Psoriasis, otitis media and smoking

Short on time to read the research? Dr Simon Hunter summarises his pick of the recent papers.

Psoriasis and mortality
Arch Dermatol 2007; 143: 1,493-9

Some previous studies have indicated that the presence of psoriasis is associated with an increase in the risk of mortality while others haven't. This UK-based cohort study compared patients with mild psoriasis, patients with severe psoriasis (requiring systemic therapy) and controls with no psoriasis.

Those with mild psoriasis had no increase in mortality, but those with the severe form had a 1.4 times greater risk of mortality, after adjusting for risk factors.

On average women with severe psoriasis die 4.4 years and men 3.5 years younger. The increased risk existed even when excluding those with psoriatic arthritis and rheumatoid illnesses. Who says the dermatologists just look after benign conditions?

Novel approach to otitis media
Arch Dis Child 2008; 93: 40-4

The treatment of childhood otitis media is fraught with controversies. Multiple studies have shown that antibiotics have minimal effect on pain and duration of illness, but on the other hand the child is usually ill and very miserable and the parents want something done.

This study looked at the effect of topical 2% lignocaine drops, administered into the ear canal. The outcome measures were pain at 10, 20 and 30 minutes compared with placebo drops. They found a significant reduction in pain at 10 and 30 minutes.

Complemented by oral analgesia, this really could be a workable non-antibiotic solution.

Poor sleep and obesity
Am J Epidemiol 2007; 166: 1,368-73

An area of research that is gaining interest is the role of sleep in obesity and insulin resistance, as studies have shown an increase in cardiovascular mortality in poor sleepers.

This study compared maternal-reported poor sleep at ages two to four years and risk of obesity at age 21. They found, after adjusting for all the confounders they could think of, that there was a correlation.

Various explanations were mooted, such as poor sleepers would be too tired to exercise, and the more active you were in the day time, the more tired you would be at night.

Prevention of diabetic ulcers
Am J Med 2007; 120: 1,042-6

Diabetic foot wounds are common and once present are expensive and difficult to heal. They are frequently caused by repetitive minor trauma to a limb already affected by neuropathy causing inflammation and then skin breakdown.

This inflammation prior to the skin breakdown was used in this study to see if ulcer formation could be predicted and thus prevented.

Patients were divided into two groups, all of whom received foot education and instructions on how to perform a daily visual check, but the intervention cohort were given an infrared skin thermometer to compare the temperature between their two feet in six places on a twice daily basis. A temperature difference of more than 4 degsF was considered significant and the patient then rested the foot until the temperature normalised. Subjects in the intervention group were a third as likely to ulcerate as those in the control group.

I think this is a genuinely good idea and I hope a system can be devised where it can be mimicked simply in a clinical setting.

Delayed-release steroids in rheumatoid arthritis
Lancet 2008; 371: 205-14

Glucocorticoids are now in their 60th year of use, and are still used frequently and new roles continue to be found, but they are not without side-effects so research goes on into increasing their targeted effectiveness.

In this study, delayed-release steroid tablets were given at bedtime, which released their therapeutic load at 2am at the same time as the natural circadian cortisol release and peak of stiffness symptoms. This was compared against immediate-release prednisolone on waking. The modified release group had a reduced level of morning stiffness.

By implication one could assume you could get better control for the same amount of steroid or reduce the steroid taken.

Exercise is good for you
Am J Cardiol 2007; 100: 1,759-66

As the nation becomes fatter, more of the population will develop the collection of cardiovascular risk factors known as the metabolic syndrome.

To assess the effect of exercise on the parameters of this syndrome, subjects were divided into three groups.

The first had to walk 19km (about 12 miles) a week, the second jogged 19km a week and the third jogged 32km a week.

The first group showed a definite improvement over inactive comparators and the third group even more so.

Annoyingly, the second group didn't show any advantage over inactive subjects. As someone who runs four miles three times a week, I am somewhat peeved by this. What we can glean from this is that the current advice on walking is valid and a lot of vigorous exercise is very good for you.

Ageing from smoking
Arch Dermatol 2007; 143: 1,543-6

There has, for a few decades, been observations that you can spot a smoker from their face.

They often have an unhealthy, prematurely aged appearance. However, in medicine we like controlled proof. This paper showed photographs of two identical twins who had lived near each other, had the same sun exposure and the same type of job.

One, however, had a 52.5 pack- year smoking history. The effect is striking, with the smoker's facial skin showing much more signs of ageing.

I have previously wondered if the unhealthy look of smokers came from a frequently coexistent lifetime of poor nutrition, but these photos show that, for at least these twins, smoking is a huge factor. Many people who spend a fortune on miracle anti-ageing creams still smoke the evil weed.

Dr Hunter is a GP in Bishop's Waltham, Hampshire and a member of our team who regularly review the medical journals.

The quick study
Severe psoriasis increases mortality risk.

Otitis media pain might be relieved with topical lignocaine, reducing the need for antibiotics.

Poor childhood sleep may correlate with obesity in adulthood.

Foot ulcer risk in diabetic patients may be predicted by measuring skin temperature differences.

Rheumatoid arthritis is better controlled by delayed-release steroids at night than the same dose on waking.

Exercise has a better effect on cardiovascular risk when moderate intensity, versus vigorous intensity for a shorter period.

Smoking ages the skin, as shown by twin studies.

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