BMJ 2010: 314: 1171 – 1226 (4th December)

Not much for me in the research studies this week. About the only possibly useful point was that the people who think measuring BMI in children isn’t helpful may be wrong, at least in 9 – 12-year-olds, in whom it correlates with cardiovascular risk factors at age 16. There are various potential flaws in this that I can think of but can’t get my brain together well enough to write an articulate sentence about with ‘Ben 10 Alien Force’ playing in the background (such is the life of parents trying to keep up with their CPD), so I’ll just leave that one in the ‘Skeptical’ category for now.

However, other journals seem to be making up the shortfall, judging from the Short Cuts page:

Is it OK to give pregnant women PPIs for their reflux? Almost certainly, although with a slight question mark over Lansoprazole.

We know exercise is even more important for people with diabetics than for the rest of the population, but should it be aerobic or resistance? Both of the above, it appears – a mixture of the two produced slightly better glycaemic control than either separately.

One of the biggest problems for obese people is how to keep the weight off after losing it. It seems their best bet, diet-wise, is a high-protein, low GI diet.

And, despite the regular LFTs we’re expected to perform in all patients on statins, there is no good evidence that they cause serious or lasting harm to the liver. What this means in practice is that it’s probably OK to prescribe statins to people who have moderately abnormal LFTs.

This issue also has some useful review articles. Oesophageal cancer, for one. I was vaguely aware that there were different histological types, but hadn’t realised that the risk factors are completely different. Smokers and boozers are increasing their risk of squamous cell oesophageal carcinoma; obese people with reflux get the adenocarcinoma variety. (Men are much more at risk of both than women.) Interestingly, Helicobacter infection decreases the risk of oesophageal adenocarcinoma by about half, which raises the question of whether we should discuss this with patients before eradicating it. To keep it in perspective, though, the absolute risk of developing oesophageal adenocarcinoma as a result of eradicating your H. pylori is somewhere in the range of one in a thousand (though obviously that’s an average and will be quite a bit higher if you’re an obese man with reflux and quite a bit lower if you’re a normal-weight woman without.) Another interesting point is that regular aspirin or NSAIDs may decrease the risk by about 35%, though I’m not sure how well the studies involved corrected for the rather obvious potential confounder there. Ditto the above about very low absolute risk reduction, so not really worth the increased risk of all the things NSAIDs increase your risk of.

The latest gospel among GPs, which I preach as enthusiastically as anyone, is that getting ill people back to work is better for their long-term health. However, it seems there is surprisingly little hard, non-confounded evidence for this. Since it seems intuitively correct and there doesn’t seem any evidence against it either, I suppose I’ll go on keeping this as my aim, but with an uneasy background feeling that I may be doing so as much out of principle and economic expediency as evidence-based medicine.

A few days ago I saw a woman about her mild memory problems and advised her on how to preserve her memory function as best as possible. If she were to come to see me now, I could give her some extra advice; Vitamin D. Dietary intake of 35 mcg or more per week was associated with cognitive problems in a Neurology paper mentioned by Minerva.

And a useful review article on gout. I thought podagra was some sort of B-vitamin deficiency, but I was, of course, confusing it with pellagra; podagra is gout presenting in the classic first MTP joint. When making that often-tough call on whether this is gout or septic arthritis, speed of onset can be helpful – a time of 6 – 12 hours from onset to maximal pain/swelling/tenderness is highly suggestive of crystal arthropathy (which, of course, covers other things apart from gout, but makes septic arthritis usefully unlikely). If that’s not enough, then turn to Janssen’s clinical prediction rule.

When it comes to deciding what to do about it, the batting order of preference, all else being equal, seems to be NSAIDs as first choice, colchicine as second choice, and steroids third choice. This is based on speed of effectiveness and likelihood of SEs. The recommended dose of colchicine is two 0.6 mg tablets taken together, a third an hour later, and one tablet three times daily after that. For Prednisolone, it’s 20 to 40 mg daily for three days tapered off over a further fortnight. NSAIDs are simply given at the maximum dose.

Don’t forget non-medical interventions, either – ice packs, rest, and elevation of the affected part can all help. Also, advise the patient to drink up to two litres of water per day and reduce alcohol intake. There are also lifestyle interventions that can reduce the risk of recurrence – weight loss, reduction of meat or fish intake (try cutting down by one portion per day), drinking wine instead of beer, and drinking one glass of skimmed milk daily.

Edited to add: Just had a patient in with gout, so managed to give him lots of useful lifestyle advice thanks to this.  Though I did edit the bit where I accidentally managed to write that patients should drink wine instead of bear.