly improved pain-related function and various biopsychosocial outcomes such as pain intensity, physical function, depression, and fatigue compared to usual care. The interventions were scalable, low-resource, and showed similar efficacy, with greater likelihood of achieving a 30% improvement in pain-related outcomes.
View ArticleAge Ageing
Evaluation of glucose-lowering medications in older people: a comprehensive systematic review and network meta-analysis of randomized controlled trials
Clinical Bottom Line: For older adults with type 2 diabetes, newer medications like GLP-1RAs and SGLT2 inhibitors should be prioritized due to their cardiovascular and renal benefits, along with reduced risk of hypoglycemia, compared to traditional treatments like sulfonylureas.
Summary: This network meta-analysis assessed glucose-lowering medications in older adults with type 2 diabetes, analyzing 22 trials with 41,654 participants. GLP-1 receptor agonists (GLP-1RAs) were found to reduce cardiovascular events and body weight, while SGLT2 inhibitors decreased the risk of heart failure hospitalization, renal issues, and body weight. Sulfonylureas were associated with significantly higher risks of both mild and severe hypoglycemia. All included treatments effectively lowered glucose, but the number of required treatments generally decreased with increasing age.
View ArticleMcMaster
Examining the association between hearing loss and dementia
Clinical Bottom Line: Hearing loss is associated with an increased risk of all-cause dementia, and early interventions such as the use of hearing aids may help reduce cognitive decline. Further research is needed to clarify the mechanisms and specific impacts on different types of dementia, particularly Alzheimer’s disease.
Summary: This rapid evidence profile investigates the relationship between hearing loss and dementia. It identifies a consistent association between hearing loss and all-cause dementia, with hearing loss preceding dementia onset by 5-10 years. Evidence supports a positive association between hearing loss and cognitive decline, with hearing loss increasing the risk of dementia, particularly in cases of all-cause dementia. There is less consistent evidence regarding specific types of dementia like Alzheimer’s disease and vascular dementia. Some studies also indicate that hearing aids may help reduce cognitive decline, although findings are mixed regarding their impact on cognitive function in patients with Alzheimer’s disease.
View ArticleAHRQ
Genitourinary Syndrome of Menopause: A Systematic Review
Clinical Bottom Line: Vaginal estrogen remains the most effective treatment for GSM, improving both vulvovaginal dryness and overall quality of life. Non-hormonal options like moisturizers offer modest benefits. More research is needed on energy-based treatments like CO2 lasers, as current evidence suggests limited additional benefits over conventional therapies. Careful consideration of risks and patient preferences is recommended when choosing treatments for GSM.
Summary: The systematic review on Genitourinary Syndrome of Menopause (GSM) evaluated various treatments to manage symptoms such as vulvovaginal dryness, discomfort, and dyspareunia. The findings suggest that vaginal estrogen is effective in improving dryness and quality of life. Vaginal moisturizers provide some benefit in relieving dryness but are less effective in other symptoms. Energy-based treatments like CO2 lasers showed little to no difference compared to sham lasers or vaginal estrogen creams for symptom relief. The review highlights that while many treatments improve symptoms, the certainty of evidence varies, with most interventions having low to very low certainty in terms of effectiveness and harms.
View ArticleAge Ageing
The role of the World Guidelines for Falls Prevention and Management's risk stratification algorithm in predicting falls: a retrospective analysis of the Osteoarthritis Initiative
Clinical Bottom Line: The WGFPM falls risk stratification algorithm shows good specificity, meaning it effectively identifies people unlikely to fall. However, its limited sensitivity indicates it may miss some individuals at higher risk. As such, while useful for opportunistic case finding, additional measures may be needed to more accurately predict falls in clinical practice.
Summary: This study assessed the sensitivity, specificity, and accuracy of the World Guidelines for Falls Prevention and Management (WGFPM) falls risk stratification algorithm using data from the Osteoarthritis Initiative (OAI). Participants aged 40 to 80 were categorized into low, intermediate, and high-risk groups for falls. The study found that the WGFPM algorithm demonstrated high specificity (89.9%) but limited sensitivity (33.7%) in predicting falls. Overall accuracy was 72.4%, showing that the algorithm was effective at identifying individuals at low risk but less sensitive for detecting all those at high risk of falls.
View ArticleWHO
Clinical practice guidelines for influenza
Clinical Bottom Line: WHO recommends integrated, evidence-based strategies to improve global health, focusing on prevention, health equity, and strengthening healthcare systems to tackle key public health challenges.
Summary: The document is a World Health Organization (WHO) report focusing on public health strategies, disease prevention, and global health priorities. It highlights guidelines and interventions aimed at improving health outcomes, particularly in vulnerable populations. Key areas include managing infectious diseases, addressing non-communicable diseases, and strengthening healthcare systems. The report emphasizes evidence-based practices and international collaboration.
