Journals watch: The smokers' paradox, eating behaviours in young adults and children's headaches

Dr Jonathan Holliday selects the latest papers of interest to GPs including the smoker's paradox, impact of a military background on the mental health of children, eating disorders in young adults, children's headaches and breast cancer.

Paradoxically, smokers had a higher rate of survival after cardiac arrest (Photo: iStock)
Paradoxically, smokers had a higher rate of survival after cardiac arrest (Photo: iStock)

The smokers' paradox

Am J Cardiol 2014; 114: 169-74

Cardiac arrest in hospital is common and is associated with poor prognosis. This study set out to examine the impact of smoking status on the outcome, looking at neurological deficit and mortality.

The authors analysed the Nationwide Inpatient Sample database from 2003 to 2011 for all patients aged 18 years or over who underwent CPR for in-hospital cardiac arrest.

Of the 838,464 patients in this group, 116,569 (13.9%) were smokers. This group had a higher prevalence of dyslipidaemia, coronary artery disease, hypertension, chronic pulmonary disease, obesity and peripheral vascular disease. But AF, heart failure and diabetes with complications were less prevalent in smokers.

Smokers were more likely to have a primary diagnosis of acute MI (14.8% versus 9.1%) and ventricular tachycardia or VF as the initial cardiac arrest rhythm (24.3% versus 20.5%).

Smokers had a higher rate of survival to hospital discharge compared with non-smokers (28% versus 24%), consistent with the 'smokers' paradox', and were less likely to have a poor neurological status compared with non-smokers (3.5% versus 3.9%).

Impact of a military background on the mental health of children

J Adolescent Health 2014; 54: 672-7

Our practice, in a garrison town, is acutely aware of the impact of war on the mental health of children and families who have a family member away fighting.

This study used data from the 2011 California Healthy Kids Survey, which included 12,385 children who had no connection with the military, 1,305 who had a military connected parent (9%) and 609 (4.3%) who had a military connected sibling.

Those who had military connections were more likely to report depressive symptoms.

When asked: 'During the last 12 months did you ever feel so sad or hopeless almost every day for two weeks or more that you stopped doing some of your usual activities?', 35% of children with a sibling serving in the military said yes, as did 34% of those with a parent serving. This compared with 31% with no military connection.

Similarly, suicidal ideation was higher in the military groups: 26 % of those with a sibling currently serving reported suicidal ideation and 25% of those with a parent serving did so, compared with 19% of those with no military connection.

The researchers concluded that their findings emphasised the increased risk to mental health among young people with parents and siblings in the military, and the need for vigilance among them.

Dieting and disordered eating behaviours in young adults

J Adolescent Health 2014 doi: 10.1016/j.jadohealth.2014.04.016

This study aimed to find out if personal or socioenvironmental behaviours could be identified that would predict which adolescents would have persistent disordered eating or dieting into young adulthood.

In total, 4,746 adolescents completed an eating survey. Ten years later, 1,902 of the original participants completed a second questionnaire (1,082 females and 820 males).

Perhaps unsurprisingly, weight concerns, weight importance and body satisfaction were predictive traits, and depressive symptoms in the adolescents might be predictive.

I found these figures impressive: 26% of males with low levels of weight concern at baseline reported engaging in disordered eating in adulthood, compared with 60% of those with high levels of weight concern at baseline. The importance that the adolescents placed on weight was also significant.

The researchers also discovered things that appeared not to be important, which was surprising. Parental weight concerns, peer dieting and weight teasing at baseline were not found to be predictive of dieting or disordered eating 10 years later.

This does perhaps open the door for us to do some quick and simple questioning of adolescents who present at possible risk.

Children's headaches

J Paediatr 2014 doi: 10.1016/j.jpeds. 2014.04.053

In this prospective cohort study, the researchers looked at all children aged six to 18 years presenting to a tertiary centre A&E with moderate to severe headache and focal neurological deficit.

Those with a history of trauma, fever or neurosurgical intervention were excluded. The final diagnosis was made after a year of follow-up.

Of the 101 children in the study, 66 received a final diagnosis of primary headache and of these, 94% were migraine with aura. In total, 34 received a final diagnosis of secondary headache and of these, 76% were due to focal epilepsy. Those with bilateral localisation of pain had a higher likelihood of secondary headache.

The effect of radiotherapy after mastectomy and axillary surgery

Lancet 2014; 383: 2127-35

It is known that radiotherapy can be beneficial following breast surgery in node-positive disease. This study set out to assess whether this was true for one to three positive nodes as well as four or more, in women who had undergone mastectomy and axillary dissection.

Meta-analysis was carried out for 8,135 women randomly assigned to treatment groups during 1964-86 in 22 trials. The trials compared radiotherapy to the chest wall and regional lymph nodes after mastectomy and axillary surgery versus the same surgery but no radiotherapy.

Follow-up lasted 10 years for recurrence and to January 1 2009 for mortality.

For 700 women who had axillary dissection and no positive nodes, radiotherapy had no significant effect on locoregional recurrence, overall recurrence or breast cancer mortality.

By contrast, if there were any positive nodes, all three parameters improved, even in the presence of chemotherapy.

The authors suggest that in countries where women are at lower risk of recurrence, there may still be
larger proportional gains because of more effective radiotherapy.

Modern breast cancer screening and breast cancer mortality

BMJ 2014; 348: g3701

This study included all Norwegian women aged 50-79 years between 1986 and 2009, gleaning individual information about screening history and breast cancer mortality from public screening programmes.

During the period of the study,  (1995-2005), a national mammography screening programme was gradually introduced.

This was a large study, with more than 15m person-years of observation. Breast cancer mortality rate ratios were compared for women who were invited to screening and those who were not invited.

A clear distinction was made between cases of breast cancer diagnosed before (without potential for screening effect) and after (with potential for screening effect) the first invitation for screening.

Deaths from breast cancer occurred in 1,175 women with a diagnosis after being invited to screening and 8,996 women who had not been invited before diagnosis.

After adjustment for age, birth cohort, county of residence and national trends in deaths from breast cancer, the mortality rate ratio associated with being invited to mammography screening was 0.72.

In other words, invitation to modern mammography screening may reduce deaths from cancer by about 28%. To look at it another way, 368 women would need to be invited to screening to prevent one death from breast cancer.

  • Dr Holliday is a GP in Berkshire 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.

  • Consider mounting a stop smoking campaign in your practice.
  • Assess the need for raising awareness of mental health problems in children from military families.
  • Use opportunities to discuss eating and dieting behaviours whenever possible when reviewing adolescents and young adults.

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