Patients with moderately severe or severe Alzheimer’s disease benefit from continued treatment with donepezil, a year long UK study has found. Dr Phillip Bland, GP with an interest in mental health, Dalton-in-Furness, comments: 'The present study suggests that community residents with an MMSE score between 5 and 13 may derive a modest but potentially important benefit from continued treatment.'

Women are often older than men at hospitalisation for myocardial infarction and present less frequently with chest pain. It is generally accepted that patients without chest pain tend to present later and are treated less aggressively than those presenting with more typical symptoms, and have almost twice the short-term mortality rate. Clinicians should not be dissuaded from urgent referral in high-risk patients by a rather atypical presentation and the lack of classical cardiac sounding chest pain.

Around 1,200 people die from asthma every year in the UK. A National Review of Asthma Deaths, led by the Royal College of Physicians, in collaboration with a consortium of professional bodies and patient organisations, will consider all asthma deaths in the UK during the 12 months from 1 February 2012.  This editorial includes a link for UK clinicians who want to participate.

'Starting ART later than recommended in the guidelines resulted in up to 15 years of life lost.' 

Obesity is defined as a body mass index (BMI) ≥30 kg/m²and it is estimated that almost a quarter of the population of England are obese. Primary care physicians are familiar with the subsequent problems that can arise such as diabetes, cardiovascular disease and osteoarthritis to list but a few. At present the Quality and Outcomes Framework places little emphasis on obesity management and there are few options available in traditional models of primary care. Patients will often self select for various commercial weight management programmes and in some areas these are available on the NHS. There is certainly evidence to support the notion of centrally funded commercial weight loss programmes. Another option is for primary care teams to develop in-house obesity management programmes. Dr Peter Savill looks at recent evidence on the effectiveness of such options for treatment.

Stroke is a major cause of morbidity and mortality. Primary care has a central role to play in prevention with the identification and management of hypertension, obesity, high cholesterol, atrial fibrillation (AF) and diabetes. A recent study has found that both the incidence of stroke and stroke deaths declined significantly over the past decade in the UK. This was accompanied by a notable increase in GP prescribing for primary and secondary prevention which is likely to have been a major contributing factor, the study authors conclude. However, the study also found underuse of anticoagulants in patients with AF at high risk of stroke, particularly in women.

A cross-sectional study using data from the 2007 household survey in England has founda strong association between work stress and common mental health disorders, which is independent of the effects of non-work stressors. Adjustment for non-work stressors had very little effect on the results, indicating that work stressors have an independent effect on common mental health disorders. It would be of interest to investigate the link between work stress and specific psychiatric conditions, but this would have required a much larger sample size. More than half of those with a common mental health disorder (55%) had mixed anxiety and depression (MADD) i.e. subthreshold depressive and anxiety symptoms. The status of ICD-10 MADD is questionable: it is poorly defined and usually self-limiting, but is associated with significantly impaired quality of life and high levels of work absence.Dr Philip Bland comments in the editorial: 'A cross-sectional study cannot demonstrate that work stress causes mental ill health. Alternative explanations for the association could be that individuals who are at increased risk of developing common mental health disorders are more likely to choose stressful jobs, or that depressed patients are more likely to perceive their work in a negative way. The Dunedin longitudinal study attempted to control for both of these possibilities and found that excessive job demands were associated with a doubling of the risk of major depression or GAD.Doctors have the highest incidence of work-related mental ill health of any profession. This may be the consequence of high demands (e.g. increasing complexity of consultations) and diminishing autonomy (guidelines and performance measures). Doctors who have an excessive need for approval and esteem from work (overcommitment) are particularly vulnerable. Conversely, doctors who work within supportive partnerships will have a reduced risk. In my experience, 360° appraisal can facilitate positive feedback and help colleagues and staff to feel both valued and supported.'

