Clean break

Fragility fractures are often linked to osteoporosis. NICE has just opened consultation on draft guidance to assess the risk of fragility fractures in adults. Responses are due in by 8 March. There's a comparison of UK case-finding strategies for management of hip fractures in the latest issue of Osteoporosis International, looking at the Royal College of Physicians strategy and the newer National Osteoporosis Guideline Group approach. Some more detail is provided on the SCOOP trial of community based screening for osteoporosis. Finally, Value in Health offers a systematic review of cost-effectiveness in strategies for selecting and treating people at risk of osteoporosis and osteopenia.

It's a mystery

Or, it's difficult to see how C diff spreads in hospital wards, as NHS Choices Behind the Headlines put it. The study from the John Radcliffe Hospital in Oxford considered ward-based transmission of Clostridium difficile, finding that contact with infected patients is not the main cause of new cases in hospital.

Venn diagram

The overlap between long term conditions relating to physical health and mental health conditions is substantial. According to a report from the King's Fund and the Mental Health Foundation, over a third of people in England with a physical long term condition also have mental health problems; on the flipside, nearly half of people in England with a mental health problem also have a long term physical health condition. Either way, this amounts to something like 4.6 million people and between £8 billion and £13 billion per year in healthcare spending. The report argues that we could do better and that the main route to improvement is through integration. Doing nothing to address the emotional and mental health problems attendant on long term conditions risks the ability of people to manage their physical health. A study from the US looks at how to improve medical adherence amongst people in primary care with co-morbid long term physical and mental conditions (diabetes, coronary heart disease and depression). An analysis of results from the CO-MED trial focuses on depression treatment in patients with general medical conditions. A Cochrane systematic review of self monitoring of blood glucose for people with type 2 diabetes finds this has limited effect on glycaemic control in patients not using insulin. A study underway in Australia, Diabetes MILES, assesses the psychological aspects of living with diabetes: an early publication examines the methods and sample characteristics.

Keep up

There's a raft of evaluations and monitoring reports for active travel programmes, including the I Bike project in Scotland, the Living Streets community walking programme and the Travel Actively projects. A study of urban, multi-ethnic school children considers the association of active travel to school with general physical activity levels. Do "use the stairs" notices work, asks a team from the New York City Department of Health and Mental Hygiene. This study examined the effectiveness of a prompt ("burn calories, not electricity") across a range of different sized buildings and found an immediate increase in stair climbing, which was also maintained after 9 months. An analysis of the Aerobics Center Longitudinal Study adds a little more to the sum of knowledge about the dynamic relationship between fitness, overweight and cardiovascular health. Exercise on prescription schemes are examined in a systematic review and meta-analysis and are found to be of uncertain value in increasing physical activity, fitness and other health outcomes. A cost effectiveness study also suggested that exercise referral schemes only delivered a "modest increase in lifetime costs and benefits."

Lies, damned lies ...

Widely reported in the press was a study by a team at Oxford University's Department of Public Health that revealed a significant improvement in heart attack mortality over the past 10 years. This was a huge study, using HES data, but although the headline numbers tell a clear story, the reasons behind them are less evident. The study shows both a reduction in heart attacks and a rise in survival from attacks; the fall in heart attacks may well be attributable to improvements in lifestyle, detection and management, but as usual further study is needed. Another day, another set of data: the fourth annual national heart failure audit reports relatively poor outcomes, with high mortality rates, particularly amongst patients not admitted to cardiology wards. In-hospital mortality rates for patients admitted to cardiology wards were less than half those for patients admitted to other wards (8% for cardiology ward patients, 15% for general wards and 17% for other wards). Less than half of all patients with acute heart failure were admitted to cardiology wards. Finally, for the cynics, a paper in BMC Public Health considers the question of how to measure and analyse this kind of data, taking US decline in coronary heart disease as a case study.

No smoke ...

A study questioning the efficacy of nicotine replacement therapy (NRT) gained the attention of the press. The prospective cohort study carried out by the Harvard School of Public Health looked at relapse rates for quitters, finding that "persons who have quit smoking relapsed at equivalent rates, whether or not they used NRT to help them in their quit attempts". According to the study's authors, NRT is wrongly perceived to help with quitting, rather than simply withdrawal symptoms. A meta-analysis of varenicline for smoking cessation considered 10 trials, finding the treatment effective over 52 weeks, although with the caveat that psychiatric adverse effects merited caution as regards people with pre-existing mental illnesses.

Croydon strikes again

Low clinical priority procedures (aka those that appear on the Croydon list) returned to the top of the pile briefly at the end of last year as the Right Care elective surgery project released its phase 1 report. The programme was prompted by an earlier Audit Commission study on reducing spending on low clinical priority procedures. The government took to heart the recommendation that national guidance be developed. However, critics (amongst which was the Federation of Surgical Specialty Associations - FSSA) have argued that the evidence base for this kind of decision-making is poor and that it doesn't sit at all well with the patient choice agenda. Hence the Right Care project, which involved the FSSA. Initial themes from the project include guarded support for national guidance, the suggestion that, since the current terms of art are unhelpful, "there should be a change in terminology to reflect a more holistic approach" and that blanket bans and resultant postcode lotteries should be avoided. A briefing from solicitors Mills and Reeve looks at the legal issues behind decisions about restricting access to low priority procedures.