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18th May 2023
Diabetes care in England has been deemed inadequate, according to the findings of a report by the charity Diabetes UK. Here, Rod Tucker digs into the evidence.
Diabetes is a common condition. In a 2023 report, the charity Diabetes UK estimated there are 4.3 million people in the UK living with diabetes, 850,000 of whom are living with undiagnosed diabetes. Uncontrolled diabetes leads to severe micro- and macrovascular complications.
In the UK, the Quality and Outcomes Framework incentivises primary care practitioners to provide better care to patients with diabetes. In addition, the National Diabetes Audit (NDA), introduced in 2003, sought to link attainment of clinical indicators with outcomes. The NDA has a set of nine care processes representing markers of best long-term care.
But to what extent does diabetes care in the UK meet these standards?
Data from the 2019/20 NDA on complications and mortality, published on 11 May 2023, revealed that diabetes accounts for 25-30% of hospital admissions for cardiovascular disease, despite only 7% of the adult population having diabetes.
Failure to achieve the diabetic care standards detailed in the nine processes increases the risk of death. For instance, attaining only five or fewer standards, increased mortality risk by 32% in people with type 2 diabetes. In contrast, satisfactory control of HbA1c, cholesterol and blood pressure, reduces hospital admission rates in people with type 2 diabetes.
Despite these obvious benefits from reaching at least some of the care processes, there is still much to be done. For instance, a 2019 study found disparities in glycaemic control, diabetes-related monitoring the and prescription of newer therapies for people with type 2 diabetes.
The latest report from Diabetes UK provides a stark reminder of how the provision of diabetes care in England is suboptimal. The online survey of 11,304 individuals reveals how nearly half (48%) experienced difficulties managing their condition. The primary reason, cited by 50% of those having difficulties, was access to their care team. In fact, 38% said that they found it difficult to make an appointment with their care team.
The report also highlights the problems of social inequality. For example, one in three living in the most deprived areas found it difficult to contact their diabetes team. In contrast, only one in four of those in the least derived areas experienced these difficulties.
Over 20 years since the introduction of the NDA, questions remain over how effective diabetes care is today. The Diabetes UK report incorporates data from the latest NDA (2021/22). This reveals how across England, only 47% of people with diabetes received all the relevant care processes. In fact, across the country, this figure ranged from 25-62%.
Achievement of the full diabetic care processes in England is currently substandard and driven in part by social inequality. Nevertheless, tackling inequalities in healthcare was a stated aim of the Health and Social Care Act in 2012. It could therefore be argued that the persistence of health inequality represents a breach of that act.
Poor control of diabetes and the ensuing complications have a hugely negative impact on patient’s quality-of-life. Such complications also increase healthcare expenditure, which provides a powerful case for greater investment in diabetes care. The title of the Diabetes UK report asks ‘is diabetes care fair enough?’, to which the current answer is a resounding no.
IV paracetamol provides similar analgesic relief to other treatments used for acute pain in emergency care, but might not be the best first-line drug, a new study has found.
Use of intravenous (IV) paracetamol for patients presenting at an emergency department (ED) with acute pain, irrespective of the aetiology, provides a similar level of analgesia after 30 minutes as both IV NSAIDs or opiates. However, NSAIDs require less rescue analgesia than paracetamol, suggesting that in the absence of contra-indications, the former would be a better first-line choice. This is according to the findings of a meta-analysis by Qatarian researchers.
Pain is a common presenting complaint within an ED. For instance, a review of 1,665 visits to ED found that in 61.2% of cases, pain was documented somewhere on the chart. IV paracetamol is a commonly used analgesic, with some, albeit limited evidence of efficacy according to a review of 14 studies. Nevertheless, many of the studies included in the review had several methodological flaws, hence lowering the certainty of the findings.
Given these flaws, the researchers undertook the current study to update the earlier review, particularly as over 20 studies had been published since the original review in 2016. The team examined the comparative analgesia provided by IV paracetamol, NSAIDs (intravenous or intramuscular) or IV opioids all used alone, in adults attending an ED with acute pain due to various causes.
