QRISK2 and teen birth rates

Been too busy to catch up with the journals? Dr Jonathan Holliday brings you the latest research.

QRISK2 is more accurate at identifying patients at high risk of cardiovascular disease (Photograph: SPL)
QRISK2 is more accurate at identifying patients at high risk of cardiovascular disease (Photograph: SPL)

Validation of QRISK2  - BMJ 2010; 340: c2442
The aim of this prospective cohort study was to evaluate the performance of QRISK2 against the NICE version of the Framingham equation and QRISK1.

The participants were 1.58 million patients registered with one of 365 Health Improvement Network practices in the UK between 1993 and 2008. Among the participants were 71,465 cardiovascular events.

Since QRISK2 applies to British people and takes account of many more influences (including ethnicity) you would expect it to be a better predictor.

Not only was it better at placing high-risk patients in the high-risk group but it removed patients from the Framingham high-risk group who did not belong there. It seems the most missed piece of input data is the total cholesterol/HDL ratio.

That is not surprising as we tend only to request full-fasting lipids for those in risk groups or in cardiovascular risk groups.

Management of subclinical hypothyroidism - J Primary Health Care 2010; 2: 29-34
This paper attempts to add some clarity to the discussion of whether and when to treat subclinical hypothyroidism (SCH). Two New Zealand practices with an adult population of 21,000 collected data on TFTs that were performed between December 2005 and November 2006.

SCH is defined by a raised TSH with a normal free thyroxine.

International literature suggests a prevalence of 6-10 per cent.

The New Zealand Best Practice Advocacy Centre (BPAC) recommends initial testing for thyroid dysfunction be based on clinical suspicion (and not just as a battery of tests) and the use of TSH only. It goes on to advise re-testing with free thyroxine added if the initial TSH is low.

If the free thyroxine is in the normal range they advise testing auto-antibodies to assess further risk. Of course, if the free thyroxine is low then just treat.

They identified 265 patients with SCH. The study confirmed with the further breakdown of the re-tested group that there was great variability in the management of this condition.

The BPAC gives a clear management plan for monitoring these patients, with those confirmed with SCH being re-tested every six to 12 months.

Infrared thermometry in the diagnosis of hand-arm vibration syndrome - J Occup Med 2010; 60: 225-30
Hand-arm vibration syndrome (HAVS) is a recurring presentation for many doctors involved in occupational medicine. A quick, safe and reliable form of diagnosis is helpful.

This study from Vancouver aimed to validate a thermometric method. Fifteen workers with photographically-confirmed HAVS-related Raynaud's phenomenon were compared with controls without Raynaud's and an occupational history of hand-arm vibration exposure.

Digit temperatures were measured using an infrared thermometer before and after immersion in 5 degsC water for one minute. The HAVS patients were found to differ significantly in terms of baseline temperature, rewarming time and rate. Time to rewarm three finger tips to baseline in excess of eight minutes was considered diagnostic.

Borderline glandular cells on liquid-based cytology - BJOG 2010; DOI 10.1111/j.1471-0528.2009.02477.x
This review was of the clinical outcome of women presenting with borderline glandular cells on liquid-based cervical cytology. It included women presenting to a colposcopy clinic with borderline changes over a 26-month period.

Sixty-nine women were identified (0.19 per cent of all smears); 27 (39 per cent) had pre-malignant or malignant lesions, five had cancers and 22 had intraepithelial neoplasia.

Importantly, no women under 35 with normal and satisfactory colposcopy had pre-malignant or malignant lesions.

However, despite normal and satisfactory colposcopy, three women in the over-35 age group had significant lesions.

Given these findings the authors recommend that in women over 35 a 'large loop excision of the transformation zone' procedure be carried out, irrespective of the colposcopic findings. In the under 35-year-olds a conservative approach would be reasonable.

Teen birth rates - J Adolesc Health 2010; 46: 517-24
Although this refers to the US, the messages are also important for us in the UK. In the US, there has been a rise in the birth rate for adolescents aged 15-19 in consecutive years (by 3 per cent in 2006 and 1 per cent in 2007).

This study aimed to find the demographic and policy reasons for this. They examined sex education, demographic features and family planning service policies.

They found abstinence-only education programmes were linked with an increase in teen birth rates in both black and white youngsters while removing cost from family planning services was associated with reduced teen birth rates.

Obvious enough, but a rem-inder that we need to develop teenage contraceptive and sexual health services.

Accupuncture for pain relief in labour - BJOG 2010; DOI 10.1111/j.1471-0528.2010.02570.x
The evidence for acupuncture as an analgesic during labour is weak. This study's authors believe the primary studies were diverse and often flawed.

They found 10 RCTs from around the world and by using visual analogue scales, they found that acupuncture reduced pain by only 11 per cent in the first 30 minutes and that this benefit was not maintained.

Electroacupuncture (EA) reduced pain by four and six per cent at 15 and 30 minutes compared with placebo EA but again this was not maintained.

The authors said that it was difficult to blind participants, care providers and/or evaluators and that at least there were no adverse events reported.

The Quick Study

QRISK2 was better than QRISK1 and the Framingham equation at placing patients at high risk of cardiovascular events in the high-risk group.

Thyroid dysfunction testing should initially be based on clinical suspicion and TSH only according to the New Zealand BPAC.

Hand-arm vibration syndrome can be diagnosed on the basis of time taken for fingertips to warm up after immersion in water.

Normal colposcopy findings do not necessarily rule out lesions in women over 35.

Abstinence-only sex education programmes were linked with an increase in teen birth rates in the US.

Acupuncture was not proven to provide sustained pain relief during labour.

 

  • Dr Holliday is a GP in Eton, Berkshire, and a member of our team who regularly review the journals

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