Venous thromboembolism is a common condition that can cause significant morbidity and mortality. It is preventable with the appropriate use of interventions in high-risk patients. Such individuals could be identified by a new Q algorithm, QThrombosis (www.qthrombosis.org), according to a study in the BMJ. The authors propose several areas in which their risk score could be used. They first suggest that it would allow for risk assessment of patients before hospital admission or long haul flights. Second, it could be used prior to starting medication which could increase the risk of venous thromboembolism such as the oral contraceptive pill, tamoxifen, HRT, or antipsychotic drugs. Third, it could be used to identify high-risk patients suitable for further testing, closer monitoring, or preventative treatment. It is not clear how useful this score would be in general practice. Dr Peter Savill comments, ' I think the score could potentially be used in patient education to illustrate the benefit of lifestyle modification and promote adherence to thromboprophylaxis and early mobilisation. It may be in this area that the score finds most use in primary care.' 

Pulmonary embolism is a common cause of cardiovascular morbidity and mortality and the annual incidence is similar to that of stroke and MI. Inactivity is associated with an increased risk of poor health and in particular can increase the risk of arterial disease. A recent study in the BMJ investigating a link between these two has shown an increase in the risk of pulmonary embolism with physical inactivity.The Nurses' Health Study, an American longitudinal

Recently measles cases have increased dramatically. England and Wales have seen a ten-fold increase in measles. Most of the cases in the UK have been in unvaccinated children and young adults, many of whom have acquired the disease abroad or in small clusters in university, school, or family settings. GPs can do a great deal to improve uptake, by using their systems to flag up all patients who are not known to be fully vaccinated, and ensuring that whenever they have contact with the practice, they are offered the vaccines they are overdue. It's never too late to get vaccinated. Good information systems help. Children who have missed appointments should be offered further appointments, and all patients should be offered vaccination opportunistically when they attend for other reasons. If this is done rigorously many more children can be vaccinated, leaving only a few others whose parents are willing for them to be vaccinated: in some areas domiciliary vaccination is offered to these children, with good effect - the numbers are relatively small. Confidence in vaccination is improving, with almost 90% of children vaccinated by their second birthday.

'The jury is still out on calcium and vitamin D supplements and CV risk. On the current evidence we cannot be sure if there is a risk or not. However, in practical terms I think we should probably be cautious in using calcium and vitamin D in high-risk CV patients until more evidence is available. '

Compared with those with neither condition, women with both diabetes and depression are more than twice as likely to die from all causes, and nearly three times as likely to die from cardiovascular disease (CVD), a study from the US has found. The Nurses' Health Study is a prospective study which has followed up a cohort of 121,700 women since 1976. Dr Phillip Bland,GP with an interest in mental health, Dalton-in-Furness, reviews the study results. He commenting on its practical implications. He writes: 'Screening of all diabetes patients linked to antidepressant prescribing is wasteful of resources and of doubtful benefit. Improved recognition of patients who are struggling to adjust to their diabetes linked to the provision of physical activity programmes and group-based peer support may be a better approach to reducing the risk.'

'Obesity is now commonplace and, given the higher prevalence of morbidity, GPs may well see as many obese as non-obese patients every day. While we can treat raised blood pressure and cholesterol, and diabetes effectively, obesity poses a difficult challenge. Even if time and resources were available, the evidence shows that often only small amounts of weight loss are feasible, and even these are difficult for patients to maintain long term. We still need to confirm that weight reduction actually results in the long-term health benefits that non-intervention, cohort studies ....predict. Urgent work is required to find effective methods of helping patients lose weight that also result in an improvement in health outcomes. In the meantime, it is important to promote a healthy lifestyle and help patients with weight loss as much as possible. It is worth remembering that, for most, weight maintenance will be a significant improvement on inevitable weight gain.'

A recent study has further underlined the importance of smoking in the development of RA. It found that smoking is responsible for 35% of ACPA-positive cases in a dose-dependent manner (55% in patients with two copies of SE alleles). Furthermore, risk of RA in ex-smokers diminished with time.The Epidemiological Investigation of Rheumatoid Arthritis (EIRA) study from Sweden collated data on incident RA cases and controls matched for age, gender and residential area. 'This study provides further evidence that cigarette smoking is associated with the development of RA. There is a need for public health campaigns to educate the public regarding this risk. Encouragement of smoking cessation is especially warranted in relatives of patients with RA.'