The primary outcome was the mean difference (MD) in pain reduction for each group (i.e. IV paracetamol, NSAIDs or opiates), 30 minutes (T30) post-dose. Secondary outcomes were the MD in pain reduction after 60 (T60), 90 (T90) and 120 (T120) minutes. The team also considered the need for rescue medication at the different time points for the three treatment interventions.
The review identified 27 trials with 5,427 patients and of which, 25 trials had data for use in the meta-analysis.
There was no significant difference in the mean pain reduction at T30 between IV paracetamol and opiates (MD = −0.13, 95% CI −1.49 to 1.22). Similarly, the difference between paracetamol and NSAIDs was also non-significant (MD = −0.27, 95% CI −1.0 to 1.54). However, while there were no important analgesic differences between the treatments, the researchers did identify significant heterogeneity across trials for all comparisons (p < 0.001 in all cases).
Despite the similar analgesic effects, the need for rescue analgesia at T30 was higher in the paracetamol compared to NSAID group (risk ratio, RR = 1.50, 95% CI 1.23 – 1.83) but not for paracetamol and opiates (RR = 1.07, 95% CI 0.67 – 1.70). Furthermore, adverse effects were 50% lower with paracetamol in comparison to opiates (RR = 0.50, 95% CI 0.40 – 0.62) but not different compared to NSAIDs (RR = 1.30, 95% CI 0.78 – 2.15).
At T60, T90 and T120, there was no difference between paracetamol and opiates though paracetamol was inferior to NSAIDs at T60.
These findings led the authors to conclude that while reductions in pain from IV paracetamol after 30 minutes were similar to the other two drug classes, since NSAID use was associated with a lower need for rescue analgesia, these drugs should be considered as a first-line treatment option unless there are contra-indications.
Patients’ self-reported, health-related quality of life significantly improves in all domains following use of medical cannabis, research shows.
Use of medical cannabis significantly improves all domains on the 36-item Short Form Health Survey (SF-36), which looks at health-related quality-of-life, according to the findings of a recent study by Australian researchers.
A legal framework to allow prescription of medical cannabis in Australia has been available since 2016. Moreover, a 2022 systematic review found that cannabinoids are effective for several indications including epilepsy and chronic pain. The term ‘medical cannabis’ refers to a wide array of products, such as dried flowers and oils, that contain bioactive constituents in addition to tetrahydrocannabinol and cannabidiol.
However, the lack of randomised trial data means clinicians cannot know with any level of certainty whether a particular medical cannabis product would be efficacious. Nevertheless, one means through which clinicians can gain a better understanding of the impact of medical cannabis is through an assessment of health-related quality of life.
This was the subject of a recent study published in JAMA Network Open. Australian researchers assessed if use of medical cannabis led to improvements in health-related quality of life and if these benefits persisted over time. The team retrospectively reviewed the medical records of those prescribed medical cannabis across the country. The outcome of interest was the change in health-related quality of life based on changes from baseline in the SF-36. This questionnaire consists of eight domains that evaluate the impact of an intervention, such as medical cannabis, on several measures including physical and mental health, body pain and physical functioning.
A total of 3,148 patients with mean age 55.9 years (53.6% female) had usable data for analysis and 15 follow-up consultations were examined for each patient.
Medical cannabis was used mainly for chronic non-cancer pain (68.6%), cancer pain (6%), insomnia (4.8%) and anxiety (4.2%). After commencing treatment, significant improvements occurred in all eight domains of the SF-36. After controlling for potential confounders, SF-36 domain scores increased from 6.6 to 18.31, (all with p <0.001). Moreover, these improvements largely persisted over time.
Despite the clear benefits to quality of life, the researchers noted a total of 2,919 self-reported adverse events, with at least two considered serious. They concluded that clinicians should exercise caution in the prescription of medical cannabis, avoiding where possible in those with known contra-indications.
17th May 2023
An early amyloid PET scan provides a high certainty diagnosis in memory clinic patients three months after their diagnosis, according to a new study.
