Weekly ultrasound for venous leg ulcers
BMJ 2011; 342: d1092
Dressing venous leg ulcers takes enormous resources in primary care. Current clinical evidence showing that low dose, high frequency ultrasound can help heal ulcers comes from methodologically weak, small studies with varying application regimens.
This study involved 337 patients with at least one venous leg ulcer of more than six months' duration or >5cm2 area and an ankle brachial pressure index of ≥0.8. They compared 12 weeks of weekly low dose, high frequency ultrasound alongside standard care with standard care only.
There was no significant difference in healing rates or change in ulcer size after four weeks' treatment. There were slightly more adverse events in the ultrasound plus standard care group.
The conclusion was that giving low dose, high frequency ultrasound therapy did not increase ulcer healing rates, affect quality of life or reduce ulcer recurrence.
Adiposity measures and cardiovascular disease
Lancet 2011; doi:10.1016/S0140-6736(11)60105-0
This study looked at the separate and combined associations of BMI, waist circumference and waist-to-hip ratio with risk of first-onset cardiovascular disease.
The authors analysed data for 221,934 patients in 17 countries and serial adiposity assessments were made in 63,821 people. The study found that BMI, waist circumference and waist-to-hip ratio, whether assessed singly or in combination, do not improve cardiovascular disease risk prediction in people in developed countries when additional information is available, such as systolic BP, history of diabetes and lipids. BP, lipids and diabetes are far more important predictors of a first cardiovascular event.
Treating bone metastases in prostate cancer patients
Lancet 2011; 377: 813-22
In this phase III study, 1,904 men with castration-resistant prostate cancer and no previous exposure to IV bisphosphonate were enrolled from across 39 countries. Patients received either 120mg subcutaneous denosumab plus IV placebo (n=950) or 4mg IV zoledronic acid plus subcutaneous placebo (n=951), every four weeks for approximately 12 months. The primary endpoint was time to first skeletal-related event.
Median time to first skeletal-related event was 20.7 months with denosumab and 17.1 months with zoledronic acid. Adverse events occurred in 97 per cent for both groups.
Serious adverse events were recorded in 63 per cent of patients on denosumab and 60 per cent on zoledronic acid.
Hypocalcaemia occurred more in the denosumab group (13 per cent) than in the zoledronic acid group (6 per cent). Osteonecrosis of the jaw occurred infrequently but was twice as common with denosumab.
Denosumab was better than zoledronic acid for prevention of skeletal-related events, but has a higher risk of osteonecrosis of the jaw and hypocalcaemia.
Screening for testicular descent in boys
Br J Gen Pract 2011; 61(584): 173-7
It is known that early surgery for undescended testes is beneficial. This study aimed to identify the value of screening for testicular descent at six to eight weeks, eight to nine months, and 39 to 42 months of age.
The authors reviewed data for patients undergoing surgery for abnormal testicular descent and compared whether screening had an impact on the median age of first operation.
The study found that all boys that attended screening had surgery at a younger age than those who did not. Referral was triggered by screening in 48 per cent of cases and by incidental examinations in 27 per cent.
The authors suggest that doctors should be encouraged to check testicular descent in boys throughout childhood.
It is unethical for GPs to be commissioners
BMJ 2011; 342: d1430
This ethics article makes two important points about the health reforms. Dr Mark Sheehan, ethics fellow at University of Oxford, says the main strength of primary care is that patients know that GPs have their best interests at heart.
There are difficult decisions about resource allocations in the NHS, but given the importance of patient trust, these decisions should not be made by GPs. The GP is the patient's advocate, and this will be lost if GPs become resource allocation managers.
The second point is that there is a trend for public involvement in healthcare, although there is no evidence that this works or that outcomes are better. Dr Sheehan suggests that asking a patient who needs a hip operation whether their hip operations should be funded will yield an obvious response. This patient does not perceive that they are in competition with another patient requiring a statin.
Dr Sheehan concluded that disbanding the current system in favour of GP consortia would be unethical.
Social inequalities in quitting smoking
J Pub Health 2011; 33: 39-47
This study assessed whether socioeconomic position (SEP) impacts on smoking cessation. Data was collected from 2,397 smoking cessation patients across Glasgow, Nottingham and North Cumbria.
The patients were offered pharmacotherapy, one-to-one support and group support and smoking status was measured at one year follow up.
At follow-up, 14.3 per cent of the most affluent smokers had continued not smoking compared with only 5.3 per cent of the most disadvantaged.
From the results in Glasgow those from the most affluent SEP were nine times more likely to quit than the lowest SEP, and the lowest SEP tended not to engage in 'group support'.
The study also found that if a physician had recommended the patient quit, that person was more likely to succeed than someone who had self-referred.
- Dr Hope is a GP in Woodstock, Oxfordshire, and a member of our team who regularly review the journals
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