Journals Watch - Fracture risk and melanoma

Not had time to read the journals? Let Dr Sally Hope bring you up to date with the latest research.

Type-2 maturity onset diabetes was shown to increase fracture risk (Photograph: SPL)
Type-2 maturity onset diabetes was shown to increase fracture risk (Photograph: SPL)

BMD and fracture risk in type-2 diabetes
JAMA 2011; 305: 2184

Type-2 maturity onset diabetes mellitus (MODM) is associated with high bone mineral density (BMD), but MODM patients also have an increased fracture risk. The reason for this is unknown.

This paper investigated if the femoral neck BMD T score and the WHO fracture risk algorithm (FRAX) score are associated with hip and non-spine fracture risk in older adults with type-2 diabetes.

The researchers looked at prospective studies of self- reported fractures. Participants with MODM had a higher fracture risk than those without. For a similar fracture risk, participants with type-2 diabetes had a higher T score than those without type-2 diabetes. For hip fracture, the estimated mean difference in T score for women was 0.59 and for men, 0.38.

It would be useful for GPs to consider these findings when assessing fracture risk in patients with MODM.

gp100 peptide vaccine and interleukin-2 in melanoma
N Engl J Med 2011; 364: 2119-27

The use of vaccines to stimulate an immune response against cancer is still in its infancy.

This group of researchers combined a melanoma vaccine with interleukin-2 for the treatment of malignant metastatic melanoma. In this randomised, phase III trial, 185 patients with stage IV or locally advanced stage III cutaneous melanoma were randomly assigned to receive interleukin-2 alone or gp100 peptide vaccine followed by interleukin-2.

Compared with the interleukin-2 only group, the vaccine plus interleukin-2 group had a significant improvement in clinical response (16 per cent versus 6 per cent, p = 0.03) and a longer progression-free survival. The median overall survival was longer in the vaccine plus interleukin-2 group than in the interleukin-2 only group (17.8 months versus 11.1 months). This gives some hope for future therapeutic vaccines.

Efficacy of complementary medicine in osteoarthritis
Rheumatology 2011; 50: 911-20

Every practice must have hundreds of patients with osteo- arthritis who say they are fed up with the pain and with having to take painkillers.

Gastric erosion, renal problems and long-term cardiovascular risks have made all GPs more cautious in prescribing NSAIDs. This meta-analysis assessed RCTs of complementary and alternative medicine, taken orally or applied topically (excluding glucosamine and chondroitin), in the treatment of patients with osteoarthritis.

There was consistent evidence that capsaicin gel and S-adenosylmethionine are effective in the management of osteoarthritis. There was also some consistency to the evidence that Indian frankincense, methylsulphonylmethane and rosehip might be effective.

Most of the compounds studied were free from major adverse effects, which cannot be said for NSAIDs.

Long-term care of breast cancer survivors
Maturitas 2011; 69: 106-12

GPs see many breast cancer survivors who have been discharged from hospital.

Women with early node negative breast cancer now have a five-year survival of 95-98 per cent and RCTs show that primary care follow-up is as good as oncology follow-up.

This paper is a review of a more holistic approach towards caring for such patients, covering menopausal symptoms, relationship and sexuality concerns, the psychiatric problems of living with uncertainty, depression, contraception and bone and cardiovascular health.

A clinical examination of the breasts is advised, in addition to mammography, because a significant proportion of ipsilateral breast cancers are detected by clinical examination.

Annual screening for contra-lateral breast cancers picks up 45-90 per cent of new cancers. Only two-thirds of new breast cancers in breast cancer survivors are detected by mammography, so any new presentation to a GP of a breast change must be investigated promptly with imaging and needle biopsy.

The 5HT transporter and response to antidepressants
B J Psych 2011; 198: 464-71

SSRIs and noradrenaline reuptake inhibitors (NARIs) are not always effective in patients with depression. The serotonin transporter gene SLC6A4 has a 44 base pair insertion/deletion polymorphism within the promoter region 5-HTTLPR. There is in vitro evidence that the long (insertion) L/L 5-HTTLPR type is functionally more active than the short S/S form.

This study aimed to determine whether patients homozygous for the long (insertion) polymorphism of 5-HTTLPR have increased response to SSRIs but not NARIs.

Approximately 600 patients with depression were included. It found no evidence to support an influence of 5-HTTLPR on antidepressant treatment.

The health benefits of urban green spaces - J Pub Health 2011; 33: 212-22

Globally there has been a huge demographic shift to urbanisation. In the next 50 years, the percentage of people living in urban areas will increase from 46.6 to 69.6 per cent.

There are papers reporting that the availability of green spaces is independently associated with survival in the elderly. Although the link between physical activity and health is strong, the link to green spaces is weak. One study showed that urban 'greenness' was positively correlated to a perception of general health, but provided poor hard evidence about psychological well-being.

This meta-analysis shows how difficult public health policy is at an evidence-based level. The causal relationship between physical and mental health and urban green spaces is one everyone believes, but to plan urban green areas, we need better data. Access alone may not improve utility, because factors, such as fear of crime, also need to be addressed.

  • Dr Hope is a GP in Woodstock, Oxfordshire

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE credits

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Consider carrying out an audit of all of your patients with type-2 maturity onset diabetes for fragility fractures in the past five years and check that they are being appropriately treated.
  • Consider reviewing your protocols for breast cancer survivors to include yearly breast checks, discussion on bone health if on aromatase inhibitors, vaginal bleeding if on tamoxifen, contraception and mental well-being.
  • Research the evidence base for complementary therapy in osteoarthritis and share your findings with colleagues at a practice meeting.

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