Timeliness of reperfusion in myocardial infarction
Registry data suggest that timeliness of reperfusion is critical in myocardial infarction, but are often prone to selection biases. A registry study in the NEJM goes to some lengths to provide a complete picture of reperfusion therapy at 80 Quebec hospitals in 2006–2007, including ~1800 patients. Under multivariate analysis, delayed reperfusion was associated with increases in mortality at 30 days (odds ratio 2.1) and a composite of death, recurrent infarction or heart failure admission at one year (odds ratio 1.6), roughly confirming previous findings. An accompanying Editorial examines how registry studies can improve cardiac care.
Preventing diabetes
Readers are doubtless familiar with the somewhat chequered history of rosiglitazone as a therapy for type 2 diabetes. The CANOE trial, published in the Lancet, tries a low dose in combination with metformin for prevention of diabetes in 207 patients with impaired glucose tolerance. Over nearly 4 years, the combination was certainly more successful than placebo, with incident diabetes in only 14% of the treatment group, vs 39% of the placebo arm, and a fairly modest increase in diarrhoea (16% vs 6%). An accompanying Comment is cautiously optimistic, but sees unaddressed areas of doubt.
Urinary incontinence
A clinical review in JAMA, centres on the case of an active 83-year-old woman who complains of urgency of micturition and stress incontinence. It makes the point that although urinary incontinence is common among older women, many don’t seek treatment, partly because of embarrassment, and partly because they often believe that it’s a normal and untreatable part of aging. The authors suggest enquiring about incontinence as a routine in older women, making an accurate diagnosis of the underlying cause, and being aware of the range of effective ways of managing the condition.
Falls in older people
Using a National Hospital Discharge Registry, a study from the Netherlands in Archives of Internal Medicine finds that the absolute number and the incidence of fall-related hospital admissions in older people have both risen dramatically over the last 25 years. The change can’t be explained by improved access to medical care, and the authors are inclined to attribute it to an increasingly active lifestyle among older members of the population. They reckon that improvements to falls prevention programmes are urgently needed.
Can single-lens spectacles prevent falls?
One known risk factor for falls in the elderly is the use of multifocal lenses, particularly outdoors. An Australian study in the BMJ investigates provision of single-lens distance glasses to elderly people at increased risk who used multifocals outdoors at least three times a week. There was no overall change in the intervention group as a whole. However, in prespecified subgroup analyses, falls were reduced in those who regularly took part in outdoor activities, but unexpectedly increased in those who left the house least often. An accompanying Editorial weighs the findings, recommending communication between doctors and optometrists as key.
Pneumococcal vaccination of children not cost effective in the Netherlands
The benefits originally estimated for universal PCV-7-based pneumococcal vaccination are proving over-optimistic in the face of increases in non-vaccine-serotype disease. A study in the BMJ re-evaluates the Netherlands’ vaccination programme, and finds it wanting, with an estimated incremental cost effectiveness ratio of €113 891 (£98 300) per QALY. A move to a 10- or 13-valent vaccine combined with a 2+1 dose schedule might bring this back to about €35,000/QALY, although the uncertainties are of course considerable. These conclusions don’t necessarily apply to the UK, whose PCV-7 programme has significant differences, but an equivalent analysis appears timely.
Botulinum toxin for tennis elbow
A few years ago, a small trial suggested that botulinum toxin injected into the area around the lateral epicondyle improved the symptoms of tennis elbow. It’s hard to see why, since the motor point of the wrist extensors is miles away. The Canadian Medical Association Journal reports a more rational intervention, injecting at one third of the way along a line from the tip of the lateral epicondyle to the posterior midpoint of the wrist: the point where the posterior interosseus nerve innervates extensor digitorum and extensor carpi ulnaris muscles. Temporary paralysis of these muscles is thought to reduce tension on the common extensor tendon origin, allowing healing of the epicondylitis. It seems to work, but with only 48 patients, a larger trial is clearly needed.
Genomic medicine
On the day that completion of decoding the human genome was announced, President Clinton declared: Our children's children may know cancer only as a constellation in the night sky. But for many at the sharp end of medicine, genetic research has had little influence on clinical practice. A general practitioner argues, in the BMJ, that it probably never will and that modern genetics is a blind alley. There’s a strong rebuttal by a professor of molecular medicine, who points out that benefits have already emerged in, for example, prenatal diagnosis and communicable diseases. He does admit, however, that many scientists drastically underestimated the time needed for genetic research to bear practical fruit.