Journals watch: NSAIDs in ankylosing spondylitis and exercise in pregnancy

Too busy to read the journals? Dr Simon Hunter summarises the key papers of interest to GPs.

Treatment of ankylosing spondylitis is aimed at limiting structural damage

NSAIDs in ankylosing spondylitis

Ann Rheum Dis 2012; 71: 1623-9

Ankylosing spondylitis (AS) is characterised by syndesmophyte formation and fusion leading to disabling spinal immobility. Treatment is aimed at limiting structural damage. It has been noted before that new TNF-blocking drugs seem to have little effect on structural damage.

In this post-hoc study, data from a previous study were re-examined. Patients with AS were grouped into those with high or low inflammatory markers (CRP or ESR) and high or low AS activity assessment scores (ankylosing spondylitis disease activity score (ASDAS) or Bath ankylosing spondylitis disease activity index (BASDAI)). They were randomised to receive continual celecoxib for two years or to take it only when they were in pain or stiff.

They found that in patients with high ESR or CRP, slowing of radiological progression of AS was greater in those patients on continuous NSAIDs. This was also the case for those with a high ASDAS score, but not BASDAI. They also noticed that patients with a high ESR had a faster rate of structural progression than those with a normal ESR.

These findings could be taken into account when assessing the risks and benefits of using NSAIDs in patients with AS.

Exercise in pregnancy Am J Obstet Gynecol 2012; 207: 179e1-6

Information about the effect of strenuous exercise on the fetus in pregnancy is scarce.

These US researchers looked at 45 women who were 28-32 weeks pregnant; 15 were non-exercisers, 15, moderate exercisers and 15, highly active. They ran on a treadmill until they reached volitional fatigue. They were monitored with uterine artery dopplers, umbilical artery dopplers and a fetal heart trace.

Overall, fetal well-being seemed unaffected by short-burst vigorous exercise, although five of the usually highly active women showed transient fetal heart rate decelerations shortly after exercise and changes on uterine and umbilical dopplers.

These results indicate that exercise is likely to be safe in pregnancy, although there is a question mark over those who are usually highly active pushing themselves to the limit.

Infant CPR: fingers or thumbs? J Pediatr 2012; 161: 658-61

The current resuscitation guidelines for infants recommend a two- fingered technique for chest compressions for infants under one year of age. The team behind this research questioned whether this was the best approach and whether we should be using a two-thumbed technique, with the fingers either side of the chest and the thumbs meeting over the sternum (as if you were going to pick up the baby by the trunk).

Twenty trained resuscitators tried both methods on infant manikins, with the manikin on the floor, a table and a radiant warmer.

They found the two-thumbed approach achieved greater depth of compression and less variability of compressions, and they tired less quickly. They found the table to be the most comfortable place to perform CPR. They recommended this should be the preferred method for teaching lay people.

Beta-blockers in stable CHD JAMA 2012; 308(13): 1340-9

This study looked at patients with a previous history of MI, patients with coronary artery disease but no MI and patients with risk factors.

The researchers compared patients who had and had not taken beta-blockers over the median follow-up period of 44 months.

The data were extracted from a previous study (REACH). The outcome measures were for cardiovascular death, non-fatal MI and nonfatal stroke.

They found that in patients with previous MI and known coronary artery disease, use of beta-blockers conferred no protective effect.

The researchers commented that the patients in their study had stable myocardia and were often on statins, aspirin and an ACE inhibitor, unlike the patient who was just post-MI and whose necrotic myocardium could produce an arrhythmia that beta-blockers might prevent.

Patients with just risk factors on beta-blockers had a slightly higher rate of revascularisation procedures. It seems putting a stable post-MI patient on a beta-blocker to keep QOF happy would not be the thing to do.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

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

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

  • Perform a search for patients with ankylosing spondylitis and see whether inflammatory markers have been recorded.
  • Invite the local resuscitation trainer to the surgery to hold an emergency resuscitation practice session.
  • Refresh your knowledge of pharmacotherapy for post-MI patients.

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