BMJ 2011; 342: 237 – 288 (29th January)

The main articles were on preventing exacerbations of COPD, and on joint hypermobility syndrome .

Preventing exacerbations of COPD

Pulmonary rehabilitation: Was near the bottom of the list but deserved to be moved up, as evidence shows it to be a ‘highly effective and safe’ method of decreasing frequency of hospital admission, not to mention decreasing mortality and increasing health-related quality of life.  I’ll have to bear it in mind as an option for patients much more often.  (I’m not clear on whether it does anything for overall frequency of exacerbations, though.)

Tiotropium: Reduces exacerbations more effectively than placebo or ipratropium.  (Edited to add: According to a study in the Lancet, mentioned in ‘Short Cuts’ in the April 2nd BMJ, it’s also more effective than salmeterol.)

LABAs: Salmeterol slightly reduces risk of exacerbations (NNT 24)

ICS: Moderate reduction in risk of exacerbations if used in patients with FEV1 <50% predicted.  Unhelpful in other cases.  Increases the risk of pneumonia, which always confuses me as surely pneumonia is a type of COPD exacerbation?  Interestingly, adding an ICS to a LABA marginally reduces the risk of moderate exacerbations (needing antibiotics and/or oral steroids), but not of severe exacerbations (needing hospitalisation).

Triple therapy: i.e. all three of the above.  Not enough evidence to say whether it works any better than just having two of the above, although in practice seems a fair bet we’d try it anyway.

Mucolytics: Marginal effect on frequency of exacerbations, and some doubt as to whether they have any further beneficial effect in patients who are using an ICS already.

Vaccination: Influenza vaccination does help reduce numbers of exacerbations, but pneumococcal doesn’t – or, at least, doesn’t have any benefit on morbidity or mortality.  (So why are we giving it, then?)

LTOT: Although it improves survival and is worth having in appropriate cases, it does not appear to improve the frequency of exacerbations.

Patient education: May reduce admissions, but really not a lot of information about whether it’s helpful or not (although it usually seems to make patients feel better about the situation generally, so I’m all in favour of it personally).

Nurse led disease management programmes: Some contradictory evidence as to whether they’re helpful or not, though some of the evidence certainly looks promising.

Joint hypermobility syndrome

This underrecognised problem is a possible and easily missed cause of chronic joint/muscular problems.  Scored via the Beighton score and diagnosed by use of the Brighton diagnostic criteria (which incorporate the Beighton score) as there are no investigations for it.  Symptoms include recurrent dislocations, joint/soft tissue pain on minor trauma, increase in pain, and reduction in mobility, but also several problems you might not expect.  The collagen changes in the bowel can cause sluggish bowel habits, bloating, rectal evacuatory dysfunction, and rectal prolapse.  Other problems include genital prolapse, hernias, and varicose veins, due to the general laxity of the supporting tissues.

Treatment includes referral to physiotherapy, to podiatry if there are foot problems (for mechanical foot assessment and tailor-made orthotics), and to an occupational therapist if there are hand problems.  The physiotherapy is to work on core and joint stabilising, proprioception, and general fitness training to reverse the body’s tendency to lose condition, as well as to mobilise joints that have lost mobility due to kinesiophobia.

And in other news

A strike against the polypill – a Cochrane review of statins for primary prevention in people at low cardiovascular risk found that relative risk reduction was about 17%, but confidence intervals were wide and there were problems with selective reporting.  Overall, absolute benefit is likely to be very small.  No shit, Sherlock.

And CBT for sleep problems is likely to be more effective if given face-to-face rather than as written information.  An hour’s consultation with a trained NP, followed by a shorter follow-up visit and a couple of phone calls, was effective in about two-thirds of patients, compared to written information and a ten-minute phone call, which only worked in about a quarter of patients.


About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in COPD, Psychiatry, Rheumatology. Bookmark the permalink.

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