Journals Watch - UTI, nail psoriasis and asthma

Too busy to read the journals? Let Dr Suzanne Hunter bring you up to date on the latest research.

Clinical presentations of UTI and renal scarring - Arch Dis Childhood 2009; 94: 278-81
In recent NICE guidelines on the treatment of childhood UTI, it is assumed that the presence or severity of systemic symptoms, especially fever, predicts renal scarring.

Persistant urinary reflux cacn lead to kidney damage and UTI in children

When these guidelines were released, it changed the management of UTI, especially with respect to investigation. Essentially the guidance said if the child is systemically unwell, they should be investigated for renal scarring.

This study questions that guidance. It was a retrospective case note analysis of children under five years old referred for a first UTI who were assessed for scarring.

About a quarter of the children assessed had scarring. Vomiting, anorexia or malaise at presentation had a weak correlation with renal scarring, but sex, age, fever or hospitalisation did not.

The authors concluded that clinical signs at presentation in childhood UTI cannot be used to predict for mild or multiple scarring, and therefore the recommendation from NICE to use clinical signs to predict scarring is not justified.

I am reassured that my gut instinct is still functioning as the guidance never felt right.

Nail psoriasis - Arch Dermatol 2009; 145(3): 269-71
Nail psoriasis affects up to 78 per cent of patients with psoriasis, in some it is their only sign. It can be a major problem with pain and poor cosmesis.

This Italian study aimed to evaluate the therapeutic efficacy of acitretin in patients with isolated nail psoriasis.

Thirty-six patients with moderate-to-severe nail psoriasis were given a low dosage (0.2-0.3mg/kg/day) of the retinoid acitretin and assessed at six months.

Clinical evaluation at six months showed that a quarter of patients show complete clearing of the nail psoriasis. Moderate improvement was seen in a quarter, mild improvement in a third and no improvement in 11 per cent.

The authors suggest that acitretin be considered for treatment of nail psoriasis.

Efficacy of esomeprazole for poorly controlled asthma - N Engl J Med 2009; 360: 1,487-99
Patients with poorly controlled asthma are often tried on a course of proton pump inhibitors, in case otherwise asymptomatic gastroesophageal reflux is the cause.

In this parallel-group double-blind trial, patients with poorly controlled asthma taking steroids with minimal or no symptoms of gastroesophageal reflux received 40mg of esomeprazole twice a day or placebo. They were followed up for 24 weeks, monitoring their asthma symptoms.

Ambulatory pH monitoring was used to ascertain the presence or absence of gastroesophageal reflux in patients.

The researchers found gastroesophageal reflux was present in 40 per cent of the patients but unfortunately the esomeprazole made no difference to any of the parameters of asthma control.

Novel treatment for resistant hypertension - Lancet 2009; 272: 1,275-81
This is not something that we will be doing in our surgeries tomorrow but it might become a common treatment in the future. Renal sympathetic hyperactivity is associated with hypertension, and with chronic kidney disease and heart failure as it progresses.

This trial looked at the principle of percutaneous therapeutic renal sympathetic denervation by a catheter-based radiofrequency treatment in 45 patients.

The participants in the study had resistant hypertension with their systolic above 160 mmHg despite being on three or more antihypertensives including a diuretic. Patients were monitored for a year for BP and safety concerns.

In the intervention group the BP was reduced by 27/17 at 12 months while in the control group the BP had increased by 26/17 mmHg at nine months. There were no lasting adverse events. This was just a small initial trial but it looks hopeful for a new direction in treatment.

Skin test for adverse drug reactions - Brit J Dermatol 2009; 160: 786-94
This is a cautionary tale. When a patient has a purported reaction to a medication, it is possible to do a skin prick, patch or intradermal test to assess if the patient did react to the drug, or to see if the patient is also sensitive to a drug in the same class.

In this study, the initial skin tests were compared to later oral provocation tests where the patient orally took the medication or a similar drug. They found that the skin tests had approximately a 90 per cent negative predictive value, or in other words it will miss one in 10 reactions.

The authors recommend re-administration should be performed in a hospital setting.

  • Dr Hunter is a GP in Bishops Waltham, Hampshire and a member of our team who regularly review the journals

The quick study

  • Renal scarring cannot be predicted by clinical signs at presentation.
  • Nail psoriasis may be effectively treated by acitretin.
  • Asthma control was not improved by the use of proton pump inhibitors.
  • Resistant hypertension was reduced by renal sympathetic denervation by catheter-based radiofrequency.
  • Skin tests for adverse drug reactions had approximately a 90 per cent negative predictive value.

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