On The Pulse - 29th June 2012

Apolipoproteins and other markers
Several lipid-related markers have emerged in recent years that are closer to pro-atherogenic pathways than cholesterol and HDL-cholesterol, and it’s reasonable to ask whether they’re better indicators of an individual’s risk of cardiovascular events. According to a large study in JAMA, the short answer is no. Adding information about apolipoproteins A1 and B, lipoprotein-associated phospholipase A2 and lipoprotein(a) to risk scores based on cholesterol and HDL-cholesterol hardly improved predictive value at all, when evaluated over > 10 years of follow-up.

Chronic kidney disease and cardiovascular risk
Chronic kidney disease is a recognised risk factor for cardiovascular disease, but how does it compare in seriousness to diabetes or a previous myocardial infarction? A study in the Lancet analyses a Canadian database of >1 million patients with stage 3 or 4 disease, finding an unadjusted rate of incident myocardial infarction of 6.9 per 1000 person-years, less than half that for a previous infarction (18.5), but greater than the rate for patients with diabetes (5.4). An accompanying Comment thinks that the worse outcomes from myocardial infarction in patients with chronic kidney disease make a compelling case for primary prevention anyway.

Gene expression testing for thyroid nodules
Thyroid nodules are common, especially in women and older patients. Fine-needle aspiration yields a clear result in 70–85% of patients, but the remainder frequently undergo precautionary surgery. A paper in the NEJM assesses a new gene-expression classifier test in 4812 aspirates from 3789 patients. Of 265 nodules testing indeterminate on aspiration, 85 were malignant, of which 78 were correctly classified by the test. An accompanying Editorial reckons the test could reduce surgery rates, and save substantial costs, but only if we can devise an effective strategy for dealing with the false-negative rate of 5–10%.

Mountaineering
While dangerous, high-altitude mountaineering is increasingly popular, and commercial expeditions offer people without Himalayan experience the chance to climb the highest peaks, one might expect a heavy cost in terms of injury and loss of life. But in an analysis in the BMJ of database of 39,000 expeditions in Nepal between 1970 and 2010, mortality was no higher among climbers on their first expedition than in people with previous experience, and commercial expeditions appeared no more dangerous than other types. Fatal events gradually decreased during the same period, suggesting that accumulated collective knowledge, good weather forecasting and better equipment may be more important than individual experience. 

Short course antibiotic treatment for acute pyelonephritis
Acute pyelonephritis is a common infection in adult women, but its optimal management is uncertain. A study in the Lancet compares 7 days of ciprofloxacin with 14 days, in 248 women aged ≥18 years. The two regimens were equally effective both in the short-term and over longer-term follow-up, but the 14-day regiment was associated with more adverse events, particularly Candida infection. An accompanying Comment praises the study for enrolling a wider spectrum of patients than previous trials, giving more confidence in the result, but agrees with the authors that the results should not be assumed to apply to other antibiotics.

NHS productivity
As anyone who works in the NHS knows, it has to save £20 billion by 2015 while still treating the same number of patients – a target many think is unachievable. An article in the BMJ predicts worse to come. With no economic recovery in sight, savings may have to increase to £50 billion by 2020. Can this be done by improving efficiency? The author, chief economist at the Kings Fund, thinks not and suggests that the NHS is being set up to fail.

Statins in women
Do statins work as well as women as in men? A meta-analysis in Archives of Internal Medicine raises the possibility that they may not. Across 11 RCTs in 43,000 patients, statins as secondary prevention were associated with reduced risk of cardiovascular events in both sexes, but reductions in stroke and all-cause mortality were significant only in men. An accompanying Commentary is sceptical, arguing that other analyses have shown benefit to women, and that a better question would be whether the effect sizes are comparable. However, as an Editorial says, this question can only be answered by recruiting more women into trials.

Electronic records
An essay in JAMA describes a picture of a clinic visit drawn by a 7-year-old girl. The girl herself sits on an examination couch. Her elder sister is on a chair nearby, as is her mother, who is cradling a baby. All are smiling. The doctor sits at a computer, with his back to everyone in the room. It’s not the first time that the point has been made – patients often complain that doctors spend more time looking at a screen than at them – but if this is the image that a child takes away from a medical consultation, it’s surely time we paid more attention to how we use electronic records.