Amyloid-β is the predominant pathologic protein in Alzheimer’s disease (AD) and which affects disease progression and prognosis. Moreover, an amyloid-imaging PET tracer, provides quantitative information on the extent of these protein deposits in living subjects. Despite this, other work suggests the current appropriate use criteria for imaging cannot effectively identify patients who will benefit from such imaging.
In the current study, researchers sought to assess the value of amyloid scanning in patients from a memory clinic. They wondered if a PET scan performed soon after the patient’s diagnosis, enabled a more confident aetiological diagnosis. Patients had either subjective cognitive decline with symptoms of preclinical AD, mild cognitive impairment or dementia.
Researchers randomly placed individuals into three arms. Arm one (early scan), arm two (scan after eight months) and arm three (scan at the physician’s discretion). The aetiological diagnoses were grouped into three main categories: AD; non-AD and undetermined. The primary outcome was the proportion of participants receiving a high confidence (>90%) etiological diagnosis in arms one and two after three months.
The study included 840 patients with a similar proportion in each of the three arms. The prevalence of amyloid positivity was higher in those with a baseline diagnosis of AD versus participants with non-AD (69% vs 36%, p < 0.001) at baseline.
After three months, 40% of arm one patients and 11% in arm two, had high confidence diagnosis (p < 0.001). This effect was consistent across cognitive stages.
The findings led to authors to conclude that an early amyloid PET allowed memory clinic patients to receive an aetiological diagnosis with very high confidence after only three months. The findings supported the implementation of amyloid PET early in the diagnostic workup of memory clinic patients.
Individuals quitting smoking after their diagnosis of renal cell carcinoma potentially have improved overall and progression-free survival, according to new research.
The incidence of renal cell carcinoma (RCC) varies considerably across the globe. Data suggests the highest incidence of this cancer occurs in developed countries and among smokers, people who are obese and those with hypertension.
In fact, cigarette smoking is a recognised, independent risk factor for advanced renal cell carcinoma. In addition, it is also clear that quitting smoking reduces the risks of developing and dying from RCC. While smoking cessation lowers the risk of developing RCC, whether quitting smoking following a RCC diagnosis affects prognosis is uncertain.
For the present study, researchers investigated if post-diagnosis smoking cessation impacted upon disease progression and mortality risks among smokers diagnosed with RCC. The researchers followed newly diagnosed RCC patients over several years and repeatedly assessed smoking behaviour. Using regression models with adjustments for factors such as age, gender and the amount of cigarettes smoked, researchers estimated survival and disease progression.
There were 212 patients with a median age of 56.1 years (80%) with evaluable data and followed for a 8.2 years. Among this cohort, 84 stopped smoking during follow-up.
Over the next eight years, 110 cases of disease progression, 100 total deaths and 77 cancer-specific deaths occurred. Quitting smoking was associated with improved survival based on a lower risk of all-cause mortality (hazard ratio, HR = 0.51, 95% CI 0.31 – 0.85). Additionally, disease progression was also lower among quitters (HR = 0.45, 95% CI 0.29 – 0.71). There was also a reduced risk of cancer-specific mortality for those who stopped (HR = 0.54, 95% CI 0.31 – 0.93).
The benefit of quitting smoking was evident across all of the different subgroups, such as light smokers versus moderate-heavy smokers and those with early-stage versus late-stage tumours. These findings led the authors to conclude that smoking cessation treatments should form part of the management of RCC patients.
16th May 2023
Medical cannabis for cancer-related pain in a real-world study indicates that it is safe and reduces opioid consumption.
Pain is a common symptom in patients with cancer. In fact, a previous systematic review of 52 studies, found that 59% of patients undergoing anti-cancer therapy reported experiencing pain. The World Health Organization recommends the use of NSAIDs, paracetamol or opiates, either alone or in combination for initial cancer pain management. Moreover, opiates are the preferred treatment choice for ongoing pain relief.
