Heart surgery, sterilisation and athletes

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

Coronary artery bypass graft surgery Ann Thorac Surg 2008; 85: 1,233-7
Increasing numbers of the very elderly are undergoing coronary artery bypass graft (CABG) surgery but few studies have monitored the long-term outcome. This was a cohort study of 54,397 consecutive patients undergoing primary isolated CABG between 1987 and 2006.

A total of 2,661 were aged 80-84, and 587 were aged 85 or more. Patients over 80 were more likely to be female, more likely to have co-morbidities and most importantly more likely to be an emergency priority.

Those over 85 were more likely to have intraoperative or postoperative morbid events. However, once clear of the hospital, their long-term survival was surprisingly good.

Among patients younger than 80 the medial survival was 14.4 years with annual incidence of death of 4.2 per cent. Among the 80-84 years range the figures were 7.4 years and 10.3 per cent, while in those over 85 the figures were 5.8 years and 13.7 per cent.

HPV vaccination BMJ 2008; DOI:10.1,136/BMJ.39541.534109.BE
This early study assesses the feasibility and acceptability of delivering HPV vaccine to adolescent girls.

Set in 36 secondary schools in Greater Manchester it has the advantage of early information, but the disadvantage of not giving information about the uptake rates for the completed course. This was a good-sized study with 2,817 pupils all in year eight (12- and 13-year olds).

Two previous studies of parental attitudes had predicted a 70-80 per cent uptake, and this study of the reality bore this out. Uptake was 70.6 per cent for the first dose and 68.5 per cent for the second. However, these figures were not easily achieved and 16.3 per cent (dose 1) and 23.6 per cent (dose 2) missed their vaccination day and had to be offered alternative appointments.

Some 20 per cent of parents did not respond to the invitation letter, and 8 per cent returned a refusal form. Of these, the main reason given was insufficient information about the vaccine and concern about its long-term safety.

Uptake was lower in schools with a higher proportion of ethnic minority girls and where a higher proportion were entitled to free school meals.

Anogenital warts Sex Transm Infect 2008: doi:10.1,136/sti.2007.029116
This UK study looked at psychological functioning, relationship factors and regret (among other things) following diagnosis of anogenital warts in patients who disclose their condition to their partner and non-disclosers (36 and 18, respectively).

The disclosers were significantly less anxious, they rated their relationships as longer lasting and closer and they were less likely to express regret about disclosure.

Authors concluded that relationship factors, in particular duration, were key predictors of disclosure and so perhaps it is the relationship that allows disclosure rather than the disclosure that helps the relationship.

How to use topical steroids Br J Dermatol 2008; 158: 917-20

Topical steroids are being applied too thinly, and GPs are the culprits.

Current advice to apply sparingly contributes to 'steroid phobia', increasing the risk of poor clinical response and treatment failure. When used appropriately and at suitable dosage they are effective.

Experts suggest a change in labelling to reflect this, with 'fingertip unit' dose information and the inclusion in the packaging of images as well as a chart to show the number of units for different specified areas of the body.

Medication in sports Clin J Sport Med 2008; 18: 143-7
This study looked at the use of declared medication in athletes. It used 18,645 doping-control forms gathered between 2002 and 2005 by national doping organisations in Belgium and the Netherlands.

Overall, the declared use of medication belonging to one of the monitored categories increased from 19.8 per cent in 2002 to 24.7 per cent in 2005.

The declared use of corticosteroids in cycling increased to 36 per cent in 2005. The authors concluded that the granting of therapeutic use exemption for corticosteroids needs to be revised.

Hysteroscopic sterilisation J Fam Plann and Reprod Health Care 2008; 34: 99-102

Essure is a coiled spring contraceptive device made from nickel/titanium alloy containing polyethylene fibres. It is a 'dynamic expanding microinsert' that is placed in the openings of the fallopian tubes under direct hysteroscopic visualisation.

It induces a tissue reaction that permanently blocks the tube within three months. It is done awake, with 8-13 minutes of hysteroscopy time and with admission to discharge time of 80-180 minutes.

Unfortunately, despite these impressive figures, it appears that UK data still make laparoscopic sterilisation cheaper.

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

The quick study

  • CABG surgery has better outcome statistics in patients younger than 80 than in those over 85, although long-term survival was generally good.
  • HPV vaccination uptake has been good, at around 70 per cent in initial programmes.
  • Patients with genital warts who disclose their status to partners have better psychological wellbeing than those who do not.
  • Topical steroids are effective if used correctly and 'steroid phobia' is largely unjustified.
  • Athletes appear to be using monitored medications increasingly, and regulation of this may need to be addressed.
  • Female sterilisation could be carried out in future using a new coiled spring device.

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