Another new drug for alcoholism
Back in October, news emerged that topiramate was showing promise in helping alcoholics reduce their drinking. A report in the Lancet of a double-blind randomized trial in patients with liver cirrhosis now suggests that baclofen does something similar. Like topiramate, baclofen also reduces craving, probably by facilitating GABA neurotransmission. It's also claimed to have a better safety profile, without the changes in hepatic function tests sometimes seen with topiramate. But the main message remains that either of these drugs offers a real possibility of hope to a patient group in whom most other interventions have been unsuccessful.
Topical or oral treatment for knee pain?
A investigation in the BMJ used a combination of a randomized trial and a patient preference study to find out whether it’s better to advise people complaining of pain in the knee to use topical or oral ibuprofen. It turns out that there’s not much difference either way. At a year, scores for pain and disability were the same for both treatments, whether they had been allocated randomly or according to the wishes of the patient. Minor adverse effects were slightly commoner in the group given oral treatment, but only in the randomized trial. The author of the accompanying editorial reckons that the benefits of topical ibuprofen have more to do with the age-old practice of ‘rubbing it better’ than any pharmacological effect, but he welcomes the trial, because the results now allow him to prescribe a placebo with a clear conscience.
What patients think
Nested within the same study of knee pain was a qualitative investigation exploring patients’ views about the condition and its treatment. Even though they didn’t know much about how the medications worked, patients made sensible decisions about the use of NSAIDs. Their general view was that topical NSAIDs were for mild, local, and transient pain, while oral NSAIDs were appropriate for more severe, generalized, and constant pain. Who could disagree?
Smoking and diabetes
It seems unlikely that readers of this column need a new reason to stop smoking. But on the off-chance that you do, a meta-analysis in JAMA has revealed a link between smoking and the risk of type 2 diabetes. The analysis includes some 45,000 cases of diabetes, in 25 prospective cohort studies, and finds a relative risk of about 1.4. There was also something of a dose-response relationship: more like 1.6 in heavy smokers, and nearer 1.3 in light smokers. Correlation is not causation, of course, and smokers may simply have a less healthy lifestyle, including dietary choices more likely to result in diabetes. The authors dismiss the need for further cohort studies, and call for more investigation of plausible mechanisms and mediating factors.
Rosiglitazone back in the dock
Speaking of diabetes, there have been concerns about the cardiac side-effects of thiazolidinediones for several years, culminating in a recent US Food and Drug Administration advisory panel on the safety of rosiglitazone, which controversially ruled that there were insufficient data to remove it from the market. A study in JAMA now casts further doubt on that decision. Compared with people taking other oral diabetes treatments, those on monotherapy with thiazolidinediones were at increased risk of congestive heart failure, myocardial infarction, and death. Subgroup analyses suggest that the effect was largely confined to rosiglitazone, with a relative risk of ~1.5 for each of the three outcomes.
Caesarean section and respiratory problems
The continuing increase in elective Caesarean sections has prompted equally growing interest in their consequences. When there are clear medical indications for a Caesarean, minor adverse effects can be discounted. But when a healthy mother wants to make an informed decision, giving sound advice is not simple. The task is not made much easier by an observational study from Denmark in the BMJ. It examines ~35,000 pregnancies at a single hospital over the last 8 years, and links elective Caesareans (7.8% of deliveries) to respiratory morbidity in the baby. The effect is particularly strong at lower gestational age (nearly 4-fold increase at 37 weeks), but still significant at 39 weeks. If, as the authors suggest, low hormone levels, particularly of catecholamines, are the most likely mechanism for such an effect, the use of antenatal steroids is a possible remedy, albeit of unknown long-term safety.
Platelets
Tiny, anucleate and insignificant in appearance, platelets exert a powerful influence on health and disease. It’s good that they stick together to cause primary haemostasis and repair endothelial damage, but it’s bad when the same process initiates acute coronary syndromes, strokes, and atherosclerotic plaque formation. The New England Journal has a comprehensive review of platelet physiology, which should interest anyone involved in the primary or secondary prevention of vascular disease.
Plant power
James Lovelock, the originator of the Gaia theory, discusses Oliver Morton’s new book Eating the Sun in Prospect magazine. As you might guess from its title, the book is about how plant life provides most of the power that drives human and animal activities on our planet. Quite apart from its enthusiasm for the book, Lovelock’s review is worth reading for the side-swipes he takes at the peer review system, orthodox science and computer modelling. Here’s a taste: "I see modern science as like the medieval Christian church, burdened with the intricate theology of reduction… The technique of inquisition is not the rack but the peer review: a well-intentioned instrument for sifting good from bad science that has become the great upholder of conventional wisdom… The idea that we can stabilise rising temperature at some convenient level, say just two or three degrees above the pre-industrial norm, is probably the delusion of computer modelers."