The best diet for optimal blood sugar control & health
Adapted from BMJ 2 Dec 2023
Should women have grade 2 cervical intraepithelial cancer treated with large loop excision or should they just be kept under surveillance?
A Danish study sought to find out. Women who had CIN 2 diagnosed between the ages of 18-40 were followed up from 1998 to 2020. The study involved 27.5 thousand women.
The cumulative risk for cervical cancer was only 2.65% but women who had had the loop excision biopsy were four times less likely to get cervical cancer.
Adapted from BMJ 13 January 2024
What are the chances of having a second epileptic seizure?
After a first unprovoked seizure:
one in four adults and children will have another fit within the first six months
one in three will have a fit in the first year
two in five will have a fit in the first two years
Children have a slightly higher chance of further fits than adults.
More than 633 thousand people in the UK have epilepsy. A diagnosis is made if you have had two unprovoked seizures at least one day apart.
One in 25 people will have an unprovoked seizure in their lifetime. People want to know how much at risk they are of another. This is important for driving, some jobs, bathing, swimming, and travelling.
Studies have put the risk between 24 to 65%. This review looked at 58 studies covering the experience of 12,160 people and covered both adults and children.
If you have a fit in the UK, you will be banned from driving completely in the first six months and for a year if they have a further fit.
Researchers want to continue the work to find out what factors may precipitate further fits in the ten years after the first one.
Adapted from BMJ 7 September 2024
Although pelvic floor yoga has been advised after childbirth and pelvic surgery for decades, it has never had a firm evidence base.
In California, a randomised trial was conducted with 240 women aged between 45 and 90. All reported urge, stress or mixed incontinence.
One group were given 12 weeks of twice weekly group instruction of pelvic floor Hatha yoga and the other group was given the same time and frequency of general muscle stretching and strengthening exercises. The women all had to keep three day diaries of their voiding habits.
At the start the mean frequency of unwanted voiding occurred 3.4 times a day. This fell to 1.1 episodes with pelvic yoga and 1.5 with general physical conditioning.
There were similar improvements whether the woman had stress or urge incontinence.
My comment: I’ve been doing a wide variety of exercise almost daily for the last 35 years, including pelvic floor exercises. Although pelvic floor exercises are taught to almost every pregnant woman, as a GP, nearly all women I met who had incontinence said they had rarely practised the exercises or had given them up after a few months. Due to my exposure to incontinent women I have been really good at keeping my pelvic floor strong. Whatever your age, but particularly if you have been pregnant or have hit the menopausal years, it seems a good idea to make pelvic floor exercises a daily habit.
Adapted from BMJ 23 September 2023
Women have long been advised to take iron supplements with orange juice to increase iron absorption. This is mainly done through the years of menstruation and particularly in pregnancy and the post partum months.
A study was done using radioactively labelled iron to establish how effective or not this advice was.
Women with low iron levels were divided into three groups. Iron with orange juice, with coffee, and with a breakfast that included both orange juice and coffee.
Taking iron with just orange juice increased the iron absorption by four times the amount by taking it with coffee or a breakfast with both coffee and orange juice.
You can increase the absorption by 20mg per dose by doing this.
Another use for iron supplementation is in older people who get leg cramps. Sometimes iron deficiency is the cause, and they will benefit from this advice as well.
Adapted from BMJ 8-15 March 2025
We know that bright light therapy is effective for seasonal depression. A systematic review has also found that it works for non seasonal depression too.
In eleven trials, remission and response rates almost doubled in groups receiving bright light therapy.
Speed of response was also accelerated.
My comment: we all need more sunshine in our lives!
Cold water immersion therapy is said to improve various health measures by some practitioners. A systematic review found that reliable evidence of benefit was thin on the ground.
Most trials were vulnerable to bias and few results were replicated consistently.
One change that was consistent however, was that sickness absence fell by a quarter in participants who took cold showers.
My comment: I tried this years ago and I didn’t get any benefit. I have a friend who swims in the sea every week in Ayrshire. She enjoys it, but it doesn’t seem to have changed her health one way or another. I know a very fit farmer who has been having cold baths and showers daily for over 20 years.
Adapted from BMJ 22-29 March 2025
Nice has approved a new daily pill for the treatment of endometriosis. It contains relugolix, estradiol, and norethisterone.
Patients must be of reproductive age and have had medical or surgical treatment but are still symptomatic.
The new pill works on a block and replace method. Relugolix blocks the woman’s own hormones that affect endometriosis and supplies a steady dose of oestrogen and progestogen to replace them.
Users take it at home and it does not need regular clinic visits.
