Ann Intern Med 15 May 2007

At first glance, the message from the abstract of this paper is startling: an in-practice intervention can reduce 5-year mortality in seriously depressed elderly patients by 40%, entirely due to a reduction in cancer deaths. But in the main body of the paper, there was hardly any difference in survival for the generality of depressed patients, and the authors concede that because of the small number of patients involved, misclassification errors could have made a big difference to outcomes.

The British MASS trial of abdominal aortic aneurysm screening by one-off ultrasound in men between 65 and 74 showed borderline cost-effectiveness in the short term, but a seven-year follow-up study shows a mortality benefit which makes general screening appear highly cost effective (especially at the cited conversion rate of $1.58 to the £ sterling). It would be even more cost-effective if confined to ever-smokers (editorial p.749).

A study of a pharmacist-based intervention for heart failure has been waiting patiently on the BMJ website for some weeks, and meanwhile this one has beaten it into print. Never mind: these studies are not fresh news, having been replicated over the last ten years. I spoke to some pharmacists who took on this role in Tayside a few years ago, and yes, they were all trained up to titrate ACE inhibitors, add beta-blockers, encourage blood testing, daily weighing and all the rest. But they all found that their patients wanted to talk about tiredness, uncertainty, futile hospital admissions and a lack of hope. There is no neat little algorithm for dealing with such things.
Some days in general practice you just long for a patient who does not have tiredness, pains all over, stiffness and a large number of tender points. Fibromyalgia, according to this review, is present in 3.4% of US women and 0.5% of men; I wonder what the UK prevalence is, and particularly how common it is in women from the Indian subcontinent in arranged marriages. This review only deals with the pathophysiology, which undoubtedly includes aberrant pain processing. The treatment?

Having found your aortic abdominal aneurysm, what do you do about it? If it’s over 5.5cm wide, you repair it, naturally, if the patient is fit for surgery. Endovascular repair is less invasive and carries a smaller intra-operative mortality than open repair, but has no long-term advantages and a higher complication rate, as this systematic review confirms. Nevertheless it is popular with surgeons and patients, and outcomes may improve with time.