Gliflozins and reducing cardiovascular events . . . and other storiesBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2677 (Published 07 June 2017) Cite this as: BMJ 2017;357:j2677
Gliflozins and cardiovascular protection
Plenty of drugs lower blood glucose in people with type 2 diabetes, and produce millions in revenue for their manufacturers. But it came as a surprise even to the trialists when one drug, empagliflozin, produced a clear signal of benefit in reducing cardiovascular events as well as sugar (Circulation doi:10.1161/CIRCULATIONAHA.117.029190). Most trials of other drugs in the sodium-glucose co-transporter-2 inhibitor (SGLT-2i) class were not powered to show a similar effect, but an observational study based on registry data from more than 300 000 patients in Europe and the United States suggests a reduction in heart failure and cardiovascular death from all drugs in the SGLT-2i class.
Parent delivered CBT for anxious kids
Mental health services for children in the UK are unable to match demand, especially for one to one cognitive therapy. Could parents help by being trained to deliver cognitive behavioural therapy (CBT) to their offspring? A randomised trial in Oxfordshire produced mixed results (Lancet doi:10.1016/S2215-0366(17)30149-9), but showed that parental CBT might be as good as solution focused, brief therapy for anxious children. Minerva wonders if it works worse or better if the parent is the source of anxiety.
Loneliness and death
“Be not solitary, be not idle” was Robert Burton's advice in The Anatomy of Melancholy (1621). This applies beyond melancholia: the association between premature death and loneliness has long been recognised. Not to mention the benefits of activity. The UK Biobank Study includes 466 901 men and women with enough social information to examine the connection between isolation and loneliness and death rate over 6.5 years (Lancet doi: 10.1016/S2468-2667(17)30075-0). There is a definite association (hazard ratio 1.38) but this is completely mediated by known risk factors, many of them modifiable by more activity and better support and care.
Population oral steroid use
Oral corticosteroids always carry some risk. For example, a recent BMJ paper (doi:10.1136/bmj.j1415) showed a fivefold increase in the risk of sepsis after short courses, as well as an increased risk of thromboembolism and fractures. All the more alarming, then, to read a survey showing that about 3% of the Danish population redeemed at least one prescription for a systemic steroid annually between 1999 and 2015 (BMJ Open doi: 0.1136/bmjopen-2016-015237). In the oldest age groups, who are at highest risk of harm, this approached 10%.
Shared decision making with patients has been advocated for the past 30 years, and since the Montgomery v Lanarkshire case it is now a legal requirement. This raises thorny issues about how well the preferences of patients match those of clinicians, and how such differences can be resolved. One way to study the problem is by discrete choice experiments, and a recent review identified 38 of these exploring 16 interventions in 26 diseases/indications (BMJ Open doi:10.1136/bmjopen-2016-014719). They showed a variety of discordances, highlighting the need for better skills and better tools for clinicians in their dialogue with patients.
Sex differences in inpatient outcomes
“The association of sex with daily risk of rehospitalisation varies across conditions” is a perfectly correct use of words, though it could be misconstrued as referring to pleasures which Minerva, the chaste goddess, has little knowledge of. In a survey of three million Medicare admissions, US researchers explored differences between men and women in three common causes of hospital readmission (Circ Outcomes doi:10.1161/CIRCOUTCOMES.116.003271). Women were more at risk for rehospitalisation (but not death) after myocardial infarction and heart failure, but not pneumonia.