Journals Watch - Caesareans, HIV and aspirin

Not had time to read the journals? Let Dr Louise Newson bring you up to date on the latest research.

The likelihood of psychopathological issues was lowest in children born by elective caesarean delivery (Photograph: SPL)
The likelihood of psychopathological issues was lowest in children born by elective caesarean delivery (Photograph: SPL)

Elective caesarean sections result in children with fewer psychological problems
BJOG 2011; 118: 42-8

The number of women in the UK choosing to have an elective caesarean section has risen over the past decade. This retrospective cohort study from China looked at more than 4,100 pre-school children who had been assessed using the child behaviour checklist, which measures emotional and behavioural problems.

Any differences in their scores were analysed among children who had been born by elective caesarean section, assisted vaginal delivery and spontaneous vaginal delivery. Their results showed statistically significant differences.

The likelihood of childhood psychopathological problems was found to be the lowest in children born by elective caesarean delivery, followed by those born by spontaneous vaginal delivery. The highest probability of childhood psychopathological problems was observed in those born by assisted vaginal delivery.

Pre-exposure treatment for HIV prevention in those at risk
N Engl J Med 2010; 363: 2587-99

Although the prognosis for those who are HIV positive has improved dramatically, measures to reduce transmission of the virus are of paramount importance.

In this study, nearly 2,500 HIV seronegative men or transgender women who were sexually active with men were randomly chosen to receive a combination of two oral antiretroviral drugs, emtricitabine and tenofovir disoproxil fumarate, or placebo once daily.

These people were then followed for an average of 1.2 years. The results were that 10 people were found to have been infected with HIV at enrolment, and 100 became infected during follow-up (36 in the treatment group and 64 in the placebo group). This equates to a 44 per cent reduction in the incidence of HIV.

Although nausea was reported more frequently during the first four weeks in the treatment group these results are very promising. Giving antiretrovirals can therefore reduce transmission of HIV infection in high risk groups.

Treatments for children with gastro-oesophageal reflux
Arch Dis Child 2011; 96: 9-13

PPIs are one of the treatment options for children with gastro-oesophageal reflux disease. This study evaluated the effects of three treatment strategies after eight weeks of lansoprazole therapy on gastro-oesophageal reflux disease in children.

The patients were divided into three groups by symptom assessment. The first group was observed without treatment in the 'symptoms-resolved' group, the second had on-demand treatment for an additional 16 weeks in the 'symptoms-attenuated' group and the final group received continuous treatment in the 'symptoms-persistent' group.

The results showed that all patients in the 'symptoms-resolved' group remained improved at weeks 16 and 24.

The vast majority of patients (81.8 per cent) in the 'symptoms-attenuated' group had improvement of symptoms at 24 weeks. A total of 66.7 per cent of the patients in the final group also remained improved at 24 weeks.

This study demonstrates that it is worthwhile giving different treatments depending upon the assessment of symptoms after eight weeks of treatment with lansoprazole.

Clopidrogel and aspirin after coronary artery surgery
Circulation 2010; 122: 2680-87

The majority of my patients are given clopidogrel with aspirin after coronary artery bypass surgery. Clopidogrel is given because it inhibits intimal hyperplasia in animal studies and it is therefore thought that it may reduce saphenous vein graft intimal hyperplasia after coronary artery bypass grafting.

In this double-blind study, 113 patients undergoing coronary artery bypass grafting were randomised to receive aspirin plus clopidogrel daily or aspirin plus placebo daily for one year.

At one year, saphenous vein graft intimal area did not differ significantly between the two groups and the incidence of bleeding in both groups was also similar. This suggests that these patients do not benefit from receiving both treatments.

Cardiovascular risks of snow shovelling
Am J Emerg Med 2011; 29: 11-17

This US study analysed the diagnoses given to patients attending A&E with snow-shovelling complaints over a 17-year period. Results indicated that snow shovelling may precipitate adverse cardiac events, especially among men aged 55 years or older.

This is likely to be due to the extra demands it places on the cardiovascular system. Freezing temperatures also increase cardiac workload by causing peripheral vasoconstriction and increasing blood viscosity.

Patients aged at least 55 years had at least a fourfold greater risk for developing cardiac-related symptoms while shovelling snow than those under 55 years.

The authors concluded that individuals, especially those with a sedentary lifestyle, should take precautions and consult a physician before undertaking strenuous snow shovelling.

Codeine treatments and cardiovascular risk
Arch Intern Med 2010; 170: 1979-86

Codeine-based analgesics are generally perceived as safe, especially when compared with NSAIDS. In this study, the safety of five different opioids was compared in 31,375 non-cancer patients with a mean age of 79 years. Their results showed that after 180 days of treatment, patients who had been taking codeine and tramadol had a marginally elevated risk for cardiovascular events.

All-cause mortality was elevated over 30 days for oxycodone and codeine users.

These results therefore suggest that the safety profiles of the various opioids are different which is contrary to current knowledge about opioids.

  • Dr Newson is a GP in the West Midlands, and a member of our team who regularly reviews the journals.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Arrange a meeting with a local paediatrician to discuss whether it would be appropriate to have different treatment options available for children with gastro-oesophagael reflux disease.
  • Read the literature and evidence concerning the use of aspirin and clopidogrel following coronary artery bypass surgery and consider how you will review patients on these drugs in future.
  • Perform an audit of your patients taking codeine-based analgesia and assess whether or not it is appropriate to change their analgesia, especially in those with a high cardiovascular risk.

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