News in brief

Study emphasises hypertension burden
A LARGE study involving 1.25 million people has found that systolic and diastolic blood pressure (BP) show heterogeneous associations across a wide range of acute and chronic cardiovascular diseases (CVD) and at different ages. The research, published in The Lancet, suggests that individuals with higher systolic BP have a greater risk of intracerebral haemorrhage, subarachnoid haemorrhage and stable angina, whereas raised diastolic BP is a better indicator of abdominal aortic aneurysm risk. The researchers examined BP data on electronic health records of 1.25 million primary care patients in the UK without CVD, aged 30 years and older. Of the primary analysis cohort, which included 58% women, 83 098 had their first cardiovascular events during a median follow-up of 5.2 years. The findings showed that despite modern therapy, the lifetime burden of hypertension remains substantial. The researchers found that in each age group, the lowest risk for CVD was in people with systolic BP of 90–114 mmHg and diastolic BP of 60–74 mmHg, with no evidence of a J-shaped increased risk at lower BPs. The effect of high BP varied by CVD end point, from being strongly positive to having no effect. People with hypertension (BP ≥ 140/90 mmHg or those receiving BP-lowering drugs) had a lifetime risk of overall CVD at age 30 years of 63.3% compared with 46.1% for those with normal BP, and developed CVD 5 years earlier. “An important advance of this study over previous reports was our ability to compare in one study the associations of blood pressure across a substantially wider range of incident cardiovascular diseases, across a broader age range (including people younger than 40 years), and a wider range of blood pressure values (including < 115/75 mm Hg)”, the researchers wrote. They said their study showed that the lifetime risk of heart failure after accounting for patients who experienced another cardiovascular outcome before heart failure is 5%, and is almost twice as high in people with hypertension as in those with normal BP. They estimated lifetime risk for stroke (combined ischaemic and haemorrhagic stroke) was 8%–10%, substantially lower than the 17%–20% reported in previous studies. An accompanying commentary said several steps “need to be taken to improve antihypertensive treatment and control”.

Risk factors for sagging eyelids
AGE is not the only risk factor for sagging eyelids, with new research showing being male, and having lighter skin colour, high body mass index (BMI) and genetic variants are involved in the origins of dermatochalasis (moderately or severely sagging eyelids). The cross-sectional study, published in JAMA Dermatology, included 5578 unrelated Dutch Europeans (mean age, 67.1 years; 44.0% male) and 2186 UK twins (mean age, 53.1 years; 10.4% male). Among the unrelated individuals, 17.8% showed dermatochalasis, with sagging eyelids graded as normal in 44.9%, mild in 37.3%, moderate in 12.9%, and severe in 4.9%. Significant and independent risk factors included age, male sex, lighter skin colour and higher BMI, with current smoking found to be “borderline significantly associated”. Among the twins, 15.6% showed dermatochalasis, with sagging eyelids graded as normal in 52.6%, mild in 31.8%, moderate in 11.8% and severe in 3.7%. Phenotypic correlation among monozygotic twin pairs was, on average, much higher than that among dizygotic twin pairs. The variance in sagging eyelids due to heritability was estimated to be 60.9%. “All 5 risk factors for sagging eyelids (age, sex, skin color, BMI, and current smoking) are associated with skin wrinkling, indicating that the risk profiles of both conditions are at least partially overlapping”, the researchers wrote. “The high heritability of sagging eyelids indicates that genetic variants are important in the origin. The C allele of rs11876749 on chromosome 18 showed a genome-wide significant protective effect for sagging eyelid severity.”

Cancer centre ads raise promote “vague” therapies
RESEARCHERS have found advertisements for cancer centres in the US are more likely to promote cancer therapies, “described in vague or general terms”, than supportive or screening services. An analysis, published in the Annals of Internal Medicine, also found the advertisements “evoked hope for survival, promoted innovative treatment advances, and used language about fighting cancer”. The researchers analysed 409 advertisements in magazines and on television placed by 102 cancer centres during 2012. Patient testimonials focused on survival (61%) with benefits described more often than risks (27% v 2%). The researchers wrote that clinical advertisements used emotional appeal without information about indications, benefits, risks or alternatives, which they speculated could lead patients to pursue care that was unnecessary or not supported by scientific evidence. “Pursuit of unnecessary tests or treatment may, in turn, expose patients to avoidable risks and contribute to increasing costs for patients and the health care system”, they wrote. “Advertisements that omit information about costs or insurance coverage may lead to distress if services prove unaffordable.” They called for research to identify if cancer centre advertising was contributing to the rapidly escalating costs of cancer care in the US. An accompanying editorial said further qualitative and quantitative studies were needed “to help tease out if and how” the advertising affected patients with cancer. “If marketing increases or decreases that burden for patients with cancer, it behooves us to know how”, it said.

