Journals watch - Lung cancer, TIA and dementia

Too busy to keep up with new research? Let Dr Jonathan Holliday update you on the latest papers.

Lung cancer: patients should be screened with a chest X-ray at 60-90 days following pneumonia
Lung cancer: patients should be screened with a chest X-ray at 60-90 days following pneumonia

Incidence of lung cancer after hospitalisation for pneumonia - Am J Med 2010:123(1); 66-71
This was a retrospective study conducted over the 'fiscal years' 2002-7 in veteran hospitals in the US. During that time, 40,744 patients over 65 years of age and with no history of lung cancer were hospitalised with pneumonia.

A total of 3,760 (9.2 per cent) developed lung cancer with a median time to diagnosis of 297 days. Only 27 per cent were diagnosed within 90 days.

Risk was increased by history of any previous malignancy or chronic pulmonary disease and being white. Being married and smoking also increased the risk.

The message the authors wished to get across was everyone so admitted should have a chest X-ray at 60-90 days.

Combined aspirin and dipyridamole therapy in TIA - Lancet Neurol 2010; doi: 10.1016/S1474-4422(09)70361-8
We have known since the ESPRIT trial in 2006 that the combination of aspirin and dipyridamole is better than aspirin alone in preventing vascular events after ischaemic stroke.

In the EARLY trial, researchers in Germany compared the safety and beneficial effects of aspirin alone for the first week followed by combined therapy (late initiation group) versus combined therapy commenced within 24 hours of TIA (early initiation group).

When assessed blind at 90 days, 56 per cent of the early initiation group had no or mild disability, while 52 per cent of the late initiation group were also unaffected or little affected.

Ten per cent of the early initiation group and 15 per cent of the late initiation group reached the combined end point (non-fatal stroke, TIA, non-fatal MI, major bleeding or death) during the 90-day trial period.

It is a reminder that there is value in starting combined aspirin and dipyridamole within 24 hours of TIA and that it is safe to do so.

Home management of early medical abortion - J Fam Plann Reprod Health Care 2010; 36: 21-5
In the UK, the Abortion Act stipulates that any treatment for the termination of pregnancy must be carried out in a place approved by the state. Once again we see the science getting ahead of the law.

Oral administration of mifepristone is followed 6-72 hours later by intravaginal misoprostol, which is either administered by a clinician or by the patient. Either way, it is administered in a place approved by the state.

This survey was to assess the acceptability to women of going home for completion of the early medical abortion, and to assess whether women would prefer to have the option of self-administering the intravaginal misoprostol at home as well. This is now the norm in many countries and has been shown to be both safe and highly acceptable.

Suitable women were selected and following their two visits to clinic for medicating were discharged home to complete the early medical abortion there.

Opinions were sought at one week. Women generally preferred the option of being allowed to go home (86 per cent) and a huge 96 per cent reported that it had been either very or somewhat acceptable to do so.

Furthermore, 62 per cent would have preferred to have been allowed to self-administer the misoprostol at home. By adopting such practice, there is the possibility of making the process more acceptable to women while reducing time in secondary care and the corresponding costs.

One for the doctor's bag - Lancet 2010: 375; 217-23
Oxytocin is the gold standard for postpartum haemorrhage but it requires refrigeration and skilled IV infusion.

However, misoprostol needs no special storage and is administered sublingually.

This trial of more than 30,000 women was double blind and set up to establish whether they were in fact equally effective, which they were.

In both groups, 90 per cent had control of active bleeding within 20 minutes, while just over 30 per cent from each group suffered additional blood loss of >300ml after administration.

The fact that postpartum haemorrhage remains a danger was underlined by six hysterectomies and two deaths.

ARBs reduce dementia incidence - BMJ 2010; 340: b5465
This prospective cohort analysis from the Department of Health Policy in Boston, USA, studied 820,000 veterans.

The objective was to determine whether ARBs reduced the incidence and/or progression of Alzheimer's disease or dementia when compared with ACE inhibitors (lisinopril) or other cardiovascular drugs.

They were found to do so for both Alzheimer's and other dementias, and both for incidence and progression (hazard rate for all around 0.8).

Fractures, calcium and vitamin D3 - BMJ 2010; 340:b5463
This study into supplemental calcium and fracture prevention looked at pooled data from seven randomised trials, each with at least 1,000 subjects and with a total population of 68,500.

All studies had at least one intervention arm in which vitamin D was given and all had fracture as an outcome. Trials using vitamin D with calcium showed a reduced overall risk of fracture (hazard ratio 0.92) and of hip fracture (hazard ratio 0.84). It was true irrespective of age, sex or previous fractures.

Where vitamin D was used alone there was no significant benefit. Co-administration of 1,000mg calcium daily is required for fracture prevention.

  • Dr Holliday is a GP in Eton, Berkshire, and a member of our team who regularly review the journals

The Quick Study

  • Lung cancer following pneumonia should be screened for with a chest X-ray.
  • Combined aspirin and dipyridamole therapy should be started within 24 hours of TIA.
  • Early medical abortion completed at home seems to be acceptable to women.
  • Sublingual misoprostol for postpartum haemorrhage is equally effective and safer than IV oxytocin.
  • Dementia incidence is reduced by ARB use.
  • Fracture risk is reduced by using vitamin D and calcium together.

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