Journals Watch - Melanoma, stroke and dementia

Too busy to catch up on the latest research? Let Dr Bryan Palmer update you on recent papers.

UK GPs excise melanoma as well as specialists  Fam Pract 2008; 25: 221-7
This caught my eye as most Australian GPs manage melanoma in primary care whereas in my experience most UK GPs would refer to secondary care.

Analysis of data from the North Wales Melanoma Database from 1993-2001 looked at 578 cases of melanoma. The study aimed to determine the quality of excision and time to diagnosis relating to the excising surgeon and the place of excision.

Sixteen per cent of lesions were removed by GPs, and they referred half (52 per cent) of these on. There were no differences in quality of excision between general practice and hospital excisions.

Time to diagnosis was shorter overall for general practice excisions than those carried out in hospital, so GPs confident in this work do just as a good job as their hospital counterparts.

Remember that early diagnosis and adequate early wide excision are the only things affecting outcome.

 

Melanoma: there was no difference in quality of excision between general practice and hospital

Radical prostatectomy  J Natl Cancer Inst 2008; 100: 1,144-54
The Swedes gave us ABBA, Volvos and the knowledge based on the Scandinavian Prostate Cancer Group-4 in 2005 that radical prostatectomy improves survival compared with watchful waiting in men with early prostate cancer at eight years.

They continued to observe this group for a further three years. A total of 695 men with clinically localised prostate cancer were randomly assigned to radical prostatectomy (n=347) or watchful waiting (n=348).

After a median follow-up of 10.8 years, 13.5 per cent of men in the radical prostatectomy group and 19.5 per cent of men in the watchful waiting group died from prostate cancer; at 12 years, the percentages were 12.5 and 17.9, respectively. However, at 12 years, the overall mortality in the two arms was not statistically significantly different (32.7 per cent versus 39.8 per cent). They did not look at quality of life, which may be more important.

Tibolone in women at high risk of stroke  Engl J Med 2008; 359: 697-708
Research examining the effects of tibolone on the risk of vertebral and clinical fractures has been halted early as it doubled the stroke risk in older women (60-85 years). The study was a randomised controlled trial of 4,538 women allocated to either tibolone or placebo and assessed for vertebral fractures, rates of breast and colon cancer and cardiovascular events.

Although tibolone was shown to reduce the risk of fracture, breast cancer and colon cancer, it doubled the risk of stroke and the trial was stopped.

I think this answers the question of whether this drug could be used compared to standard estrogen/progesterone HRT in an older age group, who by definition are going to be at risk of stroke due to age.

Vitamins and dementia J Am Geriatr Soc 2008: 56; 291-5
Some people believe that taking vitamins reduces the incidence of Alzheimer's. Almost 3,000 people over 65 were enrolled in this prospective cohort trial in Seattle. They had no evidence of dementia when recruited and were followed up every two years and asked about their use of vitamin-supplements.

At 5.5 years the incidence of Alzheimer's in the two groups was similar. Although the self-reporting aspect may have been a weakness of this trial it would seem a waste of money to recommend vitamins for preventing cognitive decline in this age group.

ARB and ACE inhibitors not the answer for CKD  Lancet 2008; 372: 547-53
In my part of the world, the ONTARGET study was promoted with a fanfare prior to it being published, but unfortunately the results didn't match the hype. The four-year randomised controlled trial showed that ARBs were no better than ACE inhibitors at reducing fatal and non-fatal cardiovascular events, and that the combination conferred no extra benefit.

So it may have been with some trepidation that the same team reported on progression of chronic kidney disease in their 25,000 patients. The results are disappointing as there's still little to choose between the agents, and the combination may even make things worse. Not a good outcome for anyone really.

No benefit to lowering homocysteine  JAMA 2008; 300: 795-804
Observational studies have reported associations between circulating total homocysteine concentration and risk of cardiovascular disease. Oral administration of folic acid and vitamin B12 can lower plasma total homocysteine levels. Previous studies have failed conclusively to show any benefit for this strategy. These researchers conducted a double-blind randomised controlled study of over 3,000 patients using four separate arms, which included two different strengths of folic acid and B12, B12 alone and B6.

They followed the patients for over three years but didn't see any reduction in cardiovascular morbidity or mortality. So homocysteine is not currently a modifiable risk factor for cardiovascular disease.

Premature babies N Engl J Med 2008; 359: 262-73
Although advances mean even more premature babies are now surviving, its not all good news to be born very young.

This team in Norway linked data from national registries to identify a cohort of nearly one million babies who were born without congenital abnormality between 1967 and 1983, and followed them through to 2003.

The prevalence of all adverse medical and social outcomes except criminality and unemployment increased with decreasing gestational age.

Autism spectrum disorder, cerebral palsy and mental retardation were all higher and fewer of the premature children obtained university degrees, but most functioned well as adults.

Dr Palmer is a former Hampshire GP working in Australia, and a member of our team who reviews the journals.

The quick study

  • Melanomas are as well treated in general practice as in hospital.
  • Radical prostatectomy benefit does not appear to last beyond 10 years.
  • Tibolone doubles risk of stroke in older women and so should not be used for fracture prevention.
  • Vitamins do not prevent dementia.
  • ARBs and ACEIs have similar effects on the progression of CKD.
  • Homocysteine may be a risk factor for cardiovascular disease, but lowering does not reduce risk.
  • Premature babies still have worse social and medical outcomes than their full-term counterparts.

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