This week in the BMJ
Volume 331, Number 7521, Issue of 15 Oct 2005Use a score to predict risks of stable angina
Use a score to predict risks of stable angina
In patients with stable symptomatic angina the risk of dying or having a myocardial infarction or stroke can be predicted with a risk score based on clinical variables. Clayton and colleagues (p 869) performed multivariate Cox regression analysis using data from a multicentre trial of 7311 patients who were followed up for a mean of five years. Patients with risk scores in the highest 10th had 10 times the risk of dying from any cause or having a myocardial infarction or stroke compared with patients with scores in the lowest 10th. On p 872, Terkelsen and Vach discuss the clinical applicability of this new risk score.
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Angiotensin receptor blockers don't seem to increase risk of MI
Angiotensin receptor blockers don't seem to increase the risk of myocardial infarction in patients at high risk of cardiovascular events, contrary to the conclusions of some earlier trials. A systematic review by McDonald and colleagues (p 873) included 19 controlled clinical trials and more than 30 000 patients. Use of angiotensin receptor blockers was not associated with increased or decreased risk of myocardial infarction compared with use of placebo or angiotensin converting enzyme inhibitors.
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Pre-eclampsia recurs across generations
Increased risk for pre-eclampsia is genetically transmitted from both mother and father. Studying a population based cohort, Skjærven and colleagues (p 877) examined almost 500 000 mother-offspring units and almost 300 000 father-offspring units from the Norwegian medical birth registry. Women born from pre-eclamptic pregnancies were more than twice as likely to develop pre-eclampsia themselves than other women, while the corresponding increased risk in pregnancies fathered by a man who was born from a pre-eclamptic pregnancy was 50%. Positive family history predicts more severe pre-eclampsia.
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Complementary medicine in the UK seems cost effective
Estimates of cost per quality adjusted life year of acupuncture for headache and of spinal manipulation for back pain compare well with other treatments approved for use in the NHS. Canter and colleagues (p 880) performed a systematic review and assessed cost effectiveness reported in one acupuncture trial and four trials of spinal manipulation. Despite the favourable estimates, the authors warn that complementary treatments could be less cost effective if offered routinely rather than in a setting of a clinical trial.
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Left handed women are at higher risk of breast cancer
Left handed women have more than twice the risk of developing breast cancer before reaching the menopause than right handed women. In a population based prospective case-cohort study of more than 12 000 women who were followed up for 16 years, Ramadhani and colleagues (p 882) also found that the risk of postmenopausal breast cancer was similar for left handed and non-left handed women. A plausible pathophysiological explanation is the existence of common intrauterine hormonal influences that determine both cerebral lateralisation and risk of breast cancer.
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One question improves diagnosing depression in primary care
Adding a question (about whether the patient wants immediate help with depressive symptoms) to two screening questions for depression in general practice improves the specificity of the screening. Arroll and colleagues (p 884) report on a cross sectional diagnostic validity study that included 19 general practitioners and more than 1000 consecutive patients in six clinics in New Zealand. Using the two screening questions and the additional help question, general practitioners correctly diagnosed 79% of people with major depression and correctly assessed 94% of those without major depression.
How to use indirect evidence on multiple treatments
On p 897 Caldwell and colleagues describe the process, with examples, for deciding what is the best treatment for a condition when three or more possible treatments are available. Large, high quality randomised trials of all available treatments are rare; most trials, and hence meta-analyses, are pair-wise, using placebo or current treatment as comparators. Thus, the need exists to develop reliable methods for incorporating indirect evidence into policy making. The authors claim that statistical methods are available for combining direct and indirect evidence and that these should be more widely used to compare multiple treatments.
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