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On the Pulse - 6th February 2009

On The Pulse

Tertius Lydgate

Friday, 06 February 2009

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Systemic or subacromial steroid?
Shoulder pain is a common complaint and rotator cuff syndrome is the usual cause. Subacromial injections of corticosteroids are thought to be a useful treatment, although the evidence is inconclusive. One area of controversy concerns the importance of accurate placement of steroid into the subacromial bursa. The findings of an RCT in the BMJ suggest that it doesn’t matter much. Outcomes at 6 weeks were much the same whether the steroid had been injected into the subacromial bursa under ultrasound guidance or simply stuck into the gluteus maximus.

BNP as a marker in heart failure
Clinicians who manage heart failure have long hoped for a single marker that could guide treatment. So far,  trials of BNP as such a marker have been small and mainly confined to  younger patients. A study in JAMA compares its use to symptom-guided therapy in 499 patients aged 60 and above, examining hospitalization-free survival and quality of life. There was no overall difference between the two methods, with an improvement in hospitalization for heart failure in those aged under 75 being offset by more adverse effects in older patients from the greater up-titration with BNP-guided therapy. An accompanying Editorial surveys the story so far, and suggests that heart failure in older and younger patients may be different disease entities.

An unresponsive patient with a poor prognosis
A 56-year-old homeless man is admitted to hospital following a subarachnoid haemorrhage from a ruptured aneurysm of the anterior communicating cerebral artery. He scores 5 on the Glasgow Coma Scale, and the neurosurgical view is that the risks of operation are high and the outlook poor. The situation is complicated by divergent but strong opinions among family members about what the patient would have wanted and by the fact that an upper GI endoscopy (undertaken to place a percutaneous endogastric tube for feeding) reveals a large ulcer with fungating edges. Three different plans of management are discussed and defended in the NEJM, and there’s an opportunity for readers to vote for their preferred option.

Acupuncture for pain
The best way to assess alternative therapies is often controversial, as few are as simple as a daily pill. Trials of acupuncture have had varying results, often with a strong placebo effect – blinding is obviously difficult to arrange, and double blinding probably impossible. A meta-analysis in the BMJ assesses the results from 13 RCTs, and again finds that the bulk of the acupuncture effect is generally accounted for by placebo, although there was large variation between studies. However, a Rapid Response from the Acupuncture Association of Chartered Physiotherapists questions the homogeneity of the studies, which admittedly embrace a wide range of clinical conditions.

SSRIs and suicide
Trial evidence has suggested that in adolescents and young adults, use of selective serotonin reuptake inhibitors (SSRIs) may be associated with an increase in suicidality. However, since such outcomes are generally self-reported in trials, and there was no corresponding increase in actual suicides, interpretation has been difficult. Does participation in a trial simply encourage young people to report suicidal feelings? To answer this question, a meta-analysis in the Canadian Medical Association Journal addresses only observational studies, in the hope that the ‘real life’ setting will offer more insight. The results confirm an increased risk of suicide or attempted suicide among adolescents, but suggest a protective effect in adults both young and old. An accompanying Commentary weighs the findings.

Mammography for survivors of childhood cancer
Girls who receive radiotherapy to the chest for a paediatric malignancy are at increased risk of breast cancer if they survive into adult life, with risk greatest among women treated for Hodgkin lymphoma with high-dose mantle radiation. Here, the cumulative incidence of breast cancer may reach 20% by the age of 45 years, which is as high as in women with a BRCA gene mutation. An article in JAMA highlights the underuse of screening mammography in this group, where annual examination after the age of 25 is recommended.

GISSI-HF sparks debate
The results of the GISSI-HF trial, mentioned in this column last year, prompt a flurry of letters in the Lancet. Some dispute the conclusion that ω-3 polyunsaturated fatty acids are of modest benefit in heart failure: one contends that the use of multiple analyses was inadequately accounted for; others suggest confounding by diet, cardiac dilatation or rosiglitazone. Other letters dispute the uselessness of rosuvastatin: one rather desperately suggests that Q10 depletion by statins might mask a therapeutic effect; another questions the matching of patient groups. A lengthy response from the original authors appears to overcome most of these objections.

Survival in living kidney donors
Last year, in a rather moving piece, the news editor of the BMJ described how she became a kidney donor for an old friend with polycystic disease who was about to need dialysis. It’s hard to imagine a more generous act than giving away a kidney, so it’s good to see from a long-term follow-up study in the NEJM that donors don’t compromise their health, longevity or quality of life. Of nearly 4000 living kidney donors, end-stage renal disease developed in only 11 – a rate substantially lower than in the general population. The majority of donors had a preserved GFR, and their rates of albuminuria and hypertension were similar to those of controls.

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Tertius Lydgate

Originally from Northumberland, Tertius Lydgate studied medicine in Edinburgh, London and Paris. There he developed a special interest in communicable diseases and hoped to make great advances in treating and preventing them. But, after a promising start in a provincial centre of excellence in middle England, he was forced by circumstances (please, don't inquire) to abandon his high ideals. He now scrapes a living by pouring cold water on the over-enthusiastic at his private cryohydrotherapy clinic. Dreaming of the contributions he once hoped to make himself, he finds consolation in the latest medical journals and is happy to share his discoveries with his readers. He thinks that his creator, George Eliot, would have approved.
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