BMJ 2010: 342:1 – 58 (1st January)

An absolute stack of useful points to start the year off.  The one that I found most important was that, in our rush to restrict prescription of NSAIDs, we may unknowingly have done more harm than good.  A study in the Archives of Internal Medicine found that, in the elderly, opioids are associated with the same risk of GI bleeding as NSAIDs (and that’s the non-selective NSAIDs), and a higher risk of cardiovascular events, fractures, hospitalisation due to side-effects, and death.  A second study compared the different types and found that codeine and oxycodone seemed to be the worst offenders for death rates.

That is, of course, quite worrying; in part because it suggests that the less harmful course of action in patients who need an analgesic stronger than paracetamol is the course of action we’re all being advised against, which puts us in an awkward prescription when it comes to prescribing.  You’ll notice I linked to both studies, which I don’t usually bother to do; in this case, I like the thought of having the references handy if I need them.

Of course, just to muddy the waters further, an editorial reminds us of the risks of being in too much of a rush to follow the latest study findings.  The topic in this case is the recent famous paper that found aspirin to be associated with a reduction in cancer rates without increasing overall mortality; a paper which, I smugly take the opportunity to remind y’all, I decided not to be in too much of a rush to act on in case later discussion and criticism revealed it to be founded on sand.  I’m glad of that, because this article pointed out that the actual reduction in cancer risk is 1 in 200 patients taking aspirin, and that the lack of increase in mortality may well have been skewed by the fact that three-quarters of the studies included in the meta-analysis were in patients at high risk for cardiovascular disease.  So, I shall continue to hold off on the aspirin for all.  As indeed, I did this very morning when a patient who frankly didn’t seem to me to be at that high a risk came to me having been advised by the cardiologists to take aspirin (and the ubiquitous statins) just in case – she was quite pleased when I told her it probably wasn’t worth it.

[Edited to add: Couple more since then, making me very glad I’d read that editorial and thus had some useful comments to offer.  One of the two decided not to go ahead with taking aspirin after I’d explained the above to him, and the other one did go ahead with it – but at least now I know he’s making a reasonably informed choice on the matter.]

So what else?  A couple of useful tips about diagnosis of rheumatoid arthritis – I look for the typical pattern of symmetrical polyarthritis of small joints of hands and feet, etc., and for heat/redness/visible swelling of joints.  But I need to be aware of the possibility that it might present as monoarthritis of a single large joint, which is apparently not all that rare; I should ask about generalised morning stiffness lasting over an hour and about systemic symptoms such as fatigue, fever, sweats and weight loss; and I need to palpate the joints for swelling that isn’t visible, as well as squeezing the MCP joints together and likewise the MTP joints, to check for tenderness.  Heat is only present sometimes and redness only occasionally.

If a woman who’s had axillary lymph node dissection for breast cancer comes to me asking whether she can weight train without risk of lymphoedema, I can reassure her that, yes, indeed she can – rates in such women who commenced a weight training programme over a period of 13 weeks were no higher than in women who hadn’t had breast cancer surgery.

I can also reassure parents who wish to give their children paracetamol but are concerned about the risk of liver injury.  As long as they stick to the recommended dose, the risk is negligible, according to a huge study in Pediatrics reported by Minerva.

I’m glad I took my supplements during pregnancy – supplementation of iron and folate during pregnancy is associated with an slight increase in cognitive performance in the children 7 – 9 years later, according to a study in JAMA reported in Short Cuts (though it is fair to point out that this was in women in rural Nepal, who may have been malnourished to start with, and we can’t assume it would have the same effect in a well-nourished population).  Zinc supplementation, however, cancels out the effect, possibly because of interference with the iron absorption.

Looks like we can dispense with the Omacor prescriptions.  Omega-3 fatty acids did not reduce the risk of major CV events in patients with a history of IHD or CVA in an RCT (the SU.FOL.OM3 trial).  Nor did B6, B12, or folate, for that matter.

Des Spence started a nice little debate with his recent claim that we should abandon grommet insertion and tonsillectomy in children.  In reply to the ENT surgeons who have rushed to argue their case, he cites research showing that the hearing improvement from grommet insertion does not appear to translate into better longer-term language skills than that obtained with watchful waiting, and that grommet surgery is associated with a 1% risk of cholesteatoma, as well as an increased risk of longer-term ‘tympanic membrane abnormalities and increased hearing thresholds’, and suggests temporary hearing aid use as a possible alternative.  He also defends his claim re. tonsillectomies, although this one he seems to have been basing more on theoretical grounds as to expected improvement levels and he didn’t really respond to a study cited by one of the ENT respondents that apparently did show increased quality of life for children following tonsillectomy compared to those who didn’t get it.  All very interesting, and not particularly relevant to my work as I won’t be called upon to make those decisions; but, if either of my children is ever having problems sufficient for grommet insertion and/or tonsillectomy to be suggested, I’ll make sure to track down these letters and check the research carefully for myself before signing on the dotted line.

Finally, a few points that are again not hugely useful to me in practice but that I found interesting:

If you’re going through IVF treatment and have got as far as getting two healthy embryos, don’t feel you have to have them both put back if you’re concerned about the prospect of twins; putting one back, freezing the other and putting that one back at a later date was associated with just as high a live birth rate as putting back both at once, and cut down on the risk of twins and all the associated problems (and, as fun as it may sound, there are a lot of potentially associated problems both medical and practical).

IUGR diagnosed in the last four weeks of pregnancy can probably be managed expectantly – outcomes for the babies of women randomised to monitoring were as good as those for the babies of women randomised to early induction, although the authors point out that the extremely low death rate either way makes it difficult to exclude higher mortality in one group or the other.

And what is the actual risk of an HIV-positive mother whose baby has been born HIV-negative infecting the baby if she breastfeeds?  8.3% over the first year if the mother’s infection is pre-existing (evenly spread throughout the year, so breastfeeding your baby from 11 months to a year presumably carries just as high a risk as breastfeeding her for the first month), but much higher if the woman acquires her HIV infection while breastfeeding, as the risk skyrockets in the early days of infection (before the tests turn positive, just to make life more complicated).


About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in BMJ, ENT, Impact, Medication, NSAIDs, Rheumatoid arthritis, Rheumatology. Bookmark the permalink.

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