Journals watch: Infantile haemangioma, antidepressant use and follow-up after medical abortion

Too busy to read the journals? Dr Alison Glenesk selects the latest papers of interest to GPs including infantile haemangioma, antidepressant use and risk of suicide or self harm, CVD risk in psoriatic arthritis, psoriasis and RA and follow-up after medical abortion.

Infantile haemangioma: leasions improved in patients taking propranolol (SPL)
Infantile haemangioma: leasions improved in patients taking propranolol (SPL)

Oral propranolol treatment for infantile haemangioma

N Engl J Med 2015; 372(8): 735-45

This multicentre, randomised, double blind, adaptive trial assessed the safety and efficacy of propranolol in infants aged one to five months with proliferating lesions >1.5cm in diameter, requiring systemic therapy.

A total of 460 children were recruited. A dose of 3mg/kg/day for six months was selected.

On this regimen, 88% of patients showed improvement by week five, compared with 5% on placebo. The figures for successful treatment at six months were 60% versus 4%, although some patients required another course of treatment. Side-effects were minimal.

Treatment of acute wheeze

Arch Dis Child 2015; 100: 121-5

In this two-stage study, emergency department (ED) and ED consultant treatment of wheezy children was assessed.

The participants were member departments of Paediatric Emergency Research in the UK and Ireland, and ED consultants treating children with wheeze. Questions were posed regarding inhaled and IV drug therapies. A total of 30 EDs and 183 consultants responded.

Of EDs, 97% had wheeze guidelines and 40% had care pathways. Despite this, there was little similarity in treatment regimens. Dose and frequency of bronchodilator therapy were not standardised, and different IV therapies were used.

The authors conclude this variation in treatment reflects the paucity of evidence for treating this condition. It is also apparent that guidelines were not followed. They suggest more research should be done and disseminated electronically.

Cardiovascular risk in psoriatic arthritis, psoriasis and RA

Ann Rheum Dis 2015; 74(2): 326-32

This population-based longitudinal cohort study involved patients aged 18-89 with psoriatic arthritis (PA), rheumatoid arthritis (RA) or psoriasis. Up to 10 matched controls were identified for those with PA.

Outcomes included cardiovascular death, MI and the composite outcome, major adverse cardiovascular events (MACE).

After risk adjustment, the risk of MACE was higher in patients with PA not prescribed a DMARD (HR 1.24), patients with RA (no DMARD HR 1.39, DMARD HR 1.58), patients with psoriasis not prescribed a DMARD (HR 1.08) and patients with severe psoriasis with DMARD (HR 1.42).

The authors point out this is the first population-based study dedicated to examining MACE in PA and the first to examine the three diseases simultaneously.

The conclusion is simple. We already assess cardiovascular risk in RA patients. This should be extended to those with psoriasis, particularly in severe disease and PA.

Antidepressant use and risk of suicide or self harm

BMJ 2015; 350: h517

The objective of this large cohort study was to assess the difference in rates of suicide, attempted suicide and self-harm in patients prescribed a range of antidepressants.

A total of 238,963 patients aged 20-64 years with depression formed the study population. Follow-up was for a median 5.2 years.

Rates of suicide and attempted suicide were similar during periods of treatment with SSRIs and tricyclic antidepressants, but significantly increased with venlafaxine, trazodone and mirtazapine. For example, the absolute risk of attempted suicide or self-harm over one year ranged from 1.02% for amitriptyline to 2.96% for venlafaxine.

Rates were highest in the 28 days after starting treatment and remained raised during the 28 days after stopping.

It is not clear if the higher suicide rate is a drug effect, or whether the higher numbers on certain drugs might reflect more severe depression - venlafaxine and mirtazapine are usually used second-line.

Follow-up after medical abortion

Lancet 2015; 385(9969): 698-704

The aim of this multicentre non-inferiority trial was to determine whether home self-assessment after early medical termination of pregnancy was as clinically safe as standard follow-up.

The study involved 924 women, of whom 466 were randomised to clinical follow-up at one to three weeks, and 458 to a semi-quantitative urinary pregnancy test followed by a telephone consultation.

The primary endpoint was the percentage of women not requiring further medical or surgical intervention after three months. Hospital follow-up is not standardised, and may include ultrasound, beta-hCG measurement or both.

No difference was seen in the rates of complete abortion between the two groups (955 in the clinical, 945 in the self-assessment group). However, there were three continuing pregnancies in the self-assessment group. The authors conclude that this is because of problems with the semi-quantitative pregnancy test.

  • Dr Glenesk is a GP in Aberdeen and a member of our team who regularly review the journals

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.

- Discuss treatment of infantile haemangiomas with your paediatric team. Debate if GPs should be more active in their management.

- Perform a search for patients with psoriatic arthropathy and severe psoriasis. The numbers should be fairly small. Suggest an appointment to look at cardiovascular risk management.

- Find out how your practice's patients are followed up after termination of pregnancy. Check what your local follow-up protocol is and if there are any plans for self-care.

Save this article and add notes with your free online CPD organiser at gponline.com/cpd Take clinical tests and claim certificates for CPD at myCME.com/gp

0.5 CPD CREDITS - For 30 minutes of learning activity and reflection based on this article

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