Intended for healthcare professionals


Incentivised case finding and other stories . . .

BMJ 2014; 349 doi: (Published 03 September 2014) Cite this as: BMJ 2014;349:g5361

At its best, general practice can be a wonderful human interchange, carried out in short encounters over many years. At its worst, it can be like the dysfunctional processes described in a qualitative study (BMJ Open 2014;4:e005146, doi:10.1136/bmjopen-2014-005146) of incentivised case finding for depression in patients with chronic heart disease and diabetes in primary care in Leeds. “Do three blood pressure readings, loads of blood tests, trouble getting a vein, had to check their feet, loads of faffing around, only got 20 minutes” is one nurse’s description of what she was expected to do while asking a patient about low mood. Like most of the patients asked about depression in the study, readers of this paper will either laugh or burst into tears.

Of the commonly prescribed drug classes, angiotensin converting enzyme inhibitors are the most likely to cause angio-oedema. Over one year, a total of 88 patients taking these drugs presented to an American university hospital with this condition (Annals of Otology, Rhinology and Laryngology 2014, doi:10.1177/0003489414543069). Eighty of them were African-American, and angio-oedema could occur within a day or after 20 years. Half of the patients had been taking the drug for more than a year, and lisinopril accounted for 78% of cases.

As the number of overweight people increases inexorably around the world, Minerva likes to find some crumbs of comfort. She has just discovered that having a high body mass index (BMI) may protect against progression in rheumatoid arthritis. The latest evidence comes from 1068 people with the disease from two clinical trials of golimumab (GO-BEFORE and GO-FORWARD; Annals of the Rheumatic Diseases 2014, doi:10.1136/annrheumdis-2014-205544). Greater BMI at baseline was associated with lower risk of progression (assessed by radiography and magnetic resonance imaging) over two years, and the higher the BMI the better.

Small countries produce great epidemiology. A country the size of Wales has just produced figures for the prevalence of diabetic retinopathy in 5003 people with type 1 diabetes and 86 390 with type 2 diabetes at their first screening by the National Diabetic Retinopathy Screening Service from 2005 to 2009. The prevalence of any diabetic retinopathy and sight threatening retinopathy was 56.0% and 11.2%, respectively, in those with type 1 diabetes and 30.3% and 2.9%, respectively, in those with type 2 diabetes. Retinopathy was strongly associated with the duration of diabetes. And the country? Wales, obviously. No other countries of the same size exist.

Chronic migraine affects 2% of adults, who typically try one treatment after another. Stimulation of the occipital nerve using an implantable device seems like a last resort, but a recent trial reports that it achieved a 50% reduction in headache days or pain intensity (or both) in about half of those in the active arm (Cephalalgia 2014, doi:10.1177/0333102414543331). The control group had the stimulator implanted but were given a sham activator.

Anyone with a sphygmomanometer can measure the ankle-brachial index, but it takes big sexy machines to measure coronary artery calcification and carotid artery intima media thickness. The Heinz Nixdorf Recall study set out to find which of these was best at predicting stroke in 3289 participants (Stroke 2014, doi:10.1161/STROKEAHA.114.005626). It turns out to be the ankle-brachial index. Hurray, says Minerva.

Can neck manipulation bring on a stroke? A statement for healthcare professionals from the American Heart Association/American Stroke Association endorsed by the American Association of Neurological Surgeons and Congress of Neurological Surgeons (Stroke 2014, doi:10.1161/STR.0000000000000016) attempts to answer this question. Carotid artery dissection causes only 2% of all ischaemic strokes, but some studies have reported a temporal association between cervical manipulation and a few cases of carotid artery dissection. A 20 page review of the evidence adopts a magisterial tone but leaves Minerva none the wiser.

Being over 85 puts you in the category of “the oldest old,” and in the UK this carries a 55% risk of having three of more chronic medical conditions and a 66% risk of being on three or more drugs (Age and Ageing 2014, doi:10.1093/ageing/afu113). Both these figures have risen by a third in the past decade, but British doctors will need to work harder to get to the levels currently seen in Florida.

“Was Killigrew a cripple?” You can guess from the c-word that this paper was not in a medical journal. It comes from that wonderful quarterly gathering of literary titbits, Notes & Queries (2014;61:388-91, doi:10.1093/notesj/gju098). Thomas Killigrew (1612-83) was a leading dramatist and theatre director in the Restoration period. A recently unearthed letter proves that Killigrew had something wrong with his legs. Far from being a hindrance to his career, the article suggests that: “Killigrew’s notorious privilege to ‘revile or jeere anybody’ even ‘the greatest person, without offence’ in the court of Charles II may have been precisely because he was, ‘Lame old Tom.’”


Cite this as: BMJ 2014;349:g5361

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