Skin cancer, diabetes and haemophilia

A round-up of the latest research papers by Dr Jonathan Holliday.

Indoor tanning was associated with an increased risk of basal cell carcinoma (Photograph: Dr P Marazzi/SPL)

Indoor tanning and non-melanoma skin cancer risk

BMJ 2012; 345: e5909

Everyone knows about the link between UV exposure and melanoma, even people who use tanning salons. But I did not know there was an increase in squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) among this group.

This meta-analysis looked at 12 studies with 9,328 cases of non-melanoma skin cancer. The comparison was made between ever used and never used indoor tanning. For those who had ever been exposed to indoor tanning, there was a 67% increased risk for SCC and a 29% higher risk for BCC.

In addition, exposure to indoor tanning at a young age showed a significantly higher risk for BCC, while the risk for SCC was not significantly raised.

The population incidence is quite high (non-melanoma skin cancer is the most common human cancer), so the excess number of cancers caused by indoor tanning is also large. It is estimated to be about 170,000 in the US alone. The authors suggest that the US should follow Australia and Canada in restricting use of sunbeds by minors.

GP recording of vital signs in children with acute infection

Br J Gen Pract 2012; 62: 526-7

This research discovers the frequency with which GPs record numerical vital signs when consulting with children with acute infections. It compares practice with NICE guidelines and determines whether GPs use alternative methods (such as words/text) to record vital signs.

Of the 850 children aged between one month and 16 years, 2.7% were classed as having a serious infection, while 58% had a diagnosis of URTI. Only a third of children had one or more numerical value recorded, with the most frequent being temperature, followed by pulse rate, then respiratory rate and capillary refill time. Text relating to global assessment was documented in 37%.

What the paper fails to tell us is the proportion of the seriously ill who had vital signs recorded, as compared with the URTI.

The authors suggest GPs must be finding other methods for assessing these children; overall activity or behaviour and gut feeling are cited as examples.

They suggest that if we are not going to use vital signs such as high temperature and tachypnoea, which are known to have high positive predictive value in identifying serious infection, we must have good evidence.

Screening for type 2 diabetes and 10-year survival

Lancet 2012 doi: 10. 1016 SO140-6736(12)61422-6

This study of 33 practices in east England set out to determine whether screening for type 2 diabetes could reduce mortality.

The practices were split in to three groups: screening followed by intensive multifactorial treatment for people diagnosed with diabetes (n = 15), screening plus routine care of diabetes according to national guidelines (n = 13), and a no-screening control group (n = 5). The study consisted of more than 20,000 individuals aged 40-69 years at high risk of undiagnosed diabetes. In screening practices, patients were invited to a stepwise programme including random capillary blood glucose, HbA1c, a fasting capillary blood glucose test and a confirmatory oral glucose tolerance test.

The primary outcome was all-cause mortality.

Of those invited for screening, 11,737 (73%) attended. A total of 466 (3%) were diagnosed with diabetes. During 184,057 person-years of follow-up (median duration 9.6 years) there were 1,532 deaths in the screening practices and 377 in the control practices (mortality hazard ratio 1.06).

There was no significant reduction in cardiovascular, cancer or diabetes-related mortality associated with invitation to screening. This large UK sample showed no benefit in all-cause, cardiovascular or diabetes- related mortality within 10 years. Not one for QOF then.

Cervical screening in sexually abused women

J Fam Plann Reprod Health Care 2012; 38: 214-20

Women visiting the website of the National Association for People Abused in Childhood who had been abused were invited to complete a survey of their views and experiences of cervical screening.

A total of 135 women completed the questionnaire. Of these, 77.5% of those who were eligible for screening had undergone at least one cervical smear, but only 42% of women aged 25-40 years had done so within the previous three years. This compares with a national figure of 79%.

This study supports the idea that sexually abused women are less likely to attend for screening. Improvements in communication, trust and sharing control were suggestions made by women to improve uptake.

GPs are often made aware of a history of sexual abuse and we could aim to encourage these women to attend for screening.

Child haemophiliacs' risk of bleeding with sports activity

JAMA 2012; 308: 1452-9

Vigorous activity is thought to increase the risk of bleeding in haemophiliacs. This study set out to quantify that risk.

The authors divided activity into category one (swimming and no activity), category two (basketball and baseball) and category three (wrestling).

The risk of bleeding associated with sport was estimated by contrasting exposure to physical activity in the eight hours before the bleed with exposures in two eight-hour control windows, controlling for clotting factor levels in the blood.

There was an increase in bleeds, but less than might be expected. Compared with category one, activities in category two were associated with a transient increase in risk of bleeding (OR 2.7). Activities in category three were associated with a greater transient increase in risk (OR 3.7).

To illustrate the absolute risk increase, for a child who bleeds five times a year and is exposed on average to category two activities twice weekly and category three once weekly, exposure was associated with only one of the five annual bleeds. They conclude that the increased relative risk is transient, so the absolute increase in risk associated with sport is small.

  • Dr Holliday is a GP in Berkshire 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.

  • Discuss with a colleague how you can inform patients about the risks of indoor tanning when relevant in a consultation.
  • Assess the quality of record-keeping in acute childhood illness by running an audit of the notes made in consultation during the two weeks before hospital admission for acute illness. Collect figures for the entry of vital signs in these records.
  • Review the records of those women who are declining cervical screening and look for evidence of sexual abuse. Consider alternative approaches to these women, with particular emphasis on communication and sharing control.

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