Journals Watch - Aortic aneurysm and concussion

Too busy to read all the journals? Let Dr Jonathan Holliday keep you up to date on the latest research.

Screening for AAA - the British view - BMJ 2009; 338: 1,538-41
It is amazing how perspective can be everything. This report on behalf of the Multicentre Aneurysm Screening Study assesses 10-year mortality and cost effectiveness of screening.

Screening for AAA in the UK is a cost effective strategy

It used a population-based sample of 67,770 men aged 65-74. Among the group invited for screening, 155 deaths related to abdominal aortic aneurysm (AAA) occurred, compared with 296 in the control group. The degree of benefit seen in earlier years was maintained in later years. The cost quoted was £100 per man invited to be screened, leading to a cost-effectiveness ratio of £7,600 per life-year gained.

After eight years there was a significant increase in cases of ruptured AAA among those originally screened as normal, but nonetheless the cost-effectiveness became more favourable over time.

The authors concluded that while screening once was worthwhile, re-screening of those originally screened as normal is not justified.

Screening for AAA - the Danish view - BMJ 2009; 338: 1,542-4
This is where as a male you find it is better to be British than Danish. This study by the Institute of Public Health in Denmark set out to establish the cost-effectiveness of screening men aged over 65 for AAA.

They used a hypothetical population of men aged over 65 invited (or not invited) for ultrasound screening within the Danish healthcare system. They delivered a wildly different cost per quality-adjusted life year gained, of £43,485. Not surprisingly they concluded that it was not cost-effective.

Consideration should be given to how these two studies manage to achieve such different results. It seems that our screening unit costs are much lower and the differential cost between elective and emergency surgery appears to be less in Denmark that in the UK.

Sports concussion and brain function decline - Brain 2009; 132: 695-708
One aspect of my job involves providing medical care for a large number of teenage boys, a lot of whom play rugby. So I was very interested to read about the possible long-term consequences of these sorts of injuries.

This was a small study comparing 19 healthy former athletes, in late adulthood, who had sustained their last sport-related concussion in early adulthood with 21 healthy former athletes with no history of concussion.

The level of concussion was (appropriately) fairly minor, classified as mild traumatic brain injury on the Glasgow coma scale, scoring between 13 and 15. Cognitive and motor functions were tested. It has already been shown that these functions can be adversely affected in the short term but this study showed that this was also true in the long term (30 years post injury) with impact on both cognitive and motor functions.

Relative to controls, the concussion group performed worse on neuropsychological tests of episodic memory and had significantly reduced movement velocity (bradykinesia).

Before you all rush to ban teenagers from rugby I have to report on an after-dinner speech I heard by long-time 'All Blacks' captain Sean Fitzpatrick. Despite many years as hooker, he clearly was 'all there' with a sharp and witty presentation and a very good recall for past events.

Bariatric surgery and cancer risk - Lancet Oncol 2009 doi: 10.1016/S1470-2045 (09)70,159-7
Obesity is known to be a risk factor for cancer. Would surgically reducing obesity protect against malignancy? The Swedish Obese Subjects (SOS) study investigated.

Starting in 1987, it involved 2,010 obese patients (BMI >34 in men and 38 in women) who underwent bariatric surgery and 2,037 contemporaneously matched obese controls. The main outcome was cancer incidence up to 31 December 2005. Cancer follow-up rate was 99.9 per cent and median follow-up time was 10.9 years.

Bariatric surgery resulted in a mean weight reduction of 19.9kg over 10 years as opposed to a weight gain of 1.3kg among the controls. The number of first-time cancers was lower in the surgery group for women (79 versus 130) but not for men (38 versus 39). Similar results were obtained after exclusion of all cancer cases during the first three years of intervention.

Lipid re-screening - Heart 2009; doi: 10.1136/hrt.2009.172619
We all have patients returning to the surgery to ask for their blood lipids (among other things) to be rechecked. While this personal responsibility for maintaining one's own health has its up side, you do wonder whether it can be too frequent both for patient health as well as the NHS purse.

This study from a teaching hospital in Japan set out to estimate the long-term true change variation ('signal') and short-term within-person variation ('noise') of the different lipid measures and evaluate the best measure and the optimal interval for lipid re-screening.

A total of 15,810 adults, who were not taking cholesterol- lowering medication, had annual lipid measurements between 2005 and 2008. Using total cholesterol (TC)/HDL ratio and LDL/HDL ratio they estimated the ratio of long-term drift ('signal') to the short-term within-person variation ('noise') for each measure.

They found that signal-to-noise ratios of standard single lipid measures (TC, LDL, HDL) were weak over three years and decisions based on these measures were potentially misleading. Reassuringly, the biggest ratio of signal to noise was for TC/HDL. The lipid re-screening interval should be more than three years for those not taking cholesterol-lowering drugs.

Adolescents and MP3 players - Pediatrics 2009; 123: e953-e958
This study from the Netherlands set out to assess risky and protective listening behaviour in adolescent users of MP3 players. In 2007, they collared 1,687 students aged 12-19 in the classroom and asked them to fill in questionnaires.

Ninety per cent reported listening to music through earphones with 48 per cent using high volume settings and only 7 per cent using a noise limiter.

The authors concluded that adolescents were much more likely to engage in risky listening behaviours than protective ones. They also found that those children living with one rather than both parents were more likely to adopt such behaviour as were those on pre-vocational (as opposed to pre-university) courses.

Hearing protection begins at home. Perhaps we should be asking parents of young children to consider intervention.

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

The Quick Study

  • AAA screening is considered cost-effective in the UK.
  • AAA screening is not considered cost-effective in Denmark.
  • Sports concussion in early adulthood can be a significant cause of deteriorating brain function later in life.
  • Bariatric surgery reduces the risk of cancer in women.
  • Lipid re-screening every three years is often enough.
  • Hearing damage may occur in adolescents adopting risky listening behaviour when using MP3 players.

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