Press releases Monday 16 March to Friday 20 March 2009

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) New diabetes risk score will help identify high risk patients
(2) Maggot therapy similar to standard care for leg ulcers
(3) Concern over Google links to worrying medical claims

(1) New diabetes risk score will help identify high risk patients
(Research: Predicting the risk of type 2 diabetes in England and Wales: prospective derivation and validation of QDScore)
http://www.bmj.com/cgi/doi/10.1136/bmj.b880
(Editorial: Screening for type 2 diabetes in primary care)
http://www.bmj.com/cgi/doi/10.1136/bmj.b973

A simple new score for predicting the risk of type 2 diabetes could be used to identify people at high risk of diabetes and proactively intervene before they develop the disease, concludes a large study published on bmj.com today.

The score uses information that is available in electronic health records, or which patients themselves would be likely to know, and does not require laboratory tests, so can be used in routine clinical practice, by national screening programmes, and also by the public (http://www.qdscore.org).

The prevalence of type 2 diabetes has increased rapidly worldwide, fuelled by ageing populations, poor diet, and the obesity epidemic. Early detection is crucial, yet no widely accepted risk prediction score has been developed and validated for use in routine clinical practice.

So a team of researchers from the Universities of Nottingham, Edinburgh, Queen Mary's and NHS Bristol, set out to develop and validate a new diabetes risk algorithm (the QDScore) to estimate the risk of acquiring type 2 diabetes over a 10 year period, using the QResearch database.

They analysed the health records of over 2.5 million patients registered at 355 general practices across England and Wales over a period of 10 years to March 2008. All participants were aged between 25 and 79 and were free of diabetes at the start of the study.

Patients who were diagnosed with type 2 diabetes during the study period were identified from the general practice computer records.

After adjusting for all other variables, the risk of being diagnosed as having type 2 diabetes in both men and women was significantly associated with age, sex, ethnicity, body mass index, smoking status, family history of diabetes, social deprivation, treated high blood pressure, heart disease and use of corticosteroids.

For example, the researchers found large variations in the risk of type 2 diabetes between different ethnic groups. Bangladeshi men and women were four times more likely to develop diabetes than white men and women, while Pakistani men and women were twice as likely to develop diabetes than white men and women.

They also found a marked difference in rates of type 2 diabetes by social deprivation, with women in the most deprived fifth more than twice as likely to develop diabetes than compared with the most affluent fifth. A similar, but less steep gradient was seen for men.

The team then tested the performance of the QDScore by comparing the predicted risk and the observed risk at 10 years in a further 1.2 million patients from a separate sample of practices. This showed the score to be highly accurate.

The QDScore also performed well when compared with another diabetes risk algorithm, known as the Cambridge risk score.

The QDScore is the first risk prediction algorithm to estimate the 10 year risk of diabetes using both ethnicity and social deprivation, say the authors. It does not need laboratory tests and thus is suitable for use in both clinical settings and also by the public. Furthermore, it is likely to reduce, rather than exacerbate, widespread and persistent health inequalities, they conclude.

The QDScore appears highly accurate and practical, and could be used to identify patients with an increased risk of diabetes, which might lead to earlier diagnosis and intervention, say doctors from the University of Dresden in an accompanying editorial.

Incorporation of the QDScore into practice computer programmes would not increase doctors' daily workload, but they point out that computer access is essential, which may be difficult for people in most developing countries.

Several organisations have recommended the use of a prediction algorithm in primary care in Europe and the QDScore will be a useful tool to help achieve these goals, they write. However, they suggest that follow-up studies are needed to assess the success of the QDScore.

Contacts:
Research: Julia Hippisley-Cox, Professor of Clinical Epidemiology and Clinical Practice, University of Nottingham, Nottingham, UK
Email: julia.hippisley-cox@nottingham.ac.uk

Editorial: Peter E H Schwarz, Department of Medicine III, Carl Gustav Carus Medical School, Dresden University of Technology, Dresden, Germany
Email: peter.schwarz@uniklinikum-dresden.de


(2) Maggot therapy similar to standard care for leg ulcers
(Larval therapy for leg ulcers (VenUS II): randomised controlled trial)
http://www.bmj.com/cgi/doi/10.1136/bmj.b773
(Cost effectiveness analysis of larval therapy for leg ulcers)
http://www.bmj.com/cgi/doi/10.1136/bmj.b825

Larval (maggot) therapy has similar health benefits and costs compared with a standard treatment for leg ulcers, find two studies published on bmj.com today.

Leg ulcers are chronic wounds most commonly caused by diseased veins in the legs. Debridement (the removal of dead tissue from the ulcer surface) is a common part of ulcer management and is widely viewed as having a role in promoting wound healing.

