Yonder: Insomnia, hyponatraemia, heart failure, and childhood cancer survivors

Ahmed Rashid

doi:10.3399/bjgp19X706805

Yonder: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature

Insomnia

If primary care consultations were meals, sleep disturbances would be on the menu under ‘main course’, ‘side dish’, and ‘dessert’. Regardless of when they come up in the consultation, they often bring with them a degree of tension, especially as we discover more about the short- and long-term adverse effects of hypnotic medications. There has, therefore, been much interest in cognitive behavioural therapy for insomnia (CBT-I) as a treatment option in recent years. Although it has been demonstrated to be effective in the clinical trial setting, a Canadian study recently tested its effectiveness in a real-life primary care setting.¹ The results were unusually conclusive: the CBT-I programme was associated with improvement on all sleep and mood measures, with effect sizes even larger than those seen in trials. Colleagues with commissioning responsibilities, take note.

Hyponatraemia

As the most common electrolyte abnormality in older people, with non-specific symptoms, and associations with potentially serious medical conditions, hyponatraemia is an important topic for GPs. A recent Malaysian study sought to determine the prevalence, potential causes, and management of hyponatraemia among older persons in a primary care setting.² Examining the medical records of over 21 000 adults over 60, they found that around 7% had hyponatraemia in at least one blood test. Potential causes were documented in only 40% of this group, with medications (specifically thiazide diuretics) the most common cause. The most common management strategy by some way was simply to repeat the test. The authors suggest that, in light of our growing awareness of the potential harms of even mild hyponatraemia, primary care-focused guidelines and education programmes on hyponatraemia are urgently needed.

Heart failure

Heart failure has a significant impact on affected individuals, with progressive and debilitating symptoms causing a clear reduction in quality of life, as well as on the healthcare system, with frequent hospitalisations and clinic visits in both secondary and primary care. The role of heart failure specialist nurses is well established, although there has been a recent focus on adjusting the model to be more community and primary care based. A recent Swedish study evaluated a new service model that moved nurse-led heart failure clinics from secondary to primary care.³ It found that the implementation of clinics in primary care significantly reduced the number of hospital admissions, hospital days, and emergency room visits. National data on heart failure admissions showed a decrease by 8% in Sweden overall during the study period (2010–2016) compared with a decrease of 27% in Sörmland, where the study took place, during the same period of time. Although primary care remains under strain due to workload and workforce issues, it clearly remains the optimal setting to deliver high-quality chronic disease care.

Childhood cancer survival

One of the great success stories of modern medicine is the considerable improvement in cancer survival, especially with childhood cancers. Even many years after initial cancer treatment, though, childhood cancer survivors are at risk of developing long-term morbidity related to their cancer and treatment, including organ dysfunction and secondary cancers. Given that recurrent presentations are likely to be to primary care, a recent Dutch cohort study focused on the primary care-based healthcare use among childhood cancer survivors.⁴ They found that childhood cancer survivors were 1.3 times more likely to contact their primary care physician than controls, and female sex, older age, and treatment with radiotherapy were determinants for having more contacts. Given that the number of childhood cancer survivors is likely to increase in the years to come, the authors suggest clearer primary care guidelines and shared care programmes are needed for this patient group.

REFERENCES

1.↵
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(2019) Effectiveness of group cognitive behavioral therapy for insomnia (CBT-I) in a primary care setting. Behav Sleep Med 17(2):191–201.
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(2019) Prevalence and documented causes of hyponatraemia among geriatric patients attending a primary care clinic. Med J Malaysia 74(2):121–127.
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(2019) Introducing nurse-led heart failure clinics in Swedish primary care settings. Eur J Heart Fail 21(1):103–109.
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