BMJ  2006;333:591 (16 September), doi:10.1136/bmj.333.7568.591

Practice

BMJ family highlights

What's new this month in BMJ Journals

High dose inhaled steroid may cause adrenal insufficiency in children

Actual and potential adrenal insufficiency has been found in many children taking > 500 µg daily of inhaled fluticasone propionate for asthma. After a death from adrenal insufficiency and the near death of a sibling (the "index case"), investigators in Glasgow recalled 422 children registered as taking the preparation. Two hundred and eighty five of the children were taking more than the licensed recommendation of 400 µg daily (for ages 4-16). A tetracosactide (Synacthen) test on 194 of the children taking 500 µg or more showed a flat response in six (all of whom were taking 1000 µg or more) and impairment in 82 (40%). The index child and one other child had been symptomatic.

Credit: NADEN/PA/EMPICS

 

The authors recommend that all children taking doses of fluticasone propionate above the recommended level should have their adrenal function monitored; should carry a steroid card; and should have specific written advice for emergency steroid replacement at the time of any severe illness. