Journals Watch - Osteoporosis, sleep and wheeze

No time to read the medical journals? Allow Dr Alison Glenesk to guide you through the research.

Cost-effectiveness of osteoporosis case managers Arch Intern Med 2009; 169: 25-31
In this complex Canadian study, a cost-effectiveness analysis was conducted alongside a randomised trial, using hospital-based case managers to encourage the use of bisphosphonates post-discharge.

Outcomes for the elderly with hip fractures are poor, with 5-10 per cent re-fracturing within the year. It is known that bisphosphonates produce a 40-60 per cent relative risk reduction in osteoporotic fracture.

Six months after discharge, this study, involving 110 patients in both the active and control groups, found only 22 per cent of control patients were taking a bisphosphonate, versus 51 per cent of case-managed patients.

For every 100 patients case-managed, six fractures (four hip) were prevented, and the intervention was cost-effective.

Sleep habits and the common cold Arch Intern Med 2009; 169: 62-7
My daughter complains that she always catches a cold after a week of night duty, so I was interested in this article which examines whether sleep duration and efficiency (the percentage of time spent in bed actually asleep), are associated with catching a cold.

A total of 153 healthy men and women who had relatively low immunity to the test virus kept a sleep diary for two weeks. They were then quarantined, had nasal rhinovirus administered, and were monitored for development of a cold.

A graded association was found with sleep duration. Those sleeping less than seven hours were 2.94 times more likely to catch a cold than those sleeping eight hours or more.

Those with less than 92 per cent sleep efficiency were 5.5 times more likely to be infected than those with greater than 98 per cent efficiency. Overall, 88 per cent of patients became symptomatic.

Breast cancer risk in post-menopausal women on HRT Obs Gynecol 2009; 113: 65-73
This paper on HRT and breast cancer attempts to stratify risk between different progestogens. All Finnish women over 50 who were prescribed E2-progestogen for at least six months between 1994 and 2005 were followed up for breast cancer incidence.

Of 221,551 women, 6,211 developed breast cancer by the end of 2005. Compared with the general population, incidence was not elevated until after three years of use. Between three and five years the incidence ratio rose to 1.31, and to 2.7 with 10 or more years use.

Transdermal and oral administration gave the same risk. Norethisterone gave a higher risk after five years use than medroxyprogesterone acetate (2.03 versus 1.64).

It can be difficult to persuade women suffering severe menopausal symptoms to consider HRT. These data may help to persuade them that short-term use, at least, is unlikely to be harmful.

Oral prednisolone for acute virus-induced wheeze N Engl J Med 2009; 360: 329-38
Attacks of wheezing induced by URTIs are common in young children. This condition is often treated with a short course of steroids, but evidence of efficacy has been conflicting.

In this randomised double-blind controlled trial conducted in three hospitals in England, an age-appropriate five-day course of prednisolone was given to children aged 10 months to six years presenting with wheeze associated with viral infection.

Approximately half of the 687 children received usual treatment (bronchodilator) plus steroid and the other half usual treatment plus placebo.

The primary endpoint was duration of hospital stay. No difference was found between the two groups at the primary or secondary endpoints.

Diagnostic difficulty and error in primary care Fam Pract 2008; 25: 400-13
This systematic review attempts to rationalise some of the difficulties GPs have with diagnostic uncertainty.

The aim was to identify common characteristics of diseases that GPs might misdiagnose.

Twenty-one relevant papers were identified. The conditions studied were: malignancies, MI, meningitis, dementia, anaemia, asthma, tremor and HIV.

Difficulties or delay in diagnosis were encountered because of atypical presentation, non-specific presentation, very low prevalence, presence of co-morbidity and perceptual failure.

The authors succinctly point out that experienced GPs work quickly mainly by pattern recognition of common diseases. This allows us to cope with our workload, but may mean we fail to appreciate when the unusual crops up.

Variation in prescribing antidepressants in Scotland Br J Gen Pract 2009; 59: e25-e31
Prescribing of antidepressants has increased threefold between 1992 and 2006 (from 1.16 million to 3.53 million scrips). This does not appear to be due to an increase in the prevalence of depression. The authors wished to investigate the influence of a number of population, GP and practice characteristics.

All prescriptions for usual daily dosages of antidepressants for the financial year 2004/5 were recorded from 983 study practices. There was found to be a 4.6-fold difference between the first and ninth deciles, standardised for age and sex.

Higher prescribing was associated with rates of limiting long-term illness (itself correlated with deprivation), urban location, and a higher proportion of female GPs in the practice.

Lower prescribing was associated with single-handed doctors, high list size, non-UK GPs, remote and rural areas, high levels of ethnic minority patients, older GPs, and the availability of psychology services.

Quality-of-care indicators, for example number of QOF points scored, showed no correlation.

  • Dr Glenesk is a GP trainer in Aberdeen and a member of our team who review the journals

The quick study

  • Osteoporosis patients with case managers were more likely to receive bisphosphonates and less like to have a hip fracture.
  • Sleep duration of less than seven hours per night is associated with an increased risk of catching a cold.
  • HRT did not confer an increased risk of breast cancer until three years of use.
  • Prednisolone was not superior to placebo for treating pre-school children with acute virus-induced wheeze.
  • Diagnosis may be delayed or difficult if disease presentation is atypical or non-specific.
  • Antidepressant prescribing is related to population, GP and practice characteristics.

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