Hello! This is the last Dragi Webdo of this season and we will be back from late August-early September. I am starting this blog post with an Irish article from the BJGP that discusses the workload of GPs and the distribution of their working hours according to duties: for around 10 hours a day of work, only 7 are dedicated to consultation (clinical consultation and prescription)!
1/ COVID-19
The BMJ has published a systematic review about the efficiency of screening serological tests. The authors find out that the sensitivity of ELISA tests is 84%, 66% for rapid tests/POC tests (LFIA) and 98% for the new techniques of chemiluminescent immunoassays (CLIA). All specificities are between 97 and 100%. A swab 3 weeks after the onset of symptoms could optimize the sensitivity of tests.
We already talked about vitamin D and the advice from the French Academy of Medicine. Finally, the BMJ confirms what I was saying: there is no proof that a supplementation would decrease the onset or the gravity of a COVID-19 infection.
And for the pleasure, as oseltamivir is not useful for the flu, some tried it for coronaviruses (not specifically for COVID). This study in the BJGP randomized patients with a positive coronavirus viral syndrome to be treated by oseltamivir or usual care. The time to recovery was 4 days with the antiviral drug versus 5 days (significant difference!). There is not enough data on the 300 included patients to study hospitalizations and adverse effects but 7 patients (5%) of the placebo group went to ED versus only 1 (1%) in the oseltamivir group. Overall, the benefit remains modest and the adverse effects were not studied to allow us to say if we should use it for COVID in general practice.
2/ Domestic violence
The French High Autority in Health has published guidelines about the screening and the management of domestic violence (against female partners only). One can think about it when the partner is too much controlling in the consultation, speaking instead of the patient or having contemptuous sayings. The guide offers some ready-made sentences, to be adapted, for example:
"Have you already been victim of any kind of violence (physical, verbal, psychological, sexual) in your life?"
"How does your partner behave with you?"
"Have you already been afraid of your partner?"
"How does your partner behave with you?"
"Have you already been afraid of your partner?"
3/ Gastro-enterology
Guidelines were published about the prevention of child diarrhea due to antibiotics. The authors recommend prescribing Lactobacillus rhamnosus GG ou S. boulardii to decrease by 40% the risk of diarrhea onset with antibiotics (with an estimated NNT = 10 for amoxicillin+clavulanate and 30 for the other antibiotics). The authors say that antibiotics trigger a long-term dysbiosis, but the consequences of this are not that well evaluated and the long-term benefits of probiotics are not studied at all. I almost forgot: these guidelines are published with the support of Biocodex, a firm selling probiotics (they also produced guidelines favoring probiotics in all-cause diarrhea for kids, whereas the NEJM finds that useless). Overall, we know that for children with risk factors, probiotics decrease the risk of C. difficile infection (and this is useful) but otherwise, for the children, it is probably more useful to question the antibiotics prescription in a vast array of situations.
4/ Neurology
A BJGP article studied the association between the difference of blood pressure between the 2 arms and the cognitive decline. The authors actually find out that a systolic BP difference over 5 mmHg between the 2 arms was associated with a greater cognitive decline (>5 points on MMSE) among patients aged 66 on average with an initial MMSE score at 26. But we mostly see that patients with the greatest BP difference between the 2 arms (>10 mmHg) had an average BP 15 mmHg higher (142 vs. 158 mmHg). So, it is equally probably that it is their uncontrolled BP that increases the cognitive impairment, because of vascular dementia.
5/ Rheumatology
About osteoarthritis, a study compared the efficacy of celecoxib vs diacerein. The authors find out that diacerein 50 bd is not inferior to celecoxib 200 mg daily in this randomized tirat that used the WOMAC score at 6 month as the primary endpoint. The conclusion is, for me, always the same: it does not prove the efficacy of the diacerein, because 200 mg celecoxib is known to be a suboptimal dose allowing fewer adverse effects but without much efficacy. Therefore, diacerein is as efficient as an inefficient treatment (or celecoxib 200 mg daily is as inefficient as diacerein, which is known to be inefficient). The same team had already published the 200 mg celecoxib vs. glucosamine study with the same result and the same conclusion as the aforementioned study.
6/ Endocrinology
The French Society of Endocrinology has published guidelines about hyperandrogenism. The authors recommend to use cytoproterone acetate as a first-line treatment, associated with an estrogen. They warn that the former molecule at a dose of 35 µg does not have a market authorization as a contraceptive and that there is a higher cardiovascular risk with it, compared to the other contraceptives. The use of higher doses is not recommended because on one hand 100 mcg doses have not shown more efficacy than 35 mcg and on the other hand the ANSM reminded the risk of meningioma. The second-line drug is spironolactone (associated with a contraceptive), out of market authorization, with 100 mg dose that can be increased to 300 mg (ouch, when you see how hypertensive patients are with only 25-50 mg...).
Here come the holidays! I wish you a good summer. There might be some posts during the summer, we'll see. To be sure not to miss the back-to-school season, think about subscribing on on Facebook, Twitter or to the e-mail newsletter if not already done. You have to put your e-mail address in the top right field of this page and confirm the subscription in an e-mail entitled "FeedBurner Email Subscriptions" that will be sent to you and may land in your junk folder.
A la prochaine, passez un bon été !
See you next time, have a good summer!
See you next time, have a good summer!
@Dr_Agibus (free translation by @carttom)
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