Journals Watch - Wheeze, flu, vitamin K and PTSD

Too busy to catch up on the latest research? Let Dr Jonathan Holliday update you on recent papers.

Inhaled steroids in infants Arch Dis Child 1 March 2009.doi: 10.1136/adc.2007.132100
Inhaled corticosteroids (ICS) are commonly used to treat wheezing disorders in children, but I have little experience of their use in infants.

Inhaled corticosteroids

In this study the use of ICS in very young children was evaluated. Forty-four children aged between four and 26 months who suffered recurrent cough and/or wheeze were formally assessed for lung function (functional residual capacity and specific airways conductance were measured).

The children were given inhaled budesonide 400 microgram/day via a chamber, or placebo, for six weeks, then the tests were repeated. Treatment improved lung function in infants with chronic cough or wheeze.

Given that the mechanism is not via receptor sites, I suppose that there is no reason why it should not be effective as a treatment.

Weight and smoking in late adolescence BMJ 2009; 338: b496
The Swedish military service conscription register gives the opportunity for large numbers of men to be followed over a long period.

This research looked at the impact of weight and smoking and sought to establish whether all-cause mortality was compound for those who were obese smokers in their late teens.

A total of 45,920 men were followed for 38 years, giving over 1.7 million years of study. The risk of dying during the 38 years of follow up was increased from 17 per 10,000 person-years to 23 in overweight and to 38 in obese men.

For smoking, the figures were 14 per 10,000 for non-smokers, 15 for light smokers and 26 for heavy smokers. The hazard ratios were very similar for overweight and light smokers, and for obese and heavy smokers. But there did not appear to be a compounding of that effect for obese smokers.

We are reminded that there is a real prize to be gained by persuading our teenagers not to become obese and not to smoke.

Oseltamivir-resistant influenza A (H1N1) JAMA 2009; 301: 1,034-41
For those of us still worrying about bird flu, the revelation that there is increasing resistance to one of the few weapons in our armoury is not good news.

During the 2007/8 flu season, resistance among influenza A viruses to oseltamivir increased significantly for the first time.

In the US, influenza A (H1N1) accounts for about 20 per cent of circulating flu virus, and during the 2007/8 season 12 per cent were found to be resistant.

There appeared to be no distinguishing features between those who acquired resistant as opposed to sensitive forms of the virus and none of those with the resistant form had been exposed to oseltamivir.

Even more worrying is the finding that 2008/9 is likely to be worse. So far, 264 of 268 influenza A (H1N1) viruses tested have proved resistant (98.5 per cent of those tested).

Oral vitamin K and over-anti-coagulation with warfarin Ann Intern Med 2009; 150: 293-300
Over the years medical registrars seem to be more blase about high INRs when a GP phones in a panic. So I was quite glad to find some evidence behind their response.

A randomised trial of low-dose oral vitamin K versus placebo was carried out in the US, Canada and Italy. All subjects were non-bleeding patients with INR values of between 4.5 and 10.

The primary outcome measure was bleeding and the secondary outcome measures were thromboembolism and death.

Around 16 per cent of patients in each group had at least one bleeding complication while more patients in the vitamin K group had a major bleed or thromboembolism, despite the INR coming down more quickly.

Curbing excessive cannabis use in young people Br J Gen Pract 2009; 59: 166-72
This study from Switzerland aimed to see if a brief intervention by the GP could reduce cannabis use.

Patients were aged 15-24 and were consulting in general practice for any reason. They were recruited before the consultation and were contacted again one month later.

It was a small study of 78 people but nonetheless produced some interesting figures. One in seven was using cannabis more than once per week and one in three was drinking excessively.

The intervention takes less than five minutes, involving five areas of questioning: ask about use, advise to stop, assess willingness to stop, assist in stopping attempt and arrange follow up.

Follow up in the study was better for those who had left mobile phone contact details rather than email, but overall there were follow-up data for 63 per cent.

The researchers seemed unable to confirm any benefit to the patient from the intervention. However, most participating GPs felt it was useful to help them to develop their knowledge of drug use.

Post-traumatic stress disorder and risk of suicide Arch Gen Psychiatry 2009; 66(3): 305-11
This was a US cohort study following 1,698 students to look at the association between traumatic events and risk of suicide. Mean age was 21 years; 47 per cent were male and 71 per cent were African-American.

The stress included both assaultive and non-assaultive traumas. The nature of the stress seemed not to relate to risk of suicide.

What did correlate with risk of suicide very clearly was the presence of post-traumatic stress disorder (PTSD). This was true even when compounding factors such as previous major depressive episodes, alcohol or drug use or abuse were taken into account.

The authors concluded that PTSD was an independent predictor of attempted suicide and that exposure to traumatic events in its absence was not associated with suicide risk.

  • Dr Holliday is a GP in Eton, Berkshire, and a member of our panel who review the journals

The Quick Study

  • Inhaled steroids can be helpful in treating wheeze and related symptoms even in the very young.
  • Weight and smoking are independent risk factors for mortality in adult life. Oseltamivir resistance is increasing quickly.
  • Oral vitamin K does not help to prevent bleeding in over-anticoagulated patients.
  • Cannabis use can be reduced by brief intervention from the GP.
  • Post-traumatic stress disorder following a traumatic event increases the likelihood of suicide.

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