Journals Watch: Migraine, antibiotics and PSA

A review of this week's medical research. By GP Dr Bryan Palmer

SPECT scan during migraine: is there a link between migraine and cognitive decline? (Photograph: Dept of Nuclear Medicine, Charing Cross Hospital/SPL)
SPECT scan during migraine: is there a link between migraine and cognitive decline? (Photograph: Dept of Nuclear Medicine, Charing Cross Hospital/SPL)

Effects of migraine on cognitive decline

BMJ 2012; 345: e5027

Women have a higher prevalence of migraine and a higher prevalence of dementia. Could the two be linked? This prospective cohort study of 6,349 women aged 65 or older enrolled in the Women's Health Study set out to discover the answer. Cognitive testing was carried out at two-year intervals up to three times using a telephone interview. Of the 6,349 women, 853 (13.4%) reported any migraine; of these, 195 (22.9%) reported migraine with aura, 248 (29.1%) migraine without aura and 410 (48.1%) a past history of migraine. They did not discover any evidence of cognitive decline in any of the migraine groups.

Statin use and diabetes risk

Lancet 2012 doi:10.1016/S0140-6736(12)61190-8

There is evidence that statin therapy increases risk of diabetes, but more information is needed. This study analysed participants from the JUPITER trial to address the balance of vascular benefits and diabetes risks of statin use. The JUPITER trial was a randomised, double-blind trial of 17,603 men and women without previous cardiovascular disease or diabetes, who were randomly assigned to rosuvastatin 20mg or placebo and followed up for up to five years for the primary endpoints.

For those with diabetes risk factors, 134 vascular events or deaths were avoided for every 54 new cases of diabetes diagnosed. For participants with no major diabetes risk factors, a total of 86 vascular events or deaths were avoided, with no new cases of diabetes diagnosed. By comparison with placebo, statins accelerated the average time to diagnosis of diabetes by 5.4 weeks.

The author's interpretation was that the cardiovascular and mortality benefits of statin therapy exceed the diabetes hazard, including in participants at high risk of developing diabetes. That may be so, but it is perhaps something that should be discussed with patients.

The association between preterm delivery and treatment at colposcopy

BMJ 2012; 345: e5174

This UK retrospective-prospective cohort study using record linkage at 12 NHS hospitals in England set out to explore the association between preterm delivery and treatment at colposcopy.

They included women who had a cervical histology sample taken between 1987 and 2009 and who had had a singleton live birth between 20-43 gestational weeks before or after cervical histology. The main outcome measures were the proportion of preterm births (<37 weeks) and the relative risk for the strength of association between preterm births and treatment for CIN.

The relative risk before and after histology did not differ. The authors concluded that the risk of preterm delivery in women treated by colposcopy in England was substantially less than that in many other studies, predominantly from Nordic countries.

Although this study is reassuring for large loop excision of the transformation zone overall, it is possible that deep conisation or repeated treatment leads to an increased risk of preterm delivery.

Controversial PSA testing

N Engl J Med 2012; 367 No 7: 595-605

It was reported that after 11 years of follow-up, the European Randomized Study of Screening for Prostate Cancer (ERSPC) found a 29% reduction in prostate cancer mortality among men who underwent screening for PSA levels. The question remains as to what extent the harms that are caused by overdiagnosis and negative treatment outcomes counterbalance the benefits of screening. The authors used something called microsimulation screening analysis to compare benefits to harm.

To prevent one prostate cancer death, 98 men would need to be screened and five cancers detected. Screening of all men between the ages of 55 and 74 would result in more life-years gained (82) but the same number of QALYs (56).

The benefit of PSA screening was diminished by loss of QALYs owing to post-diagnosis long-term effects but, as always, the authors also concluded that longer-term studies are required.

Are we moving nearer to total antibiotic resistance?

Fam Pract 2012 Doi:10.1093/fampra/cms043

The aim of this study was to determine whether there are common features of interventions for improving the problem of antibiotic resistance, which experts consider useful in changing GPs' behaviour, or whether there are important contextual differences in views. Fifty semi-structured interviews explored experts' views and experiences of strategies in five countries.

Five themes were remarkably consistent across the countries, and these could be summarised as: guidelines should be developed by healthcare professionals to better fit GPs' needs; address GP concerns about recommendations and explain the need for guidelines; design flexible interventions to increase feasibility across primary care practice; provide interventions which engage GPs; and provide consistent messages about antibiotic use for patients, professionals and the public.

It was the last one that caught my eye the most. We need to get tougher or face the consequences.

  • Dr Palmer is a former Hampshire GP now working in Australia and a member of our team who regularly review the journals.

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved:

  • Review primary prevention patients on long-term statins. Is their cardiovascular risk high enough to warrant continued use and what is their fasting glucose?
  • Discuss PSA testing at a clinical meeting. What resources are being made available to male patients?
  • Audit antibiotic prescribing in the practice. Can you reduce inconsistent behaviours?

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