Journals Watch - Stroke, birth defects and obesity

Missed out on this week's journals? Dr Raj Thakkar brings you up to date with the latest research.

Migraine with aura in women over 45 years conferred a significant excess risk of haemorrhagic stroke (Photograph: SPL)
Migraine with aura in women over 45 years conferred a significant excess risk of haemorrhagic stroke (Photograph: SPL)

Migraine in women and risk of haemorrhagic stroke - BMJ 2010; 341: c3659
Migraine is a common condition, but I wonder whether doctors take it seriously enough.

This large study used data from the Women's Health Study and analysed 27,860 women aged 45 years and over, who self-reported migraine and aura symptoms but had no previous stroke or other major disease.

The primary endpoint was time to first haemorrhagic stroke. A total of 18 per cent of women had reported migraine, 70 per cent of whom reported migraine occurring in the past year. Of these, 40 per cent had symptoms of aura.

Mean follow-up was 13.6 years, during which time 85 haemorrhagic strokes were identified through medical records.

Migraine without aura conferred no additional risk for haemorrhagic stroke, whereas the presence of aura significantly increased stroke risk (hazard ratio 2.25, 95% CI: 1.11 to 4.54, P=0.024).

While the authors concluded that further research is required before definitive conclusions are drawn, we must endeavour to minimise the risk of stroke in migraine sufferers with aura.

Postnatal depression and child growth and behaviour - Arch Dis Child 2010; 95: 690-5
The care of postnatal depression (PND) often focuses on the immediate and short-term risk assessment of the mother and child, rather than considering the longer term sequelae of PND on the offspring.

This fascinating cohort study looked at the effect of PND in mothers on the children at two years of age. The study looked at behaviour and growth in South African children.

Taking into account the family's socioeconomic status, the researchers found that PND was significantly associated with childhood behavioural problems at two years of age. In addition, the children's growth was also adversely affected compared with children of unaffected mothers.

The reasons for this require further investigation but it is clear clinicians must follow-up the offspring of PND patients to ensure their welfare.

Antivirals in first trimester and risk of birth defects - JAMA 2010; 304(8): 859-66
Herpes infections are not uncommon in pregnant women. We as clinicians often have to inform our patients of particular risks of taking drugs during pregnancy, often with limited information.

This rather helpful study based in Denmark looked at the risks of taking aciclovir, valaciclovir and famciclovir during the first trimester of pregnancy.

Of the more than 800,000 women in the study, 1,804 were exposed to these drugs in the first trimester of pregnancy.

The researchers found that 2.2 per cent of infants had major birth defects among the exposed group, compared with 2.4 per cent of unexposed infants.

This study is comforting evidence on the safety of using antiviral drugs in pregnancy and should help us manage our patients with greater assurance.

Treating adults with ADHD using CBT - JAMA 2010; 304(8): 875-80
While many of us probably focus on ADHD among children, there is far less consideration of ADHD in adults. Paradoxically, according to this paper, ADHD in adults is prevalent and has a profound impact on patients and their families.

Cognitive behavioural therapy (CBT) as a treatment for adult ADHD was assessed in this study of 86 patients. The US-based study was an RCT looking at people who were not satisfactorily treated with pharmacological treatments alone. Patients were randomised to either CBT or relaxation therapy with educational support.

ADHD severity scores were lower in the treatment group compared with the controls. In addition, patients reported improved symptoms in the treatment group. These benefits were found to continue at six and even 12 months after CBT.

This study raises two main issues: first, that CBT may be offered as a treatment modality in adult patients with ADHD. Secondly, and arguably more importantly, it raises awareness of ADHD among adults with mental health symptoms.

Laparoscopic bariatric surgery in England - BMJ 2010; 341: c4296
Bariatric surgery is often discussed in the media, not least due to the financial implications of the procedure.

This population-based UK cohort study looked at outcomes in those who had primary gastric bypass, gastric banding or sleeve gastrectomy between April 2000 and March 2008.

A total of 6,953 operations were carried out during the study period. A 10-fold rise in the total number of procedures was seen between 2000 and 2007, and there was a large increase in the number of procedures carried out laparoscopically.

The overall 30-day mortality rate was 0.3 per cent and the 28-day unplanned postoperative readmission rate was 8 per cent. Gastric banding had the most favourable outcome.

These data show a surprisingly low mortality rate given the surgical risk and will help us inform our patients about the risks of bariatric surgery.


These further action points allow you to double the credits claimed by increasing the time spent and the impact achieved.

  • Perform a search for your patients with migraine, establish whether or not they have aura and set up a disease register. Then aim to reduce their cardiovascular risk.
  • Read about adult ADHD and present what you have learned at a practice meeting. Develop a case finding and treatment pathway for adult patients with ADHD.
  • Discuss the cost of bariatric surgery with your local collaborative and consider how you may manage the demand for surgery with the development of consortia.

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Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review journals

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