Bacterial infection in patients experiencing low back pain
Eur Spine J 2013; 22(4): 690-6; 697-707
These two papers made a spectacular appearance in the popular press. The first question studied was 'Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in adjacent vertebrae?'
Modic changes are caused by bone oedema and found in 6% of the general population and 35-40% of patients with low back pain.
In this study, 61 patients having disc surgery had the disc material cultured. Culture was positive for anaerobic bacteria in 28 (46%) and for aerobic bacteria in two (3%).
Of those with anaerobic bacteria, 80% developed new Modic changes in the vertebrae adjacent to the disc hernia. None with aerobic cultures and 44% with negative cultures developed similar changes. The association between anaerobic bacterial infection and Modic change is highly statistically significant.
The second study was a double-blind RCT of 162 patients with low back pain for more than six months, occurring after disc herniation, who now had Modic type 1 changes in the adjacent vertebrae. They were randomised to 100 days of antibiotics or placebo, then evaluated at baseline, end of treatment and one year.
Of the original patients, 144 were evaluated at one year. The antibiotic group showed highly statistically significant improvement in all outcome measures.
In the commentary, the question of contamination is considered. This is thought unlikely, but there are difficulties in showing infection in patients who have not had surgery. More research is needed. A fascinating study, but not the quick fix for back pain that the tabloids described.
Setting appropriate levels of prescribing for older patients
J Frailty Aging 2013; 2(1): 8-14
The Appropriate Medication for Older people tool (AMO-tool) consists of the following areas: indications for drug, response, side-effects, interactions, effects on organ systems, duplication, dosing, alternatives and integration with care plan.
This study in Belgium evaluated the AMO-tool, which may be of use in decision-making when prescribing for the elderly.
The study population was nine GPs and 67 nursing home residents. A questionnaire was given to the residents, and the GPs completed a semi-quantitative questionnaire on their experiences when using the AMO-tool.
Further multivariate analysis was used on the GP questionnaire.
GPs found that applying the tool was feasible and resulted in more appropriate prescribing and a slight reduction in number of items prescribed. There was also a reported increase in the patients' wellbeing.
Such initiatives are welcome as we wrestle with polypharmacy in the elderly, provided they are concise enough to be used in daily practice.
Identifying prostate cancer risk
BMJ 2013; 346: f2023
This case-controlled nested study from Sweden looked at the association between PSA, risk of prostate cancer metastases and mortality in an unscreened population.
The cohort of 21,277 men aged 27-52 provided a blood sample at baseline in 1974-84. A subgroup of 4,922 provided a sample six years later. Median follow-up was 27 years. The risk of prostate cancer death was associated with baseline PSA, with 44% of deaths occurring in men with PSA in the highest 10th of the distribution at age 45-49.
The study concluded that measuring PSA in early mid-life can identify a group of men at increased risk of metastatic prostate cancer several decades later, and these men should undergo careful surveillance.
Screening at the ages of mid to late 40s, early 50s and 60 should be sufficient for at least 50% of men.
Assessing depression severity by UK QOF depression indicators
Br J Gen Pract 2013; 63(610): 309-17
There has been concern that the use of depression scales in routine consultations may have unintended adverse consequences and the evidence base for this may be flawed. This review was recommended by NICE.
Databases were searched for RCTs, but owing to a lack of these, observational studies were also used. Eight studies met the eligibility criteria.
There was very low quality evidence that use of these assessment tools resulted in improved health outcomes. The NICE advisory committee has recommended that these indicators should be retired.
The new NICE QOF process recommends piloting indicators before their adoption. This should reduce unintended consequences and make guidelines more meaningful.
- Dr Glenesk is a GP in Aberdeen and a member of our team who regularly review the journals
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