Evidence for Primary Care: the latest evidence from the Trip Database

American Heart Association

How Can Primary Care Help Promote Cardiovascular Health Through Life’s Essential 8?

Clinical Bottom Line: Primary care is crucial for implementing the American Heart Association’s Life’s Essential 8 (LE8), a framework to improve cardiovascular health through lifestyle changes, risk factor management, and addressing health disparities. Supporting primary care with better resources, policies, and team-based care is essential to reduce CVD morbidity and mortality.

Summary: The Life’s Essential 8 framework outlines 8 health behaviors and factors to optimize cardiovascular health. Primary care plays a key role in promoting LE8 through preventive care, behavioral counseling, and addressing disparities. Challenges like limited resources and workforce shortages require solutions such as team-based care, telehealth, and policy reform to maximize primary care’s impact.

Campbell Collaboration

Which Delivery Methods of CBT Are Most Effective for Reducing Depression in Adolescents?

Clinical Bottom Line: Cognitive behavioral therapy (CBT) is effective in reducing depression in adolescents, regardless of the delivery method. Self-help with therapist support is slightly more effective in the short term, but differences between delivery methods are small, and no method has proven superior over the long term. More research is needed on remote CBT and long-term outcomes.

Summary: This systematic review evaluated 68 randomized controlled trials to compare the effectiveness of different CBT delivery methods for treating depression in adolescents. Findings indicate that all delivery types, including face-to-face, group, app-based, or self-help formats, reduce depressive symptoms. Self-help CBT with therapist support ranked slightly higher for short-term effectiveness, though the differences between methods were minimal. Over the long term, self-help without therapist support ranked highest, but evidence is limited. No delivery method was found to be more acceptable to young people. More studies are needed to assess remote CBT and outcomes in younger adolescents.

Try a Trip search: Click here to look at Trip’s wider evidence on CBT and adolescents.

CADTH

Are Stimulants or Nonstimulants More Effective for Managing ADHD in Adults?

Clinical Bottom Line: Stimulants are recommended as the first-line treatment for adults with ADHD due to their rapid effectiveness, while nonstimulants are suitable second-line options for those who cannot tolerate stimulants or are at risk of misuse. Evidence for the superiority of one over the other is limited, and more research is needed, especially for subpopulations like those in correctional settings.

Summary: This review highlights the Australian ADHD Professionals Association (AADPA) guidelines for managing ADHD in adults. Stimulants, including methylphenidate and lisdexamfetamine, are recommended as first-line treatments, while nonstimulants such as atomoxetine or guanfacine are second-line options. Combination therapy may be considered for enhanced benefits. While stimulants are effective, caution is advised for individuals at risk of misuse or diversion. No comparative studies were found directly assessing the clinical or cost-effectiveness of stimulants versus nonstimulants. Further research is required to address evidence gaps, including treatment for specific subpopulations like those in correctional facilities.

Try a Trip search: Click here to look at Trip’s wider evidence on ADHD and adults.

NICE, SIGN, BTA

How Should Asthma Be Diagnosed, Monitored, and Managed According to the BTS, NICE, and SIGN Guidelines?

Clinical Bottom Line: The BTS, NICE, and SIGN guidelines provide a comprehensive asthma pathway focusing on diagnosis, monitoring, and management across different age groups and scenarios. Pharmacological treatments, including inhalers and specialist therapies, are tailored to disease severity, while non-pharmacological strategies, self-management, and risk stratification are emphasized for holistic care.

Summary: The asthma pathway integrates recommendations from BTS, NICE, and SIGN to standardize asthma care. Key highlights include:

• Diagnosis: Tailored approaches for different age groups and occupational asthma.
• Monitoring: Emphasis on regular assessment to ensure control.
• Management: Pharmacological options prioritize inhalers, specialist therapies for severe cases, and environmental considerations for device selection.
• Non-Pharmacological Care: Self-management plans and education are central.
• Special Populations: Guidance for pregnancy, adolescents, and occupational asthma is detailed.

The pathway underscores the importance of individualized care, risk stratification, and seamless care delivery, promoting optimal outcomes for patients across settings.

