From the journals, September and October 2004

New Eng J Med Vol 351 — 16 Sep–7 Oct

1175 Talking about death to your dying child must be one of the hardest tasks a parent can face, but those who managed to do it never regretted it, as detailed in this study of Swedish parents bereaved of a child by cancer.

1285 Kidney function and heart function are closely inter-related, and patients with renal impairment tend to fare badly following myocardial infarction, according to data from the VALIANT study.

1306 The croup season is about to begin, and the strange bark of parainfluenza will be heard throughout the land. Spare a thought for the exhausted child, parents, and out-of-hours doctor, and prescribe a single dose of dexamethasone early in all but the mildest cases.

1493 Carotid endarterectomy has become quite a common procedure, made safer by the arrival of emboli-preventing filters. This trial added a stent in high-risk cases; the stented group did better.

Lancet Vol 364 — 18 Sep–9 Oct

1039 Painstaking, old-fashioned bacteriology may have finally discovered the causal agent of Crohn's disease. A subspecies of Mycobacterium avium was grown from the blood of 50% of patients with active Crohn's, but none of the controls.

1045 When the first studies appeared showing the clear superiority of immediate revascularisation over thrombolysis for myocardial infarction, I wondered how the United Kingdom's system would ever cope. Fortunately, a Spanish study (GRACIA-1) has shown that immediate thrombolysis followed by revascularisation a day or two later works just as well. There is a GRACIA-2 trial to follow. Muchas gracias.

1141 We tend to think of intravenous antibiotics as more effective than oral, but this need not be true. This study shows equivalent outcomes even in severe childhood pneumonia.

1149 We are still seeking the magic cure for multiple sclerosis, and may be quite near. But it is not intravenous immunoglobulin, which did the same as placebo in this blinded RCT.

1219 Antioxidant vitamins seemed to increase overall mortality in this study of supplementation to prevent bowel cancer. Is nothing sacred?

1334 If you got drunk enough to end up in A&E, you might be forced to realise you had an alcohol problem. This useful London study proves just that — people in this situation are amenable to advice and change.

JAMA Vol 292 — 15 Sep–6 Oct

1326 A study that suggests that beta blockers reduce the risk of fractures.

1433 The ‘Mediterranean diet’ is a somewhat flexible concept in this study, which gives Brownie points for fruit, nuts, and vegetables, and finds that they do indeed improve life expectancy and reduce cardiovascular events.

1447 It is also a good idea to walk a lot, to prevent dementia as well as cardiovascular disease, in both men (this study) and women (see page 1454).

1573 A big placebo-controlled randomised trial (part of the Women's Health Initiative Study) proves that women taking conjugated equine oestrogen plus medroxyprogesterone have twice the risk of venous thrombosis.

1581 But exactly which ingredient was to blame? This case-control study finds some added risk from conjugated oestrogen taken alone, but none from esterified oestrogen taken alone. Combine either with progestagen, and the risk increases. So the HRT debate gets ever more complicated … because you also need to factor in the risks for breast cancer and cardiovascular events.

Other Journals

Arch Intern Med (164: 1788) discusses the inadequacy of serum creatinine alone as an index of renal function, and shows that general practitioners can be taught to understand laboratory reports giving an estimated glomerular filtration rate (as used in the New Engl J Med study cited above). More from the Whitehall II Study on page 1873: the more poorly paid and frustrated a civil servant, the more likely s/he is to develop type 2 diabetes. For long-term success in treating insomnia, cognitive behavioural therapy (page 1888) may be best. The Norfolk–EPIC study yields more intriguing associations in Ann Intern Med (141: 413), with glycosylated haemoglobin (HbA1c) levels predicting cardiovascular disease even in the ‘normal’ range.

Epidemiology (15: 573) analyses data from a large Swedish population study to find out what sort of everyday activity prevents myocardial infarction. Walking or standing at work, or strenuous housework are beneficial, so if you spend the day sitting in a consulting room, get the hoover out as soon as you reach home.