Debridement can be undertaken with a hydrogel, but it has been suggested that larval therapy debrides wounds more swiftly, as well as stimulating healing and reducing infection.

A team of UK researchers have carried out the first randomised controlled trial to investigate the clinical and cost-effectiveness of larval therapy on wound healing.

The trial involved 267 participants who had at least one venous or mixed venous/arterial leg ulcer with dead tissue (sloughy and/or necrotic tissue) covering at least a quarter of the wound.

Participants were randomised to receive loose larvae, bagged larvae or hydrogel during the debridement phase, followed by standard treatment. People were monitored for up to 12 months, during which time the date of complete healing of the ulcer was recorded by trained nurses.

Date of debridement was also recorded, as were bacterial levels, adverse events and ulcer-related pain. Participants completed a health-related quality of life questionnaire at the start of the study, and then again at three, six, nine and 12 months.

Larval therapy significantly reduced the time to debridement compared with hydrogel, but there was no evidence of a difference in time to ulcer healing (half of patients allocated to the larvae group were healed by 236 days compared with 245 days for the hydrogel group).

There was no difference between larvae and hydrogel groups in health-related quality of life or in bacterial load (including MRSA). Larval therapy was associated with twice as much pain in the 24 hours prior to removal of the first application compared with hydrogel.

The authors conclude that, although larval therapy is a more effective debriding agent than hydrogel, there is no evidence from this trial that it should be recommended for routine use on sloughy leg ulcers with the aim of speeding healing or reducing bacterial load. They suggest that further research is required to explore the relationship between wound debridement, healing and microbiology, and to better understand the value of debridement from the patient perspective.

In a separate analysis, the researchers calculate that larval therapy is likely to have similar cost-effectiveness to hydrogel. As such, they conclude that healthcare decision makers should generally be indifferent when recommending these two therapies for the debridement of sloughy leg ulcers.

Contacts:
Research: Jo Dumville, Research Fellow, Department of Health Sciences, University of York, UK
Email: jd34@york.ac.uk
Or
Professor Nicky Cullum, Deputy Head of Department, Department of Health Sciences, University of York, UK
Email: nac2@york.ac.uk

Cost-effectiveness analysis: Marta Soares, Research Fellow, Health Economics, University of York, UK
Email: ms602@york.ac.uk

(3) Concern over Google links to worrying medical claims
(Personal view: Google needs better control of its advertisements and suggested links)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1083
(Personal view: A Reformation for our times)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1080

Google needs better control of its advertisements and suggested links to avoid web pages that contain worrying medical claims, warn doctors in an article published on bmj.com today.

Dr Marco Masoni and colleagues at the University of Florence in Italy suggest that, as the internet is not well policed and regulated, it is up to members of the medical community to be vigilant and to suggest improvements.

They recently used Google Italia to search on the keyword "aloe" and found sponsored links to websites recommending aloe arborescens for the prevention and treatment of cancer and offering it for sale.

AdWords is "Google's flagship advertising product" and was its "main source of revenue in 2007." Through it, users can create advertisements, choose their own key words, and decide which Google queries their advertisements should match. Google decides on placement on its pages of search results: which advertisements to show and in what order.

But Google's automated matching to search terms sometimes places inappropriate advertisements. For example Google Guide (which is neither affiliated with nor endorsed by Google), says: "In September of 2003, adjacent to a New York Post article about a gruesome murder in which the victim's body parts were stashed in a suitcase, Google listed an ad for suitcases. Since that incident, Google has improved its filters and automatically pulls ads from pages with disturbing content."

But the authors argue that Google filters must be improved further.

Google has often said that it wishes to enter the healthcare arena in many ways, say the authors. "We think that a necessary first step for Google is to improve its filters and algorithms so as to prevent possible harm to its users," they conclude.

"We are experiencing a healthcare reformation," says Joanne Shaw from NHS Direct in a second article. "The internet has brought the canon of medical knowledge into the hands and homes of ordinary people, and this should be welcomed and encouraged as good for patients and doctors alike." It is true that the internet may be a further source of alarm for the worried well, but equally it encourages early presentation and action that could improve survival and reduce complications from long term conditions, she writes.

Furthermore, the internet does not diminish the role of doctors but casts them as expert advisers rather than authoritarian figures with exclusive guardianship of special knowledge denied to ordinary people.

Many doctors already act according to those principles, and many patients will continue to want a more traditional style of relationship with their doctors. But people who look to the internet as a legitimate tool to help them with their health may already be in the majority and this is something for us to celebrate, she concludes.

Contacts:
Dr Marco Masoni, Faculty of Medicine, University of Florence, Italy
Email: m.masoni@med.unifi.it

Joanne Shaw, Chair, NHS Direct NHS Trust, UK
Email: joanne.shaw@healthstrategy.org

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