British Columbia Guidelines

How Should Concussion and Mild Traumatic Brain Injury Be Diagnosed and Managed in Primary Care?

Clinical Bottom Line: Concussion/mild traumatic brain injury (mTBI) typically resolves within weeks with proper management. Primary care should prioritize early assessment, patient education, and a gradual return to activities. Emphasize aerobic exercise, symptom-specific interventions (headache, sleep, mood), and interdisciplinary care for persistent symptoms. Neuroimaging is not routinely recommended unless red flags are present.

Summary: This guideline provides a structured approach for assessing and managing concussion/mTBI across all ages. Key recommendations include:

• Assessment: Evaluate within 72 hours of injury. Rule out serious injuries using red flag criteria. Neuroimaging is unnecessary unless indicated.
• Management: Advise 24-48 hours of relative rest, followed by gradual reintroduction of activities. Incorporate aerobic exercise to improve recovery. Focus on managing headaches, sleep disturbances, and mood changes.
• Education: Provide verbal and written guidance to patients and families about recovery expectations and risk of reinjury.
• Follow-Up: Conduct follow-ups within two weeks to assess recovery and adapt management plans. Refer to interdisciplinary care if symptoms persist beyond four weeks.

Special populations, such as children, older adults, and individuals with comorbid conditions, may require tailored management strategies. Early intervention and close monitoring are critical to prevent prolonged recovery and complications.

Try a Trip search: Click here to look at Trip’s wider evidence on Concussion/Mild Traumatic Brain Injury

NIHR HTA

Can Point-of-Care Tests for Urinary Tract Infections Help Reduce Antibiotic Misuse and Antimicrobial Resistance?

Clinical Bottom Line: Point-of-care tests (POCTs) for urinary tract infections (UTIs) show promise in reducing inappropriate antibiotic prescribing by providing faster diagnostic results than traditional culture. However, current evidence on their clinical and cost-effectiveness is limited, with significant variability in test accuracy and insufficient robust data to guide widespread implementation. Further research is needed to validate these tests and their role in combating antimicrobial resistance.

Summary: This systematic review and conceptual economic model assessed the clinical and cost-effectiveness of POCTs for diagnosing UTIs. Key findings include:

• Effectiveness: Flexicult tests showed potential for reducing initial antibiotic prescribing but had mixed results in improving appropriate antibiotic use.
• Test Accuracy: Rapid tests like Lodestar DX demonstrated good sensitivity (86%) and specificity (88%) for E. coli, while others, like Uriscreen and UTRiPLEX, had variable or poor performance. Culture-based tests showed better accuracy but require 24 hours for results.
• Ease of Use: Flexicult and Uricult Trio are easier to use and interpret than standard culture methods, but data remain limited.
• Economic Modeling: Current cost-effectiveness data are too sparse and heterogeneous to draw meaningful conclusions.

Future research should focus on validating promising POCTs like Lodestar DX and Astrego PA-100, assessing their real-world impact on reducing inappropriate antibiotic use and their potential to address antimicrobial resistance.

Try a Trip search: Click here to look at Trip’s wider evidence on antimicrobial resistance.

NICE

How Should Asthma Be Diagnosed, Monitored, and Managed to Optimise Long-Term Outcomes?

Clinical Bottom Line: Accurate diagnosis and tailored management of asthma are essential to improving outcomes and preventing exacerbations. Objective tests, such as spirometry and FeNO, are critical for confirming diagnoses. Management strategies focus on individualized pharmacological therapy, adherence support, and self-management plans, including minimizing exposure to triggers. Regular reviews and adjustments to therapy are crucial to maintaining asthma control, especially in specific populations like children, pregnant individuals, and those with occupational triggers.

