Journals Watch: Osteoarthritis and melanoma

Not had time to read the journals? Let Dr Louise Newson bring you up to date on the latest research.

Bisphosphonates given prior to revision surgery increased implant survival time (Photograph: SPL)
Bisphosphonates given prior to revision surgery increased implant survival time (Photograph: SPL)

Bisphosphonates may be beneficial before knee and hip replacements
BMJ 2011; 343: d7222

Osteoarthritis is the most common form of arthritis in the UK. It is the commonest reason for a knee and hip replacement. The numbers of joint arthroplasties in the UK are increasing, mainly due to the increasing incidence of elderly and obese people.

This was a population-based retrospective cohort study. A cohort of patients from the UK General Practice Research Database was used to find patients who had a primary total arthroplasty of the hip or knee over a 20-year period. Patients over 40 years of age were included in the study and followed up for a maximum of 15 years.

The main outcome was implant survival, which was calculated as the time from surgery to revision surgery. The results showed that patients receiving bisphosphonates for at least six months before revision surgery had an almost twofold increase in implant survival time.

Clearly more work needs to be done before bisphosphonates can be recommended as a pre-operative treatment.

Early treatment with statins has lasting benefits
Lancet 2011; 378: 2013-20

It is accepted from previous large randomised trials that lowering LDL cholesterol with statins reduces vascular morbidity and mortality. This extended follow-up of the Heart Protection Study was performed to assess the long-term efficacy and safety of lowering LDL cholesterol with statins.

More than 20,500 patients at a high risk of vascular and non-vascular outcomes were randomised to receive either 40mg simvastatin daily or placebo. The results demonstrated that more prolonged LDL-lowering statin treatment produced larger absolute reductions in vascular events.

In addition, even after study treatment stopped in the trial, benefits were shown to persist for at least five years without any evidence of emerging hazards. These findings provide further support that we should be starting patients on statins early and encourage them to be taken in the long term.

Using different criteria may improve melanoma diagnosis
Br J Dermatol 2011; 165: 1251-5

Many general practices own dermoscopes to aid diagnosis of melanomas. They can improve the recognition of melanoma, usually superficial spreading melanoma.

This study was undertaken to test whether pigmented nodular melanoma could be recognised dermoscopically by the presence of a combination of blue and black colour within the lesion. The results found that the presence of the blue and black colour within the lesion had a 78.2% sensitivity for melanoma. This compared with 43.6% sensitivity using the standard criteria.

However, using a combination of these criteria led to a 91.9% specificity and 90.6% positive predictive value for malignancy.

Low coronary artery calcium score may be falsely reassuring
J Am Coll Cardiol 2011; 58: 2533-40

Coronary artery calcium (CAC) scores are increasingly used to determine if patients require further evaluation for coronary artery disease. In symptomatic patients, particularly in those with atypical symptoms, it can serve as a 'filter' for invasive angiography and/or hospital admission.

In this study, 10,037 symptomatic patients without coronary artery disease underwent coronary computed tomography angiography (CCTA) and CAC screening.

Among the patients in this analysis, 51% had a CAC score of zero. Of these, 84% had no evidence of CAD on CCTA and 13% had a non-obstructive stenosis. However, 3.5% had a stenosis of 50% or more and 1.4% had even greater narrowing (≥70%). A CAC score of zero cannot be used to fully exclude CHD.

Paracetamol prescription by age or by weight?
Arch Dis Child doi:10.1136/archdischild-2011-301374
Paracetamol is the most frequently used medicine worldwide. It has an excellent safety profile when used within the recommended dose range. It is commonly used by parents and carers, without discussion or contact with the medical profession. As such, it is essential that prescribing and administration information for paracetamol is clear and simple.

However, the dosing of paracetamol has changed recently. This article discusses the reasons behind this change. The wide variations in children's weight for a given age range mean it is possible that the dose of paracetamol may be too low (or too high) if based purely on the child's age.

In July 2011, the MHRA published new guideline dosing tables for paracetamol usage in children. These tables will appear on products entering the market by the end of 2011. This should therefore ensure children get the optimal dose of paracetamol for their age (and weight).

HRV predicts obstructive coronary disease
Heart doi:10.1136/heartjnl-2011-300033

Heart rate variability (HRV) is a marker for the autonomic nervous system and impaired autonomic responses have been documented in patients with coronary artery disease. Previous studies have shown that reduced HRV is a significant predictor of arrhythmic complications, death after MI and death caused by progressive heart failure.

In this prospective study of 470 patients undergoing elective angiography, patients with obstructive coronary artery disease, defined as 50% stenosis or more, had significantly lower HRV than individuals without coronary disease.

The results showed that HRV can predict angiographic coronary disease even after adjusting for other comorbidities. The authors of this study have stated that measuring HRV is simple, non-invasive and is a suitable tool for primary care and hospital environments.

  • Dr Newson is a GP in the West Midlands 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

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.

  • Review the evidence base for prescribing statins and note if you are up to date or if any changes could be made.
  • Improve your dermoscopy by revising your practical skills with a more experienced colleague, or consider attending a course.
  • Research the 2011 MHRA guideline dosing tables for paracetamol usage in children and ensure any changes are communicated to practice staff in a practice meeting or using posters around the surgery.

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