View ArticleEuropean Society of Cardiology
2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)
Clinical Bottom Line: AF management should focus on preventing stroke with anticoagulation, controlling symptoms through rate or rhythm management, and addressing comorbidities. A patient-centered, multidisciplinary approach, with regular reassessment, is essential for optimal outcomes.
Summary: The 2024 ESC Guidelines for the management of atrial fibrillation (AF), developed with the European Association for Cardio-Thoracic Surgery (EACTS) and endorsed by the European Stroke Organisation (ESO), provide a comprehensive update on AF diagnosis, treatment, and patient care. The guidelines emphasize a multidisciplinary, patient-centered approach, termed AF-CARE (Comorbidity management, Avoid stroke, Reduce symptoms, and Evaluation). Key updates include refined recommendations on anticoagulation, rate and rhythm control, management of comorbidities like hypertension and sleep apnea, and an emphasis on personalized treatment pathways, focusing on both clinical outcomes and quality of life.
View ArticleNIHR HTA
The effects and safety of testosterone replacement therapy for men with hypogonadism: the TestES evidence synthesis and economic evaluation
Clinical Bottom Line: TRT can benefit sexual function and mood in hypogonadal men, but its cardiovascular risks are still unclear, requiring careful patient selection and monitoring.
Summary: The study evaluates the effects and safety of testosterone replacement therapy (TRT) in men with hypogonadism, focusing on outcomes such as sexual function, mood, cardiovascular health, and bone density. It also includes a cost-effectiveness analysis. Results indicate TRT can improve sexual function and mood but has mixed effects on cardiovascular health. Long-term safety remains uncertain.
View ArticleBritish Columbia Guidelines
Primary Care Approaches to Addressing the Impacts of Trauma and Adverse Childhood Experiences (ACEs)
Clinical Bottom Line: Trauma-informed practice (TIP) fosters safer, supportive healthcare environments. Address trauma sensitively, focusing on resilience and trust, especially for patients from historically marginalized groups.
Summary: This document highlights the importance TIP in primary care, addressing how trauma, including Adverse Childhood Experiences (ACEs), affects patient health and healthcare interactions. It emphasizes building trust, cultural safety, and supporting resilience, particularly in vulnerable populations like Indigenous communities. The ACEs questionnaire is a useful tool but should be applied with care to avoid retraumatization.
View Article
Circulation
Effects of Sedentary Behavior Reduction on Blood Pressure in Desk Workers: Results From the RESET-BP Randomized Clinical Trial
Clinical Bottom Line: Reducing sedentary behavior by increasing standing during work hours does not reduce BP and may negatively affect arterial stiffness. Further research is needed.
Summary: This study examined whether reducing sedentary behavior (SB) through standing and stepping interventions lowered blood pressure (BP) and pulse wave velocity (PWV) in sedentary adults. Although the intervention reduced SB and increased standing, it did not significantly impact BP or PWV. Unexpectedly, reductions in work-time SB were linked to an increase in PWV, while non-work standing showed favorable effects on PWV.
View ArticleTools for Practice
What is the optimal initial insulin for patients with type 2 diabetes?
Clinical Bottom Line: Basal insulin is the preferred initial treatment for type 2 diabetes due to its simplicity, fewer side effects, and comparable glycemic control to biphasic insulin.
Summary: Initiating insulin in type 2 diabetes, basal insulin (once daily) is simpler and generally preferred over biphasic insulin (twice daily). While biphasic insulin slightly lowers HbA1c more than basal insulin (~0.1-0.2%), it leads to more weight gain and higher risk of symptomatic hypoglycemia. Importantly, no insulin regimen has demonstrated cardiovascular benefits in randomized controlled trials.
View ArticleNational Health and Medical Research Council
Summary of the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome: an Australian perspective
Clinical Bottom Line: The guideline recommends early diagnosis, lifestyle management, and evidence-based treatments, particularly addressing psychological and metabolic aspects, with a strong emphasis on patient-centered approaches.
Summary: The 2023 international guideline on polycystic ovary syndrome (PCOS), led by Australia, emphasizes refined diagnostic criteria, including anti-Müllerian hormone levels, and highlights the broad health impacts of PCOS. It focuses on improving awareness, evidence-based care, psychological well-being, and fertility management. The guideline stresses the need for better healthcare professional education and patient-centered care.
View ArticleJ Orthop Sports Phys Ther.
The Efficacy of Exercise Therapy for Rotator Cuff-Related Shoulder Pain According to the FITT Principle: A Systematic Review With Meta-analyses
Clinical Bottom Line: Motor control exercises may be slightly more effective than nonspecific exercises for reducing disability in RCRSP.
Summary: This systematic review evaluated the effectiveness of exercise interventions with varying frequency, intensity, type, and time (FITT) for people with rotator cuff-related shoulder pain (RCRSP). The review found moderate-certainty evidence that motor control exercise programs slightly reduced disability in the short and medium terms compared to nonspecific exercise. However, no significant difference in pain reduction was noted, and uncertainties remain about other exercise types and intensities due to low-certainty evidence.
View Article