How low to go in AF Am Heart J 2009; 158: 785-91
This was a post hoc analysis of the data from the Rate Control versus Electrical Cardioversion for Persistent AF study. The authors looked at the patients who were randomised to rate control and then divided them up into those whose resting pulses were below 80bpm and those who were above 80bpm.
The two groups had average heart rates of 72 and 90, achieved with similar drug regimens.
At the end of follow up after 2.3 years there were similar end points between the two groups (coronary heart disease, digoxin use and interrupted anticoagulation use). The quality of life was the same between the two groups.
It seems from this we do not need to be too stringent about absolute rate control.
Smoking is under-reported in pregnant women BMJ 2009; 339: b4347
Smoking during pregnancy is still relatively common despite the well-established dangers.
In Scotland, the percentage of women estimated to smoke during pregnancy varies acording to deprivation, with an alarming 38 per cent of the most deprived women smoking during pregnancy and a surprising 8 per cent of the least deprived.
In practice, smoking levels are determined by self-reporting to the midwife. Obviously some women may not be entirely truthful regarding their smoking status, which means they miss out on potential smoking cessation therapy.
In this study, the authors compared cotinine levels from a maternal blood sample against declared smoking status. They found the actual level of smoking was 25 per cent higher than the self-reported level.
A greater proportion of women in more affluent areas did not report their smoking compared with women in the most deprived areas. However, because of the higher level of smoking in deprived areas in general, the authors suspect that twice as many women in deprived areas have gone un-detected.
Overall, 2,400 smokers a year in Scotland are missed.
Rituximab used to delay diabetes N Engl J Med 2009; 361: 2143-53
Type-1 diabetes is caused by the autoimmune destruction of beta-cells in the pancreas. Typically there is some residual beta-cell function at diagnosis.
If the autoimmune process could be halted at diagnosis, this would allow endogenous insulin production to be maintained, which is known to reduce long-term complications.
This autoimmune process is associated with T-lymphocytes, but there is thought to be a B-lymphocyte component. B-lymphocytes are selectively depleted by the anti-CD20 monoclonal antibody rituximab.
In this randomised controlled double blind study, newly diagnosed type-1 patients with identified diabetes were given four infusions of rituximab.
Over the next year they had lower levels of glycated haemoglobin, required less insulin and had higher levels of C peptide (the measurable proxy marker for circulating endogenous insulin, created when proinsulin is split into insulin and C peptide).
While this is not a definitive treatment, it is an exciting new direction that could make a huge difference to patients' lives.
Inappropriate sexual behaviour J Am Geriatr Soc 2009; 57: 2161-2
This relates to only a small series of patients, but is interesting given the latest furore about controlling dementia patients.
A total of 11 patients with vascular dementia who exhibited inappropriate sexual behaviour and had benign prostatic hypertrophy were given finasteride 5mg a day for 12 weeks.
This drug inhibits the metabolism of testosterone and has known side-effects of low libido, and ejaculatory and erectile dysfunction.
Symptoms of inappropriate sexual behaviour included sexual remarks, exposing genitalia, fondling female staff or public masturbation. Six of the 11 patients had their behaviour controlled within eight weeks.
Two patients had a recurrence on stopping the drug at 12 weeks, which resolved on continuation of the finasteride.
Given that this behaviour can be a huge problem for carers or fellow residents, this is certainly a treatment to consider.
Inspiratory muscle training in heart failure Am Heart J 2009; 158: 768e1-e7
We are all well versed in the benefits of pulmonary rehabilitation, in particular the strengthening exercises that improve breathing. This small study indicates there might be an equivalent for chronic heart failure.
Patients with chronic heart failure and inspiratory muscle weakness were studied. Some subjects were randomised to perform aerobic exercises and the others to perform aerobic exercises and inspiratory muscle training.
They found significant improvements in multiple respiratory and oxygen parameters in the muscle training group. This could lead to another beneficial service to our chronic disease patients.
Fatigue post surgery Br J Surg 2009; 96: 1253-61
Postoperative fatigue is common after colonic surgery, delaying normal recovery. Research has indicated that local peritoneal inflammation may influence the development of fatigue via the neuroimmunohumoral axis and has found a correlation between levels of peritoneal cytokines and fatigue scores.
This was a double-blind randomised controlled study in which the intervention group received 8mg dexamethasone IV before surgery. The patients in the intervention group had significantly lower fatigue scores on days three and seven and correspondingly lower peritoneal interleukin levels, with no increase in adverse events.
Hopefully this trial may lead to a larger evaluation.
- Dr Hunter is a GP in Bishops Waltham, Hampshire and a member of our team who regularly review the journals
The quick study
- Average heart rates of 72 and 90 bpm both offered similar quality of life for the patient.
- Smoking in pregnant women is 25 per cent higher than the self-reported level.
- Onset of type-1 diabetes could be delayed by the use of rituximab.
- Finasteride might reduce inappropriate sexual behaviour in vascular dementia patients.
- Inspiratory muscle training coupled with aerobic exercise improves cardiorespiratory responses in patients with chronic heart failure.
- Postoperative fatigue is reduced by administering preoperative dexamethasone.