Journals Watch: BCG vaccine and exercise

Effectiveness of BCG vaccination against TB
Lancet Infect Dis 2011; doi:10.1016/S1473-3099(11)70285-7
Data have recently been published on the efficacy of the influenza vaccine, reminding us that vaccinations do not fully remove the risk of developing the infection they are designed to protect against.

This Brazilian trial was designed to assess the effectiveness of the first BCG vaccination in children of school age who had not received a neonatal BCG. Nearly 40,000 children aged between seven and 14 years were included and the primary endpoint was TB incidence.

The incidence of TB was 54.9 per 100,000 person-years (95% CI 45.3-66.7) in those who received the BCG vaccination compared to 72.7 per 100,000 person-years (95% CI 62.8-86.8) in the children who had not received the vaccine.

The researchers concluded that the effectiveness of the first BCG vaccination in school-aged children was between 3 and 43 per cent. The study highlights the importance of not excluding a diagnosis on the basis of the patient being vaccinated and opens the debate regarding current vaccination guidelines in the UK.

Early liver transplantation for severe alcoholic hepatitis
N Engl J Med 2011; 365: 1790-800
The Royal College of Physicians recently published new recommendations on alcohol consumption, reinforcing the importance of having drink-free days. Unfortunately, we can all think of patients who do not follow this advice. Severe alcoholic hepatitis has a prognosis less favourable than many cancers.

This study looked at a group of 26 patients with their first episode of alcoholic hepatitis and tested the benefits of early liver transplant. Statistical analysis showed early liver transplant conferred a sixfold increase in survival at two years.

It is important that GPs proactively facilitate alcohol cessation. Furthermore, it is crucial we are informed of studies such as this so we can manage our patients' expectations and inform them about the dangers of their condition and the current trends in treatment.

Outbreak of Escherichia coli associated with sprouts
N Engl J Med 2011; 365: 1763-70
Recent outbreaks of haemolytic-uraemic syndrome (HUS) in the UK have been caused by verotoxin-producing E coli 0157, sometimes referred to as VTEC. The German outbreak earlier this year, however, was caused by the Shiga toxin-producing E coli O104:H4.

It is crucial to trace the source in any public health outbreak. This interesting publication used a range of techniques, including case-controlled, recipe-based restaurant cohorts and other investigations, to show statistically, what the source of the outbreak was.

Those patients infected with Shiga toxin-producing E coli O104:H4 were 5.8 times more likely to have consumed sprouts than the controls. All the confirmed cases in the recipe-based restaurant cohorts were found to have eaten sprouts.

Extracranial-intracranial bypass surgery for stroke prevention
JAMA 2011; 306(18): 1983-92
Currently, surgical options for patients with significant carotid artery disease include endarterectomy, angioplasty and stenting. This North American study tested extracranial-intracranial bypass surgery as an alternative strategy. Patients with carotid artery disease and inducible ipsilateral cerebral ischaemia measured by PET were included in the study.

The technique involved anastomosis of a superficial branch of the temporal artery to a branch of the middle cerebral artery as a means of bypassing the occluded carotid artery. Of the 195 patients included, 97 received surgery and 98 did not.

While this technique was not found to reduce the incidence of stroke at two years, it reminds us that stroke is a burden on health and the economy, and GPs should be striving to reduce the risk by proactively implementing primary and secondary prevention strategies.

Exercise referral schemes in primary care
BMJ 2011; 343: d6462
We have all heard of exercise referral schemes as a means of reducing the burden of cardiovascular, pulmonary and obesity-related diseases. It is important, however, to scrutinise any intervention to ensure it is effective, cost-effective and acceptable.

This systematic review and meta-analysis aimed to assess whether exercise referral schemes improved outcomes. Eight RCTs met the researchers' criteria, which looked at referral to exercise service provider, usual care or an alternative intervention.

In comparison with usual care, only marginally more of those who were referred for exercise achieved moderate intensity activity. Reduced levels of depression in the exercise group were more convincing. Overall, the data were inconsistent and not convincing in favour of promoting referrals to exercise providers.

It is clear that more robust trials are required prior to resources being spent.

Physician billing and cardiac stress testing in the US
JAMA 2011; 306(18): 1993-2000
There are clear differences between the US and British systems; however, this US-based study set out to examine the association with physicians who bill and incidence of stress echocardiography or cardiac nuclear studies. Data were collated from a US national health insurance carrier.

The cumulative incidence of cardiac stress testing using nuclear techniques was 12.6 per cent for physicians who billed for both their time and for tests, compared with 8.8 per cent for those who billed for their time only and 5 per cent for those who did not bill for either their time or tests.

This study raises interesting questions relating to the differences between our NHS and private patients and the investigations they receive.

• Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review the journals

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