Adapted from Outside online magazine for runners by Alex Hutchinson Dec 11 2024
By understanding what factors predict longevity, you can take control of your life before it is too late. Biostatisticians in the USA examined data from the National Health and Nutrition Survey (NHANES) to compare the predictive value of 15 potential longevity markers. The winner was the amount of physical activity you perform in a typical day as measured by a wrist tracker.
It can be difficult to get a true picture of how much physical activity people actually get from self reporting or old style pedometers. This study used wrist accelerometers worn day and night between 2011 and 2014. 3,600 subjects between the ages of 50 and 80 were tracked.
The factors that were examined were: Age, gender, body mass index, race or ethnicity, educational level, alcohol consumption, smoking, diabetes, heart disease, congestive cardiac failure, stroke, cancer, mobility problems and self reported overall health.
In order of importance, the best predictors of living longer were: Physical activity, age, mobility problems, self-assessed health, diabetes and smoking. In a nutshell, how much and how vigorously you move are more important predictors of longevity than how old you are.
In 2016, the American Heart Association, realised that VO2 Max was a very important measure of cardiorespiratory fitness. They noted that a low VO2 Max tended to be stronger predictor of mortality than smoking, cholesterol levels and high blood pressure. VO2 Max is determined to the tune of 50% by your genes, whereas how much you move is up to you. (There are indeed “sporty” families!)
So get up, get out, and get moving, as much as you can.
In a separate study published in Cognitive Science, Dementia, an article written by Eric Dolan on 27 March 20025 states that verbal fluency was the most important factor regarding freedom from dementia.
Adapted from BMJ 4 Nov 2023
HRT prescriptions were given to 29% more women between 2022 and 2023 in England.
My comment: This increase could be due to the increased publicity brought about by Davina McCall and Mariela Frostrup through the media.
There were significant geographical differences. Twice as many women in affluent areas were prescribed the medication compared to women in the most deprived areas.
In a recent Pulse educational article I was reading very recently, I was dismayed to see that the author, considered an “expert” in the subject, was very strongly of the opinion that GPs should only prescribe HRT for women who were suffering symptoms of the menopause. It had been my practice for many years to discuss the pros and cons of HRT with regards to the patient in front of me, so that she could decide for herself whether taking it to suppress symptoms on the medium term or taking it long term to reduce osteoporosis, cardiovascular disease, genito-urinary problems, and bowel cancer was something that she wanted to do.
The very helpful site: Menopause Matters, has useful information to guide patients as to the pros and cons of the use of HRT and the types of formulation that are best for individual circumstances.
Adapted from BMJ 4 Nov 2023 The Bottom Line: The time to tackle rising type 2 diabetes is T2DaY by Partha Kar consultant in diabetes and endocrinology Portsmouth Hospitals NHS Trust.
England’s 18-40 year olds with type two diabetes now exceed those with type one. In the not too distant past, type two diabetes was associated with middle age rather than youth. Causes for this increase include lifestyle, environmental and societal factors.
About 4% of people with type two diabetes are now under 40 years of age. Worryingly, this rise in type two diabetes is accelerating fastest in the under 40s. It tends to affect people who are socioeconomically deprived, are in minority ethnic groups, and in those with obesity. And the complications are aggressive.
There tends to be a greater risk of the vascular complications of diabetes compared to later onset type two diabetes. There are poorer pregnancy outcomes compared to type one diabetes. If you are diagnosed at the age of 30, you can expect to live 14 fewer years of life. At diagnosis, multi-morbidity is common and even if not present, can develop rapidly.
The 18 to 40 age group are often in education or working. They face transitions from the family home, to university or the workplace. Money tends to be tight. They are considering buying homes or renting. They may pairing off with partners, and they may already have a young family or be planning to start. Increasingly they can’t afford to buy a home, and put off having children till older ages.
There are now about 140,000 young adults with type two diabetes. It is important that the correct diagnosis is made at the outset, and that pregnancy planning and outcomes are prioritised. Dr Shivani Misra from Imperial College London, has published a Type 2 Diabetes in the Young programme that she hopes will be adopted in order to improve the outlook for these young people and their families.
Meanwhile, Government initiatives are needed to reduce socio-economic deprivation, improve healthy food options, improve space for exercise, and improve people’s motivation to look after themselves.
Adapted from 28 Oct 2023
There is a strong international drive to establish networks of cardiac arrest centres. After a cardiac arrest, is it better to transfer the patient to a specialist cardiac centre or to the nearest A and E facility?
The prospective, randomised ARREST trial took place in Greater London, so results may not be applicable to rural areas, areas which are poorly served by hospitals or ambulances, or areas with even worse traffic congestion.
They found that it took on average seven minutes longer to get a patient to a specialist cardiac centre compared to the nearest A and E. (84 v 77 minutes). My comment: note the long transfer time for both!
