Journals watch: Lymphoma, herd immunity and the safety of older drivers

Too busy to read the journals? Dr Jonathan Holliday selects the latest papers of interest to GPs

NHL: head and neck masses are a key market for the disease (SPL)
NHL: head and neck masses are a key market for the disease (SPL)

The diagnosis of lymphoma in people over the age of 40 years

- Br J Gen Pract 2015; 65: 232-5

These were matched case-controlled studies using electronic UK primary care patient records from the Clinical Practice Research Datalink.

They provided large sample sizes and the ability to study symptoms recorded before diagnosis, in a primary care setting, from across the country. The main weakness was 'reliance on accurate GP recording'.

Non-Hodgkin lymphoma (NHL) makes up 90% of the total and accounts for 4,600 deaths annually. The UK lags behind Europe for NHL survival and between 1995 and 1999, there were an estimated 632 'avoidable' deaths.

Current UK guidelines recommend specialist referral for patients with persistent lymphadenopathy of more than six weeks, lymph nodes larger than 2cm, increasing size or widespread, or with accompanying weight loss, splenomegaly or night sweats.

This study showed that the most important markers for NHL were lymphadenopathy and head and neck masses. The risk of NHL with these was >5%.

Abnormal blood tests were unhelpful and at most, merely supportive. Abdominal pain or weight loss were only weakly correlated.

With Hodgkin lymphoma (HL), lymphadenopathy and head and neck masses were the main correlating signs. In HL, blood tests were a little more indicative. In particular, raised inflammatory markers, low FBC and thrombocytosis were a little helpful.

In both conditions, the authors questioned whether, in the presence of these primary symptoms, we should wait six weeks, as advised.

Herd immunity and the impact of the herd severity effect

Lancet Infect Dis 2015 S1473-3099(15)00053-5

This mathematical model set out to investigate whether getting measles or rubella (or chickenpox in the US) is the same now as it was before the introduction of widespread immunisation.

The study was based on looking at the effects of modern era vaccination practices on the severity of the infection, once caught.

By changing the landscape for disease transmission and, in particular, increasing the age of the patient, the severity of the illness has worsened. The study authors estimated this was by a factor of 4.5 in measles, 2.2 in chickenpox and 5.8 in rubella.

Currently, estimates of risk from each disease are based on data acquired before vaccination.

The authors make the point that risks for those who have not been immunised are now greater and remaining unvaccinated in a predominantly vaccine-protected community is more risky.

Parents who do not have their children immunised could potentially expose them to 'the most severe possible outcomes for many preventable diseases'.

The safety of older drivers

- Inj Prev 2015 doi:10.1136/ injuryprev-2014-041450

Although this paper comes from the US, it raises valid points about older drivers everywhere.

This was a qualitative descriptive study using interviews with providers. Four main themes were described - the complexity of defined provider roles within the primary care setting, inadequate resources to support providers (here they cite clinical prompts, local guides, and access to social workers and driving specialists), gaps in the education of providers and drivers about discussing driving, and suggested models to enhance these conversations.

Cardiorespiratory fitness in European adolescents

- Heart 2015; 101: 766-73

These 510 adolescents formed part of a group of children studied across nine European cities, in which ideal cardiovascular health was compared with cardiorespiratory fitness.

Ideal cardiovascular health is defined as meeting ideal levels of seven components - four behaviours (smoking, BMI, physical activity, diet) and three medical factors (total cholesterol, BP, blood sugar). Only one study subject met all seven.

Cardiorespiratory fitness was assessed using scores from a shuttle run test, converted into a maximum oxygen consumption.

There is a correlation between ideal cardiovascular health and cardiorespiratory fitness, but these authors correlated the two to suggest a hypothetical cardiorespiratory fitness level associated with a healthier cardiovascular profile.

It was suggested that such a fitness test could be used in schools as part of surveillance and/or screening to identify young people who might benefit from interventions.

  • Dr Holliday is a GP in Berkshire and a member of our team who regularly review the journals

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


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

  • Discuss the lymphoma study findings with colleagues and consider how to improve referral of patients with symptoms of lymphoma.
  • Review uptake figures in your practice for MMR vaccination and compare these with national and regional figures. If necessary, consider ways to promote uptake.
  • Explore with your patient participation group ways for local schools to be further empowered to promote cardiorespiratory fitness.

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