Journals watch: Sigmoidoscopy, prenatal valproate exposure and ectopic pregnancy

Too busy to read all of the research? Dr Raj Thakkar selects some papers of interest to GPs.

Colon cancer: study compared colonoscopy with sigmoidoscopy (Photo: David M. Martin, MD/Science Photo Library)
Colon cancer: study compared colonoscopy with sigmoidoscopy (Photo: David M. Martin, MD/Science Photo Library)

Interval cancer in patients having colonoscopy and sigmoidoscopy

Mayo Clin Proc 2013

I am sure most GPs have considered how long to wait after initial bowel investigations before reassuring patients they do not have cancer and in particular, how reliable sigmoidoscopy is compared with colonoscopy.

With pressures to drive up quality of referrals and commissioning budgets, such information is vital.

This US study looked at the proportion of colorectal cancers (CRC) occurring six to 36 months after a lower GI scope, so-called interval cancers.

A total of 15,484 patients with left-sided CRC were included. The proportion of patients with an interval CRC after a flexible sigmoidoscopy was 8.8%, and after a colonoscopy, 2.5%. The authors suggest a number of factors may account for this and further research is needed.

In the meantime, GPs need to be aware of what investigations their patients have had and when.

Prenatal valproate exposure and the risk of autistic disorders

JAMA 2013; 309(16): 1696-703

We recognise the teratogenicity of antiepileptics and this is reflected in the QOF. Autistic spectrum disorders (ASD) are not necessarily considered with respect to antiepileptics in pregnancy, yet they remain a topic of heated discussion.

This study from Denmark looked at more than 650,000 children born between 1996 and 2006. In this cohort, nearly 5,500 were diagnosed with ASD. A multitude of factors were considered in an attempt to minimise confounder risk.

Of those exposed antenatally to valproate, the hazard ratio for ASD was 2.9 (95% CI: 1.7-4.9). So where does this leave patients who depend on valproate for epilepsy control? GPs can use such information to help empower patients to make more informed decisions.

Identifying ectopic pregnancy

JAMA 2013; 309(16): 1722-9

The objective of this systematic review was to consider features in the history, examination and investigation to guide the early diagnosis of ectopic pregnancy.

Fourteen studies, reflecting data on more than 12,000 women, were reviewed. Factors that increased the likelihood of an ectopic pregnancy included cervical motion tenderness, adnexal tenderness and adnexal mass.

A single hCG reading, rather than serial readings, is not useful. Like most things in medicine, there are nuances that complicate matters. For example, an ectopic pregnancy may present with loose stool.

The message remains that women in early pregnancy who experience abdominal pain or bleeding require bloods and imaging to rule out ectopic pregnancy. This article prompts us to revise the presentations of what could be a devastating condition.

Achievement and self-sufficiency after bacterial meningitis

JAMA 2013; 309(16): 1714-21

The medical sequelae of childhood bacterial meningitis are well documented, but what are the consequences when these children reach adulthood?

This study from Denmark looked at educational attainment and employment in people with a history of childhood bacterial meningitis compared with controls.

A total of 2,784 cases with a history of meningococcal, Haemophilus influenzae or pneumococcal meningitis were reviewed.

By the age of 35, 11% fewer people with a history of meningitis completed school compared with matched controls. In addition, 7.9% fewer reached higher education. It is no surprise that fewer people who had meningitis were financially self-sufficient compared with controls.

Reduced attainment and self-sufficiency were particularly attributed to pneumococcal and haemophilus related meningitis.

Obstructive sleep apnoea and pulmonary embolism

Mayo Clin Proc 2013; doi: 10.1016/j.mayocp.2013.02.005

This case-controlled study from Spain aimed to compare the prevalence of obstructive sleep apnoea in patients with pulmonary embolism (PE) with a matched, population-based control group to assess the association between obstructive sleep apnoea and PE.

They looked at more than 100 cases of PE and attempted to control for several factors, including BMI and smoking. They found PE was more commonly seen in patients with an Epworth sleepiness score of 11 or more.

This study may help us to refine the risk that a given patient has a PE.

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

  • Write to your local colorectal team and ask what its current advice is on scope intervals, given the risks associated with sigmoidoscopy.
  • Hold an educational meeting regarding epilepsy drugs and pregnancy. Ensure women of childbearing age on valproate understand the risks of ASD when being counselled.
  • Review the ways in which ectopic pregnancy presents and make a poster for your clinical rooms.

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