Ann Robinson’s research reviews—16 November 2023BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2658 (Published 16 November 2023) Cite this as: BMJ 2023;383:p2658
- Ann Robinson, NHS GP and health writer and broadcaster
Take it without a pinch of salt
Reducing salt intake is as effective for lowering blood pressure as commonly used first line antihypertensive drugs in people aged 50-75 years. This small, but important, study of 213 people included roughly equal numbers of people with normal blood pressure, treated blood pressure, inadequately treated blood pressure, and untreated high blood pressure. The researchers found an average lowering of 8 mm Hg in systolic blood pressure in those who reduced their usual salt intake compared with those who increased it over one week.
Everyone seemed to benefit from cutting down on salt regardless of age, sex, race, baseline blood pressure, known hypertension or diabetes, and body mass index. The median sodium intake per day before the intervention was 4.5 g, far in excess of the WHO’s recommendation of 2 g. By cutting down their salt intake by 1 teaspoon a day (2.3 g sodium), the low salt group achieved a median 6 mm Hg reduction in systolic blood pressure. The low salt diet was well tolerated, with low and high groups reporting similar adverse effects.
A third of women who have high blood pressure during pregnancy will require medication in the next 10 years, and their risk of an early heart attack or stroke is doubled. The advice is to “monitor risk factors until disease develops,” but there’s no consensus on how to do this, and even checking blood pressure in the first six weeks after delivery is often hit and miss.
This study from Oxford of 220 postpartum women with gestational hypertension or pre-eclampsia who were discharged on antihypertensive medication found that a remote telemonitoring programme delivered better control of blood pressure than standard care. The control group typically saw a community midwife at 7-10 days and a GP at 6-8 weeks to check their blood pressure and tweak their medication if needed. The intervention group monitored their own blood pressure daily using a Bluetooth-enabled monitor and smartphone app that transmitted the results to an NHS platform, which sent back a message from remote clinicians to increase, decrease, or stick with current doses. This group tended to stay on higher doses of antihypertensives in the six weeks after giving birth, and the women were substantially less likely to be readmitted with high blood pressure. There was no difference between the groups in quality of life scores.
Older patients in the emergency department
Nobody, surely, thinks that keeping an older or frail person overnight in an emergency department, rather than admitting them to a ward, is a good idea. The sensory bombardment in a busy emergency department is discombobulating for everyone. I saw the experience through the lens of my mum, who had dementia, and it was terrifying.
This French cohort study of 1598 patients over 75 years old found that those who spent a night in an emergency department had higher in-hospital 30 day mortality (15.7% v 11.1%), an increased risk of adverse events (such as falls, infection, stroke, and bed sores), and longer hospital stays (9 v 8 days) compared with matched patients who were admitted to a ward before midnight. Unsurprisingly, those with limited autonomy who required assistance with activities of daily living were at greatest increased risk of dying or experiencing adverse events. The study wasn’t designed to explore the reasons for the observed excess mortality.
JAMA Intern Med doi:10.1001/jamainternmed.2023.5961
Amitriptyline for IBS: don’t hold back
Most patients with irritable bowel syndrome (IBS) are managed in primary care. When first-line therapies (diet, lifestyle and psychological advice, and symptomatic treatment) don’t work, NICE recommends considering a low dose tricyclic antidepressant such as amitriptyline. There’s no evidence about tricyclics’ effectiveness in a primary care setting, and only half of GPs think they help IBS; which is presumably why 95% would prescribe them for insomnia, but only 10% often do so for IBS.
This trial of 463 people is the largest to study tricyclics in IBS and the first entirely based in primary care. Over six months, amitriptyline (10 mg to start, with patient-led titration up to a maximum of 30 mg daily) was more effective than placebo in reducing global IBS symptoms and multiple other symptom-based outcomes, although it had no effect on anxiety, depression, or work and social adjustment scores. Significantly more people found taking amitriptyline more acceptable than placebo, although expected side effects such as dry mouth were more common. GPs should offer amitriptyline as a second line treatment for IBS with the option to titrate up the dose themselves, using the helpful leaflet developed for this trial, say the authors.
It’s all very well telling primary care clinicians to recognise and treat obesity, but there’s little guidance about how best to broach the subject. This cohort study comes from 38 primary care clinics in England that are taking part in the 12-week Brief Intervention on Weight Loss trial (BWeL).
Analysis of recorded discussions between 246 patients with obesity and 87 clinicians who were suggesting a referral to BWeL identified three approaches on the basis of the clinicians’ language: “good news,” which focused on the potential benefits of referral; “bad news,” which emphasised the dangers of obesity; and “neutral,” which described BWeL without any comment. Unsurprisingly, good news was associated with increased agreement to attend the programme, better attendance, and greater subsequent weight loss compared with neutral news. Scare tactics didn’t have much impact; there was no difference in mean weight change between bad and neutral news. Patient satisfaction was reportedly the same, irrespective of the approach, which seems surprising. Recordings were audio only, so couldn’t capture the all-important body language and non-verbal cues.
Ann Intern Med doi:10.7326/M22-2360
Competing interests: None declared
Provenance and peer review: Not commissioned; not peer reviewed