On the Pulse

On the Pulse - 14th November 2008

Caffeine in pregnancy
There’s been much confusion lately about whether a little alcohol in pregnancy is good, bad or indifferent for the fetus. A paper in the BMJ instead examines the risks of Britain’s other favourite drug. It finds a dose-dependent relationship between caffeine intake (mostly tea) and the risk of fetal growth restriction, with no clear safe dose. Interestingly, the correlation is stronger in women with faster caffeine clearance, suggesting that a caffeine metabolite might be the culprit. But should we be advising pregnant women to cut out caffeine altogether? An accompanying Editorial is dubious, and several of the Rapid Responses also raise concerns, mainly about possible confounders.

The CAGE questionnaire
We’re not as sharp as we should be in detecting alcohol abuse and alcohol dependency in our patients. A commentary in JAMA reminds us about the value of CAGE questionnaire which, although well established as a sensitive screening tool, is seriously underused. There are only 4 questions to ask your patient. Have you ever: (1) felt the need to cut down your drinking; (2) felt annoyed by criticism of your drinking; (3) had guilty feelings about drinking; or (4) taken a morning ‘eye-opener’? A score of 2 to 3 positive responses indicates a high index of suspicion of alcohol dependence; a score of 4 is virtually diagnostic.

Alcohol-dependent doctors
Of course, the medical profession needs to set its own house in order where alcohol abuse is concerned. A paper in the BMJ reckons that, in the US, 1 in 10 doctors develops a substance abuse disorder (most commonly alcohol dependence) at some time. The outcome however, seems a good deal better than it is in the population generally. A longitudinal study of nearly 1000 US doctors who enrolled in a state physician health programme because of alcohol or drug misuse found that over three quarters were licensed and working five years later.

Is Sure Start working? 
A study in the Lancet evaluates the government’s ambitious Sure Start scheme aimed at young children in disadvantaged neighbourhoods. As a true RCT was deemed ethically unacceptable, it compares children from Sure Start areas with children from similar areas not yet covered, using data from the earlier Millennium Cohort Study. The results show improvements in a variety of measures that included both child and parent behaviours, but a similar study 2 years ago showed far less positive (and sometimes negative) results – a discrepancy the authors struggle to explain. An accompanying Comment is cautious, pointing out that cases and controls are not contemporaneous, and that even positive changes may be slow to bear fruit.

B vitamins and cancer
Hopes that vitamin supplementation could hold the key to cancer prevention have frequently been dashed; the latest investigation in the NEJM is no exception. Women who received folic acid, B6, and B12 were followed for up to 7.3 years as part of a cardiovascular prevention study. Despite the role of B vitamins in stabilizing DNA, cancer was just as frequent in these women as in the placebo group, perhaps because they were already in little danger of deficiency. Study subjects were at high risk of heart disease, but extrapolation to the general population seems reasonable. On the positive side, it appears that vitamin supplements don’t increase risk of cancer, as has sometimes been feared.

Testosterone for postmenopausal libido 
A substantial study in the NEJM attempts to treat reduced libido in menopausal women using testosterone patches for a year: about 150 receiving placebo, with similar numbers on 150 and 300 mg doses. The higher dose produced a modest improvement in symptoms at the cost of some unwanted hair growth, although this did not seem to affect adherence. Of more concern, there were four breast cancer cases in the treatment group, versus none in the placebo group. These numbers are small, and one case probably predated treatment, but an accompanying Editorial suggests caution until more is known.

Treating mild and moderate dementia
A 72-year-old woman has just been diagnosed with early Alzheimer’s disease. Short-term memory is her predominant cognitive problem, and she scores 24 out of 30 on the MMSE. She lives at home with her husband, but has become dependent on him, and gets anxious when left alone. What treatments might help? An updated set of evidence-based guidelines in the CMAJ provides some answers. Neither cognitive training nor cognitive rehabilitation is recommended, but there is some evidence that physical exercise programmes help. The adverse effects of psychotropic medications are likely to outweigh any benefit in reducing anxiety. These guidelines are equivocal about the value of cholinesterase inhibitors but, 2 years ago, NICE controversially advised that they should only be used for people whose MMSE score was between 10 and 20.

Nice or nasty?
Speaking of NICE, Dr Lydgate wonders whether you think of it as a heartless rationing agency or an intrepid and impartial pioneer in the badlands of setting priorities in health care? An article in the NEJM describes it from an American point of view. The author admires both the way NICE takes unpopular decisions about, for example, costly cancer drugs that extend life by only a few months and the tough-minded way in which it deals with the emotional responses from disappointed patients and special interest groups. As he writes: ‘saying no takes courage – and inevitably provokes outrage.’