Tom Nolan

In September, the UK started phasing out use of the live herpes zoster vaccine (Zostavax) to replace it with the recombinant vaccine Shingrix. Vaccination is also gradually being offered to younger people, eventually from the age of 60 years. A phase 3 randomised controlled trial of Shingrix had previously found an efficacy of 97% in adults aged 50 years and above, and a longer duration of protection than from the live vaccine, meaning it could be offered from a younger age.A new observational study of over two million people aged over 50 who have had the recombinant vaccine used diagnostic codes and antiviral prescriptions as a measure of shingles incidence. The results confirm the vaccine is effective—but with lower estimates than in the randomised trial: vaccine effectiveness was 79% a year after vaccination, dropping to 73% after three years.Ann Intern Med doi:10.7326/M23-2023The Lancet …

In September, the UK started phasing out use of the live herpes zoster vaccine (Zostavax) to replace it with the recombinant vaccine Shingrix. Vaccination is also gradually being offered to younger people, eventually from the age of 60 years. A phase 3 randomised controlled trial of Shingrix had previously found an efficacy of 97% in adults aged 50 years and above, and a longer duration of protection than from the live vaccine, meaning it could be offered from a younger age.

Most studies investigating weight loss and cancer use codes for unintended weight loss in the patient record to estimate the likelihood of a subsequent cancer diagnosis. As such, they don't tell us how much weight loss is significant: it could be 1%, 5%, or 10%, depending on all the various different factors swirling around in the consultation. A new analysis tries to help us put a number on it, reviewing weight data in two major cohort studies of US healthcare workers and seeing how often people get diagnosed with cancer within a year of weight loss being recorded. It found that those with weight loss of greater than 10% of their body weight had an incidence of 1362 cancer cases per 100 000 person-years, compared with 869 cancer cases per 100 000 person-years in those with no weight loss. Those who seemed to have lost weight unintentionally (according to lifestyle data) had a higher risk of a cancer diagnosis, with a relative risk of 1.23 in those with 5-10 kg weight loss, increasing to 1.98 in those with over 10 kg weight loss.

When the infamous adverts suggesting that e-cigarettes are “95% less harmful than cigarettes” appeared in 2015, it seemed to knock the stuffing out of smoking cessation services: why should soon to be bankrupt councils pay GPs and pharmacists to help people stop smoking when they could just buy a vape instead? Since then vapes have become a permanent presence in corner shops and school classrooms. But, despite their success as consumer products, vapes are still not licensed as smoking cessation aids. A clinical trial in China randomised people motivated to quit smoking to receive electronic cigarettes, varenicline, or nicotine chewing gum for 12 weeks with minimal behavioural support. E-cigarettes came out as non-inferior to varenicline—around 15% remaining abstinent from smoking after six months in these groups, compared with only 8.8% in the gum chewers.

Each year, respiratory syncytial virus (RSV) quietly sweeps through the world killing over 100 000 children. Somehow, it barely gets a mention in the news cycle, although that may soon change if countries launch RSV vaccination programmes. A meta-analysis sought to estimate the global burden of RSV disease and risk factors for both getting the infection and severe outcomes.

Does prescribing opioids in older people increase their risk of having a serious fall? A cohort study set in New South Wales, Australia, examined the medical records of over three million people to see if they were more likely to subsequently visit the emergency department. The risk of falls was greater in all age groups (over 18 years of age) within 28 days of opioid exposure, compared with the risk beyond 29 days of exposure. In older people the risk was over six times greater (95% confidence interval of the adjusted incident rate ratio 6.20 to 6.51). However, researchers weren't able to adjust for the indication for opioid prescribing, meaning it's not clear how much the increase in falls risk is due to the opioid prescription and how much to the pain or injury that prompted it.

One of the many terrifying aspects of our healthcare system that we seem to be quietly accepting of is ambulance response times. In England in December 2023 the median response time for a category 2 emergency call—which includes stroke calls—was 45 minutes, compared with a target of 18 minutes. Of the callouts, 10% had a wait time of 1 hour 40 minutes or longer. For those unlucky people who are waiting this long and have had a stroke amenable to intravenous thrombolysis (IVT) followed by thrombectomy, the time for any added benefit from IVT and thrombectomy versus thrombectomy alone is nearly up before the ambulance arrives, according to a new meta-analysis. The study looked at individual patient data from six randomised control trials, assessing levels of disability at 90 days. Benefits of IVT plus thrombectomy versus thrombectomy alone were greater the sooner after symptom onset that treatment was received, and by 2 hours 20 minutes no statistically significant difference between the two interventions was found.

The new series of Gladiators is nearly over, although I didn't get past the first episode (I've added it to my long list of things that aren't as appealing in your 40s as they were as a teenager). The original television series from the 1990s was marred by drug controversy, and one of the stars of the new series has admitted to taking anabolic steroids in the past. With a generation of children wondering how to get bodies that look like a Gladiator's, an observational study that found an increase in mortality among males sanctioned for androgenic anabolic steroid (AAS) use seems topical. A total of 1189 males who tested positive for AAS from drugs testing at fitness centres in Denmark were each matched to 50 people of the same age. Of the 1189, 33 died over the median 11 year follow-up period—a death rate nearly three times higher than that of the controls (hazard ratio 2.81 (95% confidence interval 1.98 to 3.99)).

The Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP) study has just reported 15-year mortality findings. Between 2002 and 2009 over 400 000 men aged 50-69 years in England and Wales were either sent an invitation for prostate cancer screening or had no intervention. Those who took up the offer of screening were referred on for diagnostic testing if their PSA level was ≥3 ng/mL. Those offered screening had a 0.69% risk of dying from prostate cancer after 15 years, compared with 0.78% in those not offered screening. There was no difference in all-cause mortality between the two groups. However, it's hard to know how these findings relate to current practice. Over the 20 years or more since this study started much has changed: referral thresholds, diagnostic techniques, and treatment options.

The market for continuous glucose monitoring (CGM) devices now goes well beyond just being used for people with diabetes. They're advertised as a means of getting a “deeper understanding” of your body and getting to the “root cause” of health problems. Dubious claims aside, a study in Nature Medicine highlights the need for clarity on how to interpret fasting glucose levels in people with no prior diagnosis of diabetes who are using CGM devices. Of the 5328 people in the study using CGM whose first fasting glucose level was normal, 40% had fasting glucose levels in the prediabetic range in subsequent measurements, and 3% had subsequent measurements in the diabetes range. Should this be welcomed as an advance in diagnostic accuracy, or is it a new frontier in overdiagnosis?