Emerging evidence points to an important adjunctive role of medical cannabis (MC) for cancer-related pain in those using opiates. In addition, MC use reduces both opiate and benzodiazepine use in patients with intractable pain. But the extent to which MC reduces pain medication use in those with cancer in real-world studies is still unclear.
In the current study, Canadian researchers analysed registry data to determine if medical cannabis could reduce both pain and pain medicine use in cancer patients. Information on the use of MC products was collated as either cannabidiol (CBD) dominant, tetrahydrocannabinol (THC) dominant or CBD-THC balanced.
Outcome measures regarding MC use included the brief pain inventory (BPI) assessed at baseline and after three, six and nine months. The medication quantification scale (MQS) assessed medication burden over time and the morphine equivalent daily dose (MEDD), considered the opioid-sparing effect of MC use.
There were 358 cancer patients experiencing pain and with available data for analysis. Significant decreases in BPI scores occurred from baseline to month nine (5.5 vs 3.6, p <0.01). Overall pain severity scores also reduced from baseline over this time-frame (3.7 vs 2.4, p <0.01). Medical cannabis use lowered MQS in 26.2% of patients after nine months. Similarly, MEDD scores reduced in 14.3% of patients after nine months.
Only two serious adverse occurred with both considered unlikely to be caused by medical cannabis. The authors also observed better pain relief among patients using balanced CBD-THC products.
The findings led the authors to suggest that medical cannabis is a safe and effective complementary treatment for cancer-related pain. They called for randomised controlled trials to confirm these findings.
11th May 2023
Asthmatics have a higher risk of developing cancer, though use of inhaled steroids may have a slight protective effect, according to a US study.
Globally, cancer is the leading cause of mortality, with nearly 10 million recorded deaths in 2020. Data suggests that infection and inflammation contribute to a quarter of all cancers. In fact, the inflammatory milieu within a tumour seems to be an indispensable participant in tumour progression. In asthmatics, the inflammatory nature of their condition increases the risk of lung cancer. Nevertheless, other data either demonstrate a positive association or no association with the risk of other cancers.
In the current study, researchers sought to better understand the relationship between asthma and cancer risk. They analysed electronic health records in a US claims database. The team developed a matching cohort of those with and without asthma which served as the control group. Using regression models, researchers searched for any relationship between asthma and the subsequent development of cancer. The primary outcome was the time to a cancer diagnosis after the date of an asthma diagnosis.
The asthma cohort included 90,021 individuals matched to 270,063 without the disease. In multivariable analysis, asthmatics were more likely to develop cancer (hazard ratio, HR = 1.36, 95% CI 1.29 – 1.44). For example, significantly higher risks were observed for melanoma, blood, kidney and lung cancers. However, in contrast, risks were non-significant for bladder, colorectal and prostate cancers.
In a separate analysis examining the effect of inhaled steroid use, the overall cancer risk was slightly lower among steroid users (HR = 1.60 vs 1.11, inhaled steroid vs no steroid). Taken together, cancer risk was higher for nine of 13 cancers in asthmatics not using inhaled steroids but in only two cancers among steroid users. These findings suggest a possible protective effect of inhaled steroid use on cancer risk that requires further evaluation.
A higher BMI increases the risk of hospitalisation or death following a respiratory tract infection, according to an analysis published in JAMA.
Body mass index (BMI) has a J-shaped associations with overall mortality and with many cause-specific deaths. In addition, during the Covid-19 pandemic it became clear that being overweight increases the risk of Covid-19-related hospitalisations. Nevertheless, whether or not there is a relationship between BMI and other respiratory infections, viral or otherwise, is less clear.
In the current study, researchers used data from the UK Biobank, to explore the relationship between body mass index and the risk of hospitalisation for, or death from, respiratory infections. The team focused not only on Covid-19 but both upper and lower respiratory tract infections (RTIs). Researchers excluded participants with a chronic respiratory disease or previous hospitalisations for infectious respiratory diseases. Modelling assessed the association between BMI categories of 14 – 24.9, 25 – 29.9 (the reference point), 30-34.9, and 35-60.
Data was available for 476, 176 participants (median age = 58 years, 54% female) and the mean BMI was 27.4. Participant follow-up occurred over an average of 11.8 years.