Summary: This NICE guideline, developed collaboratively with BTS and SIGN, outlines best practices for diagnosing, monitoring, and managing asthma. Key recommendations include:

• Diagnosis: A structured clinical history and objective tests, such as FeNO, spirometry, or peak flow monitoring, are essential. Diagnosis in children under 5 is based on clinical judgment and response to inhaled corticosteroids.
• Monitoring: Asthma control should be assessed regularly, incorporating symptom scores, inhaler use, and exacerbation history. FeNO monitoring can help optimize therapy in adults.
• Management:
  • Pharmacological: Initiate therapy with inhaled corticosteroids (ICS) and escalate based on severity. Maintenance and reliever therapy (MART) is preferred for adults and some children. Tailor inhaler selection to patient preferences and environmental impact.
  • Non-pharmacological: Personalized action plans and education support adherence and empower self-management.
• Special Populations: Tailored approaches are needed for adolescents, pregnant individuals, and occupational asthma.
• Reducing Treatment: Consider step-down therapy for well-controlled asthma, ensuring close monitoring.

This guideline emphasizes a patient-centered approach to asthma care, balancing efficacy with the need for sustainable healthcare practices.

Office for Health Improvement and Disparities

Should GPs Recommend PSA Testing for Asymptomatic Men Considering the Risks and Benefits?

Clinical Bottom Line: PSA testing in asymptomatic men requires a nuanced discussion of the potential benefits and risks. While the test is a valuable tool for detecting prostate abnormalities, it may lead to overdiagnosis, unnecessary anxiety, and treatments with adverse effects. GPs should provide balanced information, consider individual risk factors (age, family history, ethnicity), and ensure patients make informed decisions.

Summary: This guidance helps GPs advise asymptomatic men considering PSA testing. PSA levels can be elevated for reasons other than prostate cancer, and the test cannot distinguish between aggressive and non-aggressive cancers. While further investigations like digital rectal examination (DRE), multiparametric MRI (mpMRI), and biopsy can provide more information, they carry risks such as discomfort, infection, and overdiagnosis. Management options for localised prostate cancer, including monitoring, surgery, and radiotherapy, may improve outcomes but often impact quality of life. GPs should discuss the potential benefits, risks, and implications of testing, following NICE guidelines, and provide materials to support informed decisions.

American Academy of Pediatrics

Clinical Bottom Line: Nitrofurantoin and cranberry products are effective in reducing the incidence of symptomatic urinary tract infections (UTIs) in children with recurrent UTIs. However, no prophylactic strategy has demonstrated a reduction in kidney scarring. Further research is required to explore nonantibiotic options.

Summary: This systematic review and meta-analysis of 23 randomized controlled trials involving 3,335 children evaluated prophylaxis options for recurrent UTIs. Both nitrofurantoin and cranberry products significantly reduced symptomatic UTI episodes compared to controls and other interventions. Nitrofurantoin showed the greatest effectiveness, but none of the interventions studied demonstrated an ability to prevent kidney scarring. Future studies should focus on nonantibiotic approaches and their impact on long-term outcomes like kidney scarring.

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Age Ageing

Which Types and Doses of Exercise Are Most Effective for Reducing Depression in Older Adults?

Clinical Bottom Line: Resistance exercise and mind-body exercise (e.g., yoga, tai chi) are the most effective exercise modalities for reducing depression in older adults. A U-shaped dose-response relationship was observed, with significant benefits achieved at a dose of 390 MET-minutes per week, which is lower than the World Health Organization’s general exercise recommendations.

Summary: This systematic review and meta-analysis of 80 randomized controlled trials involving 5,536 participants assessed the effects of various exercise modalities on depression in older adults. Resistance exercise (SMD = -0.68) and mind-body exercise (SMD = -0.54) were the most effective, followed by aerobic exercise (SMD = -0.31) and mixed exercise (SMD = -0.23). A U-shaped dose-response relationship suggested optimal benefits at doses around 390 MET-minutes per week. These findings highlight the importance of tailoring exercise interventions for depression in older adults, emphasizing resistance and mind-body exercises as effective adjunctive therapies.

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Registered Nurses’ Association of Ontario (RNAO)

What Are the Best Practices for Managing Pressure Injuries: Risk Assessment, Prevention, and Treatment?

Clinical Bottom Line: Effective management of pressure injuries involves a systematic, evidence-based approach that integrates risk assessment, prevention, and treatment. Key practices include using validated classification systems, employing multicomponent assessments, engaging in culturally inclusive care, and incorporating health technologies like thermography for early detection. Regular reassessments, tailored interventions, and shared decision-making with patients and caregivers are vital for achieving optimal outcomes.

