Research highlights – 24 June 2011

Research questions“Research highlights” is a weekly round-up of research papers appearing in the print BMJ. We start off with this week’s research questions, before providing more detail on some individual research papers and accompanying articles.

Choosing antiplatelet treatment for acute coronary syndrome
Invasive management is recommended for most patients with acute coronary syndromes, but a conservative approach is often taken in lower risk patients (something like a third of patients with non-ST elevation acute coronary syndrome are managed non-invasively). However, such patients rarely receive attention from trialists, so it’s nice to see Stefan K James and colleagues’ report of a planned subgroup analysis of patients enrolled in the PLATelet inhibition and patient Outcomes (PLATO) trial who were initially allocated to non-invasive treatment.

They compared clinical outcomes with two antiplatelet agents, the second generation thienopyridine clopidogrel and the novel non-thienopyridine ticagrelor, both given in conjunction with aspirin. Ticagrelor achieved a clinically important reduction in ischaemic events and mortality compared with clopidogrel, without increasing major bleeding. The authors report that the benefits of ticagrelor over clopidogrel were consistent with those from the overall PLATO results, and they conclude that the benefits of the newer drug apply across different management strategies.

In his linked editorial Adam Timmis is particularly impressed that ticagrelor seems to have “achieved the elusive goal of enhancing platelet inhibition and improving cardiovascular outcomes without increasing the risk of bleeding” but warns that these are still early days.

Continuing the antiplatelet theme in their Therapeutics article, Gabriella Passacquale and Albert Ferro discuss the use of clopidogrel and prasugrel (a third generation thienopyridine) for the prevention of cardiovascular events, covering how and how well such agents work.

Sharing information on violent injury
Curtis Florence and colleagues report on an information sharing partnership between health services, police, and local government in Cardiff, in which anonymised information about injuries from violence treated in emergency departments was passed to the partnership. For all patients attending an emergency department who reported injury in a violent incident, the hospital captured information about the precise location of the incident, time and day, and type of weapon, stripped it of personal identifiers, and shared it with the partnership crime analyst. The hospital data were then combined with police data and used to target violence prevention resources.

The study found that sharing of information was associated with a significant reduction in violence related hospital admissions and in woundings recorded by the police in Cardiff, relative to comparison cities. The study also showed that less serious assaults recorded by the police increased significantly.

In his linked editorial Alexander Butchart applauds this new approach to violence prevention, pointing out that such community level programmes should be more cost effective than programmes that operate at the levels of individuals, close relationships, or families.

High risk prescribing in primary care
Bruce Guthrie and colleagues used multilevel modelling to review data from 315 Scottish general practices with 1.76 million patients, of whom nearly 140 000 (around 8%) received one or more high risk prescriptions. They looked at obvious risks associated with NSAIDs and warfarin, but also flagged up the perils of prescribing risperidone or olanzapine for over 65s with dementia and giving methotrexate without explicit instruction to take it weekly. After adjustment for patient level variables (age, sex, deprivation, polypharmacy), there was still considerable—and potentially modifiable—variation between practices. This variation wasn’t explained by practice list size, single handedness, contract type, training status, rurality, dispensing status, and Quality and Outcomes Framework indicator scores for the management of medicines.

The authors acknowledge that not all high risk prescribing is inappropriate or avoidable. They point out, however, that “as all the prescribing examined is stated in national guidance to be contraindicated or to be avoided in routine practice, the high rates and large variation between practices suggest significant opportunities for improvement.” And they reckon that their methodology is generalisable, at least across UK primary care.

Priorities for women with lymphoedema after treatment for breast cancer
Afaf Girgis and colleagues explored the perceived unmet needs of women treated for breast cancer with symptoms and signs of lymphoedema (doi:10.1136/bmj.d3442).

Predicting risk of osteoporotic and hip fracture in the United Kingdom
QFractureScores are useful tools for predicting the 10 year risk of osteoporotic and hip fractures in UK patients, say Gary Collins and colleagues (doi:10.1136/bmj.d3651).