During follow-up, 20,302 individuals were hospitalised or died of severe infectious respiratory diseases. For Covid-19, the fully adjusted hazard ratios (HRs) ranged from 0.66 for those with a BMI of 14 – 24.9, to 2.27 (95% CI 1.73 – 2.97) for the highest category (e.g., 35 – 60). For a lower RTI, HRs ranged from 0.94 to 1.68 among those in the highest BMI category. A similar trend was seen for upper RTIs.
The authors suggest the implementation of approaches to reduce obesity and target vaccinations for respiratory infections in those with an elevated BMI.
10th May 2023
A study of nearly 27,000 hypertensive patients identified how roughly a third (32.5%) of patients had uncontrolled disease. Therapy guidelines invariably recommend monotherapy as a first-line approach and combination treatment only if this fails to control blood pressure (BP). Despite this, a meta-analysis of 354 RCTs in 2003, found that a low-dose combination of BP lowering drugs increases efficacy and reduces adverse effects. More recently, another analysis revealed how use of three drugs gave better blood pressure control than increasing dual therapy doses. Whether a low-dose combination (LDC) of three to four drug classes as an initial therapy provides better blood pressure control than monotherapy or usual care is uncertain.
In a recent systematic review and meta-analysis, researchers set out to determine the efficacy and safety of a LDC initial approach to hypertension management. They looked for RCTs that compared LDC to either monotherapy, usual care, or placebo. The primary outcome was the decrease in systolic hypertension using either LDC, monotherapy, usual care or placebo. Other measures assessed were the proportion achieving a BP <140/90 mm Hg, rates of adverse effects and treatment withdrawal.
Low-dose combination and systolic hypertension
A total of 7 trials with 918 patients with a mean age of 59 years (38% female) met the inclusion criteria.
Mean systolic BP was significantly lower with LDC than either monotherapy or usual care (mean difference, MD = 7.4 mmHg). LDC also increased the proportion of participants achieving BP < 140/90 mm Hg at 4 to 12 weeks (Risk Ratio, RR = 1.40, 95% CI 1.27-1.52). These findings were maintained at 6 to 12 months.
Although LDC led to more dizziness (RR = 1.28, 95% CI 1.00-1.63) no other adverse effects or treatment withdrawal occurred.
These findings suggest that LDCs with 3 or 4 antihypertensives is effective and well-tolerated as an initial treatment of hypertension.
There are several recognised co-morbidities associated with obesity including hypertension and asthma. In addition, the accumulation of more fat mass, is strongly associated with functional limitation among those with COPD. Moreover, other data suggest a positive association between abdominal obesity (AO) and asthma. This association appears to apply equally to both sexes. But whether abdominal or general obesity has a stronger association with either asthma or COPD is unclear.
The Respiratory Health in Northern Europe (RHINE) III study explored the independent association of abdominal and general obesity with asthma and COPD. In addition, the researchers examined any sex-related differences in these associations. In a cross-sectional study, the team used self-measured waist circumference (WC) as an index of AO. General obesity (GO) was a BMI ≥ 30.0 kg/m2. For the purposes of the analysis, a WC > 102 cm in males and ≥88 cm in females defined AO. Participants completed several questionnaires asking about respiratory symptoms and directly about a diagnosis of asthma and COPD.
Abdominal obesity and asthma or COPD
The study included data from a total of 12,290 participants of whom, 34.7% had AO and 6.7% GO. Abdominal obesity independently associated with the presence of wheeze (adjusted odds ratio, aOR = 1.40, 95% CI 1.24 – 1.58). This independent relationship was also present for GO (aOR = 1.96, 95% CI 1.70 – 2.27). There was a significant association between asthma and both AO and GO. In contrast, the association was only significant between COPD and GO (aOR = 2.14, 95% CI 1.54 – 2.99).
In relation to sex-related differences, asthma significantly associated with both AO (OR = 1.56) and GO in women (OR = 1.95) but not in men. This association also applied for COPD.
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