Summary: The fourth edition of the RNAO guideline emphasizes an interprofessional, person-centered approach to pressure injury management. Prevention strategies include risk assessments utilizing validated tools, pressure redistribution, and prophylactic dressings. Evidence supports repositioning every 2–4 hours for at-risk individuals and the use of silicone multilayer dressings for prevention. Health technologies, such as thermography, are recommended as adjuncts for early detection. Despite advancements, disparities persist, particularly for individuals with darker skin tones, underscoring the importance of equity-focused practices. Collaboration among healthcare providers, patients, and caregivers remains central to improving outcomes.

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J Am Coll Cardiol .

Does Cardiovascular Disease Risk Increase Decades Before a Type 2 Diabetes Diagnosis?

Clinical Bottom Line: Individuals with type 2 diabetes mellitus (T2DM) experience a significantly higher risk of cardiovascular disease (CVD) events, including myocardial infarction and ischemic stroke, starting up to 30 years before their diabetes diagnosis. This emphasizes the need for early and aggressive CVD prevention strategies in those at risk of T2DM.

Summary: A nationwide registry study in Denmark analyzed 127,092 individuals with T2DM and 381,023 matched controls over a 30-year pre-diagnosis period and 5 years post-diagnosis.

• Before T2DM Diagnosis: Individuals with T2DM had consistently higher odds of CVD events compared to controls, with odds ratios (ORs) increasing from 2.18 (25-30 years before diagnosis) to 2.96 (<5 years before diagnosis).
• After T2DM Diagnosis: The 5-year CVD incidence remained elevated in individuals with T2DM compared to controls (hazard ratio [HR]: 2.20).

Findings suggest that the elevated CVD risk begins decades before diabetes onset, underscoring the need for early screening and preventive interventions targeting individuals at risk of developing T2DM.

Try a Trip search: Click here to look at Trip’s wider evidence on cardiovascular disease and diabetes.

Age Ageing

Can a Multidomain Lifestyle Intervention Reduce Health Care Service Use and Costs?

Clinical Bottom Line: The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) demonstrated that a two-year multidomain lifestyle intervention reduced inpatient hospital care and emergency service use over an 8-year follow-up, particularly among men. While total health care costs were not significantly different, the intervention group showed lower costs when excluding long-term care.

Summary: The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) investigated the long-term effects of a two-year multidomain lifestyle intervention on health care service use and costs among older adults at risk of cognitive impairment. Participants aged 60-77 were randomized into intervention and control groups, and their health care service use was tracked over an eight-year follow-up using national health care registers. The study found that the intervention group required less inpatient hospital care and fewer emergency services, particularly among men, compared to the control group. Although total health care costs were similar between the groups, the costs excluding long-term care were lower for the intervention group. No significant differences were observed in the use of outpatient, primary care, or home care services. These results indicate that the FINGER intervention can reduce the need for certain health care services and associated costs, highlighting its potential as a preventive strategy for older adults.

Diabetes Care

Does Metformin With or Without a Mediterranean Diet Prevent Age-Related Diseases in People With Metabolic Syndrome?

Clinical Bottom Line: Metformin at 1,700 mg/day is effective in reducing the incidence of type 2 diabetes in individuals with metabolic syndrome, with the addition of a Mediterranean diet further enhancing this benefit. Both interventions, alone or combined, significantly reduced diabetes risk compared to placebo, though they did not impact other major noncommunicable diseases.

Summary: The MeMeMe trial evaluated the effects of metformin (1,700 mg/day) with or without a Mediterranean diet intervention on preventing major noncommunicable diseases (type 2 diabetes, cardiovascular diseases, and cancer) in individuals with metabolic syndrome. Over an average follow-up of 3 years, participants in the metformin group had significantly lower diabetes incidence compared to those receiving placebo. The combination of metformin and the Mediterranean diet resulted in the most substantial reduction, with diabetes risk reduced by 92%. However, the intervention did not significantly impact the incidence of cardiovascular disease or cancer. This study highlights the efficacy of metformin, particularly when combined with dietary modification, in diabetes prevention for individuals with metabolic syndrome.