Journals Watch - Bell's palsy, flu and menopause

Too busy to read all the journals? Let Dr Sally Hope keep you up to date with the latest research.

Combined treatment for Bell's palsy - JAMA 2009; 302(9): 985-93
It is always helpful to have a meta-analysis for Bell's palsy treatments, because the received wisdom has swung from steroids to nothing to steroids and/or antivirals again during my professional career.

With an incidence of 20-30 per 100,000 a year the average GP practice will have two or three new cases each year.

Eighteen trials involving 2,786 patients were analysed. Corticosteroids alone were associated with a 'reduced risk of unsatisfactory recovery' (relative risk (RR), 0.69 (95% CI, 0.55-0.87); P=0.001) (NNT=11 (95% CI, 8-25)).

Antivirals alone (aciclovir, high dosage) were no good, but when antivirals and corticosteroids were given together it had a greater benefit, compared with corticosteroids alone (RR, 0.75 (95% CI, 0.56-1.00); P = 0.05).

If seen early, it is best to give prednisolone 20mg six-hourly for five days, reducing to stop over the next five days, and a week's high dosage antivirals (for example, aciclovir 800mg five times daily).

In general, Bell's palsy follows the rule of thirds: one-third have complete recovery by four months, one-third have incomplete recovery but no noticeable abnormality and one-third have permanent damage.

Influenza vaccine in US nurses - Am J Infection Control 2009; 37: 551-6
In the lull before the storm of the swine flu pandemic, it is interesting to read this paper on 2,000 US nurses' attitudes to influenza vaccination, even though it was a postal questionnaire from 2006.

Some 59 per cent of respondents (72 per cent response rate) had been vaccinated. The most common reason for not being vaccinated (nearly 40 per cent) was concern about adverse reactions. Only 18 per cent felt that the vaccine may not be effective and 17 per cent said they forgot.

Major reasons given by nurses who had the vaccine were to protect themselves (95 per cent) and their patients (74 per cent).

The most interesting finding was that over half the unvaccinated nurses agreed that the benefits of a flu vaccine outweighed the risks, and yet they still lacked the motivation to have the vaccine, which was freely available for them at work.

In a pandemic we need the health professionals to stay well, or the whole system will collapse within days. It is suggested that to improve US nurse uptake of yearly flu jabs, clear data on effectiveness of the vaccine and adverse event statistics should be made available.

Genotype and clinical efficacy of clopidogrel - JAMA 2009; 302(8): 849-57
As clopidogrel is a pro-drug there are some people in whom it is not metabolised to have an inhibiting adenosine diphosphate (ADP)-dependent platelet activation effect.

This paper on 429 members of the Amish community looked at platelet response to clopidogrel. Thirteen single-nucleotide polymorphisms were associated with diminished clopidogrel response. The rs12777823 polymorphism was in strong linkage disequilibrium with the CYP2C19*2 variant, and was associated with diminished clopidogrel response, accounting for 12 per cent of the variation in platelet aggregation to ADP.

Patients with the CYP2C19*2 variant were more likely (20.9 per cent vs 10 per cent) to have a cardiovascular ischaemic event or death during one year of follow up. So this has life or death implications.

At present in general practice we cannot identify cytochrome genotype but I think this paper is evidence that if our patients post-stenting have further problems while taking clopidogrel it is important to rethink their medication options.

Roflumilast in symptomatic COPD - Lancet 2009; 374: 685-94
Roflumilast is a phosphodiesterase-4 inhibitor that can improve lung function and prevent exacerbations in certain patients with COPD.

In two drug-company sponsored, placebo-controlled, double-blind, multicentre trials in two different populations in an outpatient setting, patients with COPD older than 40 years, with severe airflow limitation, bronchitic symptoms and a history of exacerbations were randomly assigned to oral roflumilast (500 milligrams once per day) or placebo for 52 weeks.

In a pooled analysis, prebronchodilator FEV1 increased by 48ml with roflumilast compared with placebo (p<0.0001).

The rate of exacerbations that were moderate or severe per patient per year was reduced by 17 per cent by the active drug: 1.14 with roflumilast against 1.37 with placebo.

However, active drugs tend to have active side-effects: nausea, diarrhoea and weight loss were frequent in the treatment groups causing patient withdrawal from the trial. This new drug needs larger trials to see its true potential use clinically.

The WHO estimates that 210 million people worldwide have COPD.

Clearly efforts to assist people to stop smoking must be a priority, as well as educating the young not to start.

Testing ovarian reserve - Maturitas 2009; 63: 280-91
GPs are often asked by anxious women in their mid-30s to mid-40s about their chances of becoming pregnant if and when they find a life partner.

From the age of 31 onward, there is a decreasing primordial follicle pool leading to reduced fertility and the start of menstrual irregularities going on to the menopause when the ovaries become 'empty' (number of follicles <1,000).

Predicting the age of menopause with ovarian reserve tests may help inform younger women about their biological potential.

Some attempts at direct ovarian biopsy have been published, but follicle density varies within the cortex, so a biopsy is a completely unreliable estimate of overall ovarian content.

A raised follicle-stimulating hormone (FSH) is an 'irrefutable hallmark of reproductive aging', but levels only rise 10 years before the menopause when infertility is already occurring, so it is useless as an early predictor.

The authors evaluate the evidence for measuring estradiol, progesterone, LH, inhibin B, anti-mullerian hormone, changes in cycle pattern, ovarian stromal blood flow, ovarian volume and antral follicle count by transvaginal ultrasound.

However, there is such variability between patients that the authors conclude that 'none of the parameters has been shown to be predictive in individual women ... we cannot tell a woman with sufficient reliability when her final menstrual period will occur'.

The best predictive tests were an accurate family history of any premature menopause in mother or sisters, and the women's own age.

  • Dr Hope is a GP in Woodstock, Oxfordshire, and honorary research fellow in women's health, department of primary healthcare, University of Oxford and a member of our team who regularly review the journals.

The Quick Study

  • Bell's palsy is best treated with immediate high dose steroids together with high dose antivirals.
  • Flu vaccination was refused by more than 40 per cent of US nurses in 2006. The main reason was concern over side-effects.
  • Clopidogrel response is reduced in patients with the CYP2C19*2 genotype and associated with poorer cardiovascular outcomes.
  • Roflumilast can improve lung function and prevent exacerbations in certain patients with COPD.
  • Ovarian reserve test to predict age at the menopause at present are a waste of money.

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