Collaborative care improves  depression outcomes and chronic disease  control in patients with depression and poorly controlled diabetes and/or CHD, an American primary care study has found. Moreover, patients had a better quality of life and were more satisfied with their care. 'Our practice nurses already play a role in identifying patients with chronic conditions who are depressed. Should we also ask them to collaborate in the care of those patients they identify? It can be argued that they should either perform both roles, or neither: depression case finding is of no benefit unless it is combined with some form of enhanced care. However, collaborative care is very time consuming: in the present study, patients from the intervention group had a mean of 10 face-to-face and 10.8 nurse telephone contacts over the 12-month period. Nurses may not wish to work with patients with psychological problems and the results of collaborative care are better when case managers have a mental health background. Enhanced liaison with secondary care is unlikely to be feasible in most UK settings.'

Regular and moderate drinking throughout the week confers a low risk  of IHD whereas binge drinking is associated with a higher risk, a study comparing drinking habits in France and the UK has found. Binge drinkers had almost twice the risk of MI or coronary death compared with regular drinkers. 'Most of us would probably advise patients to drink a little alcohol but not too much to reduce their risk of coronary events and would postulate that the beneficial effects of alcohol on heart disease are mediated in part by raising HDL cholesterol whereas excessive consumption has adverse effects on the lipid profile as well as having direct toxic effects on the myocardium. It is plausible that binge drinking may lead to changes in the myocardial conducting system and to a reduction in the arrhythmia threshold in particular for ventricular fibrillation that are not seen with regular drinking. Furthermore, the favourable lipid effects of regular drinking may be absent with irregular drinking.'

Patients with depression are more likely to die. The strongest evidence links depression with cardiac mortality, but there is also growing evidence of an increase in all cause mortality, particularly among elderly patients. A prospective cohort study has found further evidence that a combination of CHD and depression is potentially lethal. The Whitehall II study has followed up 10,308 civil servants since 1985. Between 2002 and 2004, the 5,936 remaining participants, mean age 61, were asked to complete the CES-D depression screening questionnaire. There appeared to be a synergistic effect: participants with both conditions were much more likely to die than those with just one of them. 'CHD plus depression is a dangerous combination. We should be alert to the possibility of depression in CHD patients and we must treat it effectively. Structured group physical activity may be the treatment of choice, and case management may improve outcomes.'

The debate on PSA screening to detect prostate cancer is ongoing. Two large studies published in 2009 gave an unclear message. The European ERSPC trial showed a significant reduction in prostate cancer mortality as a result of screening but with a significant risk of overtreatment in order to save lives (48 additional patients requiring treatment for each life saved). The American PLCO study showed no benefit from screening, but has been criticised for the large amount of PSA testing outside the study in the control arm, contaminating the results and potentially diluting any benefit. A meta-analysis incorporating these two studies and four other randomised controlled trials (a total of 387,286 men), published in the BMJ, has examined the overall evidence for PSA screening.¹ It found that screening increased the probability of being diagnosed with prostate cancer, relative risk 1.46 (95% CI: 1.21-1.77, p<0.001) but had no significant effect on mortality from prostate cancer RR 0.88 (95% CI: 0.71-1.09, p=0.25) or overall mortality RR 0.99 (95% CI: 0.97-1.01, p=0.44). However, patients continue to ask their GPs for PSA tests, and many will ask to have their PSA monitored on a regular basis. A second study, in the BMJ, assessed the potential of another strategy to improve the efficacy of PSA screening.² It recognised that the key question in a prostate cancer screening programme is not whether a man has prostate cancer but whether that cancer is likely to cause symptoms or shorten his life.

'An association between BPH and metabolic dysfunction has been postulated ...suggesting links between factors that increase the risk of CVD with the risk of BPH.'

The revised NICE guideline on depression in adults, although based on the same stepped care model, differs substantially from the previous guidance both in its definition of depression and the range of treatments recommended.If followed, the guidance will significantly change the way in which we manage depressed patients. Whereas currently we treat most patients ourselves using watchful waiting, brief psychological interventions and targeted antidepressant therapy, most patients will now need referral to the IAPT programme or elsewhere.

Men who have multiple cardiovascular risk factors in middle age may have a reduced life expectancy of 10-15 years from age 50, according to the Whitehall study. Smoking, high blood pressure and raised cholesterol together reduced life span by 10 years. When other risk factors were also considered life expectancy was reduced by a further 5 years.

'Treatment of patients at high risk of a cardiovascular event with statins can reduce all cause mortality'