Once in the specialist hospital, patients got more interventions such as angiography and admission to intensive care. (56% v 37%) A marked difference.
However the chance of survival after a presumed cardiac arrest without ST elevation was exactly the same in both groups. The 30 day all cause mortality was 63%. Neurological outcomes were also similar.
Given that at least half of patients who have a cardiac arrest die within minutes, I would have to assume that only patients who were alive when the ambulance arrived were included in the trial. I was interested in whether the outlook after cardiac arrest had changed since I was working as a hospital doctor and GP and I tracked down the ARREST trial which was funded by the British Heart Foundation.
In the UK there are over 30,000 out-of-hospital cardiac arrests (OHCA) a year, where the heart stops beating suddenly. Less than one in 10 people in the UK survive an OHCA.
Currently, cardiac arrest patients are taken by emergency ambulance to the closest Accident and Emergency (A&E) department for treatment. But some evidence suggests that people may have a better chance of survival if they are taken straight to a specialist hospital, called a cardiac arrest centre. These centres have a team of doctors and nurses experienced in treating cardiac arrest, and facilities like on-site heart imaging services and cardiac intensive care. Often, a cardiac arrest is caused by a heart attack, and specialist centres also have catheterisation laboratories open 24 hours a day, 7 days a week, with the equipment and expertise needed to unblock an obstructed coronary artery causing a heart attack as soon as possible.
It seemed intuitive that people who’ve had a cardiac arrest out of hospital would benefit from being taken directly to a cardiac arrest centre for treatment compared with A&E. The ARREST trial was funded by the BHF to find out if this was the case.
ARREST was conducted across 35 hospitals served by the London Ambulance Service from 2018 to 2022. Seven of these hospitals were cardiac arrest centres. The trial was paused twice during the COVID-19 pandemic (from March 2020 through to November 2020, and from January 2021 through to August 2021).
Adults who’d had a cardiac arrest out of hospital were judged as eligible for the trial if they had:
In total, 862 participants were recruited into the trial from across London. Patients were resuscitated by London Ambulance staff until their heart was beating again. They were then randomly assigned to one of two groups by the paramedic crew:
If the nearest hospital emergency department was a cardiac arrest centre, then the patient was taken to the cardiac arrest centre as it was not deemed ethical to delay their trip to an emergency department for the sake of the trial. At the cardiac arrest centre or emergency department, treatment was left to the discretion of the doctors and the clinical team.
Participants were followed up for 3 months to record how many in each group had died. The trial team also recorded how well people could function at discharge from hospital and after 3 months, for example how good their memory was, if they were able to live independently, and their quality of life.
Trials of out of hospital cardiac arrest are extremely difficult to conduct, so it’s a tribute to the investigators and London Ambulance Service that they managed to deliver the trial. They persisted with the trial despite the disruptions of the COVID-19 pandemic. To complete successfully, the ARREST team had to recruit patients 7 days a week, 24 hours a day.
The expectation was that transfer to a cardiac arrest centre would improve the prognosis of patients, so the results of ARREST were surprising. Dr Tiffany Patterson, ARREST clinical lead, proposed one explanation:
ARREST was performed in London, which is a densely populated urban area served by a highly effective ambulance service with access to high quality hospitals, so the standard of care in the nearest emergency department may not be so different from that in cardiac arrest centres.
Dr Tiffany Patterson, Clinical lead, ARRESTProfessor Simon Redwood, Chief Investigator of ARREST added:
The trial does not support transporting cardiac arrest patients direct to a cardiac arrest centre in London; they would fare better going to their nearest emergency department. These results may allow better resource allocation elsewhere.
Professor Simon Redwood, Chief Investigator, ARREST
However, he stressed that the trial had excluded patients who clearly had suffered a heart attack, and that this group of patients do benefit from going straight to a heart attack centre and having an attempt at reopening the coronary artery.
ARREST draws attention to the poor survival rate of OHCA, and the importance of bystander cardiopulmonary resuscitation (CPR) and early defibrillation. BHF has developed a free, online CPR training course, RevivR, to teach people how to perform CPR. The Circuit: The National Defibrillator Network is another BHF-led initiative that provides information about defibrillators across the UK so that ambulance services can quickly direct bystanders to their closest defibrillator in the crucial moments directly after a cardiac arrest.
“A randomised trial of expedited transfer to a cardiac arrest centre for non-ST elevation out of hospital cardiac arrest. The ARREST trial.”
Award reference: CS/16/3/32615
Principal Investigator: Professor Simon Redwood, King’s College London
Trial registration number: ISRCTN96585404
Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial. Lancet. 2023;402 (10410):1329-37.
Diabetes Diet 