Journals Watch - Bacterial meningitis and cough

Too busy to read all the journals? Let Dr Raj Thakkar keep you up to date on all the latest research.

Corticosteroid outcomes for acute bacterial meningitis Mayo Clin Proc 2009; 84: 403-9
Acute bacterial meningitis is a rare but serious condition with potentially life-threatening sequelae.

MRI

Once meningitis is suspected, swift administration of parenteral penicillin and transfer to an acute facility is crucial. But, should we be administering corticosteroids as well?

This meta-analysis looked at four studies comprising 1,261 adult patients. Corticosteroid administration, in the short term, was not found to offer any mortality benefit in lower-income countries, perhaps related to the higher prevalence of HIV.

However, in higher-income countries where the prevalence of HIV was low, the administration of corticosteroids reduced short-term mortality compared with placebo (pooled relative risk 0.5 (CI 0.27-0.92)).

The NNT in high-income countries to prevent one death was 12.5 and to prevent one adverse neurological outcome was 11.0.

Schizophrenia, substance abuse and violent crime JAMA 2009; 301: 2,016-23
A number of high-profile media cases have led the public to believe that patients with schizophrenia often commit violent crimes. Some studies quote risks of up to six-fold compared with the general population.

This Swedish study aimed to establish the risk of violence among schizophrenic patients and how substance abuse influences this risk.

More than 8,000 patients were followed up in this longitudinal case-control study.

One or more violent crimes were committed by 13.2 per cent of schizophrenic patients compared with 5.3 per cent of the controls. Most of those committing crimes were under the influence of substances.

The adjusted odds ratio for schizophrenics to commit a crime was 1.2 (CI 1.1-1.4) without substance abuse and 4.4 (CI 3.9-5.0) with abuse. Interestingly, violence in schizophrenics using substances who had unaffected siblings was lower than expected (OR 1.8, CI 1.4-2.4), implying genetic or environmental factors are at work.

It is clear that the control of substance misuse, particularly in mental health patients, is crucial in preventing serious crime.

Spontaneous pneumomediastinum Mayo Clin Proc 2009; 84: 417-21
This study reviewed 62 adult cases of pneumomediastinum, aiming to understand the way in which the condition presents.

A total of 41 men and 21 women were included; 63 per cent of patients presented with chest pain, 45 per cent with cough and 44 per cent with breathlessness.

Less than half the patients (44 per cent) had a pre-existing lung condition. Overall, 84 per cent of diagnoses were made on a plain chest X-ray and the remaining 16 per cent on a CT scan.

Interestingly, nearly half the patients underwent unnecessary invasive GI diagnostic procedures. A third of patients were also found to have a pneumothorax. Patients stayed in hospital an average of 2.5 days.

This study raises awareness of pneumomediastinum in breathless patients with cough and chest pain.

The effect of cigarette smoking on the risk of CHD Heart 2009; 95: 909-16
Smoking undoubtedly confers an adverse cardiovascular risk, but does smoking increase the attributable risk of high lipid levels on CHD and stroke?

This review of 34 cohort studies aimed to address the interaction between smoking and lipid levels in patients from the Asia-Pacific region.

Patients were followed up for four years. During that period, 3,298 coronary events and 4,318 strokes were documented. The researchers found the risk of CHD was significantly higher for a 1.06mmol/l increase in total cholesterol in smokers compared with the non-smoking group.

In addition, the risk was greater in smokers for a 0.4mmol/l reduction in HDL concentration. No such pattern was noted for strokes.

The researches concluded that smoking increases the risk of cardiovascular disease, more so than in non-smokers, for a given increase in total cholesterol or reduction in HDL.

This data may help us persuade our pre-contemplating smokers to give up the habit and reduce the cardiovascular disease burden even further.

Rate versus rhythm control in patients with chronic AF Heart 2009; 95: 924-30
One debate we have with patients with AF is whether to attempt to restore sinus rhythm or merely control rate.

This study aimed to assess whether patients with persistent AF and coexisting left ventricular systolic dysfunction would benefit from cardioversion to sinus rhythm. Outcome measures included cardiac function, symptoms, exercise capacity and quality of life.

Patients were randomised to rhythm control with amiodarone and biphasic external cardioversion if required, or rate control. All patients were warfarinised and given beta-blockers or digoxin to control ventricular rate, if required.

Of the rhythm control group, two thirds were in sinus rhythm at one year, whereas 90 per cent of those in the rate control group were controlled at the appropriate ventricular rate at one year.

After one year, both groups had similar NYHA class and exercise capacity. Rhythm control patients, however, had improved left ventricular function and reduced N-terminal-proBNP at one year. This effect was particularly seen in those who remained in sinus rhythm.

This information should help guide us when deciding whether to rate or rhythm control our patients in AF.

Sex differences and cough frequency Thorax 2009; 64: 393-8
This interesting but small study looked at factors that may explain why female gender is associated with higher rates of chronic cough.

A total of 65 women and 35 men with chronic cough of unknown aetiology were followed up over a four-year period. A number of tests were carried out including flow-volume loops, citric acid cough reflex sensitivity, methacholine challenge and a cough questionnaire. Of the patients, 86 also wore a 24-hour ambulatory cough monitor.

The researchers found women did indeed cough more than men: 16.6 coughs per hour versus 9.4. Women also had a more sensitive cough reflex than men.

These results should be taken into account when managing what is sometimes a very difficult condition to treat.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review journals.

The quick study

  • Acute bacterial meningitis had a lower risk of mortality in high-income countries when corticosteroids were given with antibiotics.
  • Schizophrenic patients were more likely to commit a violent crime when under the influence of substances.
  • Pneumomediastinum should be considered as a diagnosis for patients with chest pain, cough and dyspnoea.
  • Smoking increases the risk of CHD for a given increase in total cholesterol or reduction in HDL.
  • Rate and rhythm control proved beneficial for patients with AF.
  • Cough occurs more frequently in women and they also have a more sensitive cough reflex.

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