Journals Watch: Polypectomy, back pain and CVD

A review of research impacting primary care, covering polypectomy, back pain, lithium toxicity and CVD risk assessment. By Dr Simon Hunter

There is evidence that polypectomy reduces the risk of colorectal cancer mortality (Photograph: SPL)
There is evidence that polypectomy reduces the risk of colorectal cancer mortality (Photograph: SPL)

The benefits of polypectomy
N Engl J Med 2012; 366: 687-96

There are several ways of reducing mortality from colorectal cancer, for example by detecting cancers at an early stage and removing adenomatous polyps.

This study followed up patients for up to 23 years who had had a polypectomy and compared the rate of death from colorectal cancer against the expected background risk.

They found that of the 2,602 patients who had had an adenoma removed, 12 had died of colorectal cancer, against an expected background rate of 25 deaths, giving an apparent halving of the risk.

There may be confounding factors, such as an improvement in lifestyle once a polyp has been removed, but on face value polypectomy does seem to work.

Duration of back pain
Ann Emerg Med 2012; 59: 128-33

This study set out to determine what happens to patients who attend the emergency department with low back pain in the short and medium term. It was carried out in the US where 2.74m people go to casualty every year with back pain.

Patients with non-traumatic back pain deemed to be musculoskeletal were phoned after one week and then three months later to determine the level of pain, its effect on function and patient analgesia use.

They found that after a week 70% were still reporting back-related functional impairment, with 59% stating that it was moderate or severe. At three months, 48% were still experiencing functional impairment and 42% described it as moderate to severe. This information is useful for giving patients a realistic time frame for recovery.

Reviewing lithium toxicity
Lancet 2012: 379; 721-8

Lithium, while an effective long-term therapy for bipolar disorder, is often underused. There are concerns over its safety and it has a narrow therapeutic index.

This review examined the literature from the past 60 years looking at the side-effects of lithium treatment. With the caveat that not all studies were of the highest quality, they found that lithium does have an effect on the kidneys, but it is probably not that significant clinically. There is a decrease in urinary concentrating ability of 15% with a reduction in GFR of 5%. The absolute risk of renal failure was low at 0.5%.

There is a six-fold increase in the risk of hypothyroidism.

The risk of hyperparathyroidism is 10% (against a background risk of 0.1%). Calcium monitoring is not routinely recommended but this evidence suggests it should be.

There is evidence that lithium causes weight gain. Toxicity seems to occur with sodium or volume depletion, for example from diarrhoea and vomiting, heart failure, surgery or NSAID treatment, rather than spontaneously from incorrect dosing leading to a gradual drift into the toxic range. The authors question the necessity to monitor lithium levels quarterly.

Screening adolescent drinking
Pediatrics 2012; 129; 205-12

The American Academy of Pediatrics recommends routine alcohol screening for all adolescents. The standard screening test has three components: frequency of drinking, volume drunk on each occasion and frequency of heavy drinking.

This study looked at whether just asking about the frequency of drinking, rather than also asking about volume and binges, would be just as effective a screening test.

American study recommends routine alcohol screening for adolescents (Photograph: C Stout)

They found it was indeed a sensitive and specific test and produced a set of helpful tables that are age specific, as what is normal behaviour in an 18-year-old would not be appropriate for a 12-year-old.

They recommend those at moderate risk of developing problem drinking have a motivational intervention and follow up, while those at high risk be considered for referral.

Family history in CVD risk assessment
Ann Intern Med 2012; 156: 253-62

The JBS2 score for cardiovascular risk comprises risk factors of age, sex, smoking, systolic BP and cholesterol ratio. Family history, while it will affect the score, is optional.

This UK study invited patients with no known atherosclerotic disease or related risk factors (diabetes, lipid lowering medication) for cardiovascular risk screening in the usual way (BP, smoking, lipids and so on). Half the subjects were asked to fill in a family history sheet and half had family history gleaned from the electronic medical record.

Of the participants, 98% filled in the family history sheet.

Using this data they found an increase of 4.8% in the number of patients identified as 'high risk' compared with 0.3% if the information was just gathered from the notes, compared with not using family history at all.

It seems that sending a family history sheet to fill in with well-person check invitations is a simple and effective improvement on the current system.

Children taking tablets versus liquid medicine
Arch Dis Child 2012; 97: 283-6

Conventional wisdom is that children under six years old are incapable of swallowing tablets. This puts children at a potential disadvantage as liquid medicines can have physical, chemical and microbiological instability, as well as the problem of masking an unpleasant tasting liquid medicine.

This study looked at the ability of children aged 0.5 to six years to swallow drug-free mini-pills compared with syrupy liquid medicine. The mini tablets were 2mm in diameter.

They found that fiveto six-year-olds could swallow both the liquid and tablet form without problem. In the two to four-year-old group there was a tendency to chew the tablet and they slightly preferred the syrup.

In those under one year, there was more success with the tablet over the syrup. Generally there was higher complete refusal with the liquid than the tablet. None of the children in the study choked on a tablet.

  • Dr Hunter is a GP in Bishop's Waltham, Hampshire, 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.

  • Consider if with your advice to patients with back pain you are giving a realistic timeframe for improvement.
  • Add a family history questionnaire to the current well-person invites.
  • Research best practice for talking to adolescents about drinking.

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