Journals Watch - Pneumonia, chest pain and epilepsy

Not had time to read the latest research? Let Dr Lizzie Croton bring you up to date with the journals.

Routine chest X-rays to exclude lung cancer after recovery from pneumonia are not warranted (Photograph: SPL)
Routine chest X-rays to exclude lung cancer after recovery from pneumonia are not warranted (Photograph: SPL)

Chest X-rays after pneumonia
Arch Intern Med 2011; doi:10.1001/archinternmed.2011.155
Chest X-rays can be performed following pneumonia resolution to exclude underlying lung cancer. This study aimed to determine the incidence of new lung cancer and the diagnostic yield of chest radiography for lung cancer in patients with pneumonia.

This population-based study involved 3,398 patients with radiologically confirmed pneumonia discharged from hospital and emergency departments. The authors reviewed post-discharge chest X-rays at up to five years after discharge together with new lung cancer diagnoses.

At 90 days, 36 patients (1.1 per cent) had lung cancer. The figures at one and five years were 57 (1.7 per cent) and 79 (2.3 per cent) respectively.

The characteristics that were independently associated with lung cancer were age over 50 years, male sex and smoking.

The authors concluded that as the incidence of new lung cancer after pneumonia is low, routine chest X-rays to detect lung cancer are not warranted but targeting patients 50 years or older would improve the diagnostic yield of chest radiography.

Prenatal loss and perinatal depression and anxiety
Br J Psych 2011; 198: 373-8
The prenatal loss of a child through miscarriage or stillbirth is associated with significant depression and/or anxiety, particularly in a subsequent pregnancy.

This study examined the degree to which such symptoms associated with a previous loss persisted following a subsequent successful pregnancy.

A longitudinal cohort design was used and 13,133 mothers who had experienced previous perinatal losses provided self-reported measures of depression and anxiety.

Results indicated that the number of previous losses significantly predicted symptoms of depression and anxiety in subsequent pregnancies.

This association remained constant across the pre and postnatal period suggesting that the impact of a previous loss did not diminish following the birth of a healthy child.

Non-fatal idiopathic venous thromboembolism (VTE) in users of oral contraceptives
BMJ 2011; 342: d2139

This nested case-control study used data from the UK General Practice Research Database.

The participants were women aged 15 to 44 years with no major risk factors for VTE starting a new period of use of an oral contraceptive pill containing 30microgram of estrogen in combination with drospirenone or levonorgestrel.

Cases were women with a first diagnosis of VTE. They were matched by age, duration of recorded information and general practice with up to four controls.

Results showed a three-fold higher risk of idiopathic VTE in uses of the drospirenone- containing pill when compared with levonorgestrel (OR adjusted for BMI 3.3 (CI 1.4-7.6)).

Crude incidence rates were 9.1 (CI 6.6-12.2) per 100,000 woman years in users of levonorgestrel and 23.0 (CI 13.4 - 36.9) in users of drospirenone.

Unexplained chest pain and PPIs
Gut 2011; doi: 10.1136/gut.2011.241307
Differential diagnoses of unexplained chest pain include gastro-oesophageal reflux disease (GORD) and oesophageal motility disorders. This study explored the response of unexplained chest pain to PPIs.

The authors selected six RCTs that reported chest pain response to PPIs in patients who had undergone prior endoscopy and/or 24-hour pH monitoring to differentiate between GORD -positive and GORD-negative subpopulations.

The target of >50 per cent improvement with PPIs relative to placebo was 56-85 per cent in GORD-positive and 0-17 per cent in GORD-negative patients. The relative risk of >50 per cent improvement with PPIs versus placebo was 4.3 (CI 2.8-6.7) for GORD-positive and 0.4 (CI 0.3-0.7) for GORD-negative patients.

Both these results reached statistical significance. Heartburn was a poor predictor of underlying GORD by objective testing.

The authors concluded that unexplained chest pain in patients with proven GORD tends to improve but not resolve with PPIs, whereas patients without GORD show little or no response.

Nonadherence to antiepileptic drug (AED) therapy in children with newly diagnosed epilepsy
JAMA 2011; 305(16): 1669-76
There are recognised complications for medication nonadherence in adults and so identifying rates and predictors of nonadherence in children is important.

Of 124 children aged two to 12 years with newly diagnosed epilepsy, 58 per cent demonstrated persistent nonadherence during the first six months of therapy with five different adherence groups demonstrated (severe early nonadherence, severe delayed nonadherence, moderate nonadherence, mild nonadherence and near perfect adherence).

The adherence pattern of most patients was established by the first month of therapy with socioeconomic status the sole predictor of adherence group. Lower socioeconomic status was associated with higher nonadherence.

  • Dr Croton is a GP in Birmingham 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 screening patients with a history of miscarriage/stillbirth for depression with one of the validated primary care depression screening tools.
  • Review the clinical notes of patients prescribed oral contraceptive pills containing drospirenone. Is there a valid reason for the prescription and could they be changed to an alternative preparation with a lower risk of DVT?
  • Collate a list of children with epilepsy diagnosed within the past two years and ask specifically about patterns of AED nonadherence and document the discussion in the notes.

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