Journals Watch - IBD, tonsillectomy and stroke

A review of this week's medical research. By Dr Tillmann Jacobi

There is a suggestion that certain medications may induce inflammatory bowel disease (Photograph: SPL)
There is a suggestion that certain medications may induce inflammatory bowel disease (Photograph: SPL)

Medication-induced inflammatory bowel disease
Inflamm Bowel Dis 2012; doi: 10.1002/ibd.22990

This comprehensive literature review looked at the suggestions that specific medications may induce new inflammatory bowel disease (IBD). Among the most cited medications are antibiotics, NSAIDs, oral contraceptives and isotretinoin.

The problem with the evidence so far is that it heavily relies on relatively weak methods (mostly case reports and cohort studies), with a high risk of bias or confounding factors, to show any possible association. RCTs would be difficult to conduct.

The goal of this review was to increase awareness and clarity regarding the possible associations, although it fails to come to a definite conclusion.

It is a reminder to consider the possible implications of polypharmacy and long-term continuation of medications.

How to bring back patients' speech after stroke
J Neurol Neurosurg Psychiatry 2012; 83(7): 675-80

This South Korean study tested the efficacy of the use of galantamine in 45 patients under the age of 75 (mean age 60.4 years), who had been affected by post-stroke aphasia for at least one year.

The degree of the aphasia was established and then retested 16 weeks after treatment by use of the Western Aphasia Battery. The galantamine group showed a significant increase in the test improvement (n = 23, 48.5-57 percentile; p = 0.007), whereas the control group did not achieve noticeable results (n = 22, 54.3-54.9 percentile; p = 0.308).

It was possible to distinguish good responders and poor responders in the galantamine group and associate better outcomes with a higher level of education, a higher baseline mini-mental state examination and, perhaps most interestingly, if the brain lesions were subcortical dominant.

Postoperative steroids after tonsillectomy
Otolaryngol Head Neck Surg 2012; doi: 10.1177/0194599812 447776

Tonsillectomy has generally good outcomes, but can cause discomfort and inconvenience during recovery. There has been some evidence that the use of single-dose intraoperative dexamethasone can decrease postoperative pain as well as nausea and therefore speed up the return to a normal diet afterwards.

This study sought to find out if a postoperative course of oral prednisolone might further reduce common problems and symptoms. The randomised, placebo-controlled, double-blind trial compared the outcomes between a placebo and a five-day course of oral prednisolone in a paediatric population (three to 16 years) after tonsillectomy.

The determinants were post-operative pain, nausea, vomiting, sleep and the return to normal general function.

No evidence of any benefit in any of these areas could be observed in the group with steroids.

Why be proactive in ankylosing spondylitis?
Ann Rheum Dis 2012; doi: 10.1136/annrheumdis-2011-200859

This study of 76 patients diagnosed with ankylosing spondylitis looked at the implication of timely treatment for the overall outcome, particularly with regard to the problem with new bone formation as a result of spinal inflammation.

There have been treatment developments, for example, the use of anti-TNF-alpha therapies, but these appear to only treat and resolve acute lesions.

The subjects had three staggered MRI scans over a year to look at the presence or absence of acute and advanced vertebral corner inflammatory lesions as well as fat lesions. It was possible to confirm that advanced lesions more frequently (in 16.7%) lead to new syndesmophytes, when compared with acute lesions (in only 2.9%).

Keep treatment short in pyelonephritis
Lancet 2012; doi: 10.1016/S0140-6736(12)60608-4

Acute pyelonephritis is a common infection but it is unclear internationally what course of treatment is the most effective and safest.

This randomised, double-blind, placebo-controlled trial assessed the outcomes and possible differences between seven days and 14 days of active treatment with ciprofloxacin in 248 adult women with community-acquired pyelonephritis.

The clinical and bacteriological outcome at 10 to 14 days after the completion of treatment with active drug served as the primary endpoint. The findings confirmed a quite comparable short-term clinical cure in 97% of patients in the seven-day treatment group and 96% in the 14-day treatment group with a minimal difference of -0.9% (90% CI: -6.5 to 4.8; p = 0.004).

However, the 14-day treatment group reported overall more adverse effects, especially candida infection. The principle of shorter treatment to reduce side-effects and possible resistance appears quite sound.

Antiepileptic drugs and vitamin B levels
Epilepsy Behav 2012; 24(3): 341-4

This study of a cohort of 33 patients with epilepsy examined the possible impact of enzyme-inducing antiepileptic drugs on the patient's vitamin B levels. It demonstrated that enzyme-inducing antiepileptic drugs, such as phenytoin or carbamazepine, appeared to lead to noticeable if not significant vitamin B6 deficiency in 48% of patients in comparison to only 9% in the control group.

Significant pyridoxine (vitamin B6) deficiency can lead to a number of chronic health issues including possible polyneuropathy. The deficiency was reversible in more than half of the identified patients within as little as six weeks by switching to non-inducing antiepileptic drugs, such as levetiracetam, lamotrigine or topiramate.

There were no particular or specific individual differences between any medications. The levels of other B vitamins or folate seemed to be unaffected by the enzyme-inducing activity of antiepileptics.

  • Dr Jacobi is a GP in York 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


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

  • Consider some focused advice for patients on long-term NSAIDs to inform not only about upper GI side-effects or potential increased cardiac risk, but also IBD.
  • Raise awareness of the condition of ankylosing spondylitis in higher-risk groups and consider a protocol to identify patients more quickly and to manage (refer) them promptly.
  • Liaise with the local microbiology department and review the rationale of antibiotic treatment of relatively common infections (such as pyelonephritis).


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