Heroin users older but may not be wiser
HEROIN users in the US today are more likely to be older, less likely to live in urban areas and more likely to have been introduced to opioids though prescription drugs than their counterparts 50 years ago. A retrospective analysis, published in JAMA Psychiatry, examined US data obtained from patients entering substance misuse treatment programs with a diagnosis of opioid dependence and compared it with data about heroin users who initiated use 40 to 50 years ago. They found that of users who began their opioid misuse in the 1960s, more than 80% indicated that they started with heroin. “In a near complete reversal, 75% of those who began their opioid abuse in the 2000s reported that their first regular opioid was a prescription drug”, the researchers wrote. They said recent users of heroin were older white men and women currently living primarily in non-urban areas. They were either introduced to opioids through prescription drugs or used heroin as a cheaper and more accessible alternative to their preferred prescription opioid (eg, oxycodeine). “This contrasts sharply to early studies that characterized the heroin problem as an inner-city issue among minority populations”, they wrote. The researchers noted an interesting aspect of their data was that the age at first opioid use had increased in the past 50 years from16 years to 23 years of age, “although it must be noted that recall may be limited in those reflecting back so long ago”.

Lung cancer screening a “teachable moment”
LUNG cancer screening has a significant impact on subsequent smoking behaviour and lung cancer screening programs may present a “teachable moment” for smoking cessation interventions, according to the authors of a longitudinal study published in the Journal of the National Cancer Institute. They used data from participants in the US National Lung Screening Trial to analyse the association between lung screening results and smoking cessation. The trial involved annual low-dose computed tomography for current or former smokers. They found that compared with those with normal screen results, individuals were less likely to be smokers if their previous year’s screen had a major abnormality that was not suspicious for lung cancer; was suspicious for lung cancer but stable from previous screens; or was suspicious for lung cancer and was new or had changed from the previous screen. The differences in smoking prevalence were present up to 5 years after the last screen. The researchers said that, on average, those with abnormal results suspicious for lung cancer reported approximately 6% lower rate of smoking compared with those with normal results. “This represents a clinically relevant difference”, the researchers wrote. They said it had been speculated those who had normal screens continued their unhealthy behaviours “because they think they have a clean bill of health — the health-certificate effect”. “Our findings strongly indicate that smoking cessation programs be incorporated into lung cancer screening programs”, they wrote. An accompanying editorial said that as screening programs were being initiated across the US, “they offer unique opportunities to conduct smoking cessation research to investigate the prevalence of the health-certificate effect and the intervention intensity required to achieve the maximum smoking cessation”.

Sphincterotomy no help with pain after cholecystectomy
SPHINCTEROTOMY did not reduce pain-related disability after cholecystectomy in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with manometry, according to research published in JAMA. The multicentre, sham-controlled, randomised trial included 214 patients with pain after cholecystectomy who had no significant abnormalities on imaging or laboratory studies, and no prior sphincter treatment or pancreatitis. Researchers based the success of treatment on less than 6 days of disability due to pain at 9 months and 12 months after randomisation, as well as no narcotic use and or need for further sphincter intervention. They found that 37% of patients in the sham treatment group and 23% in the sphincterotomy group experienced successful treatment (adjusted risk difference, −15.6%). In the treatment group 26% underwent repeat ERCP interventions, with 34% needing repeat intervention in the sham group. The researchers wrote that no clinical subgroups appeared to benefit from sphincterotomy more than others. “The finding that endoscopic sphincterotomy is not an effective treatment has major implications for clinical practice because it applies to many thousands of patients”, the researchers wrote. “Several series have reported residual or recurrent pain in more than 20% of patients after elective cholecystectomy.” The researchers speculate that the early reduction in pain-related disability in all groups could be related to a placebo response “in a cohort of optimistic and distressed patients who received support by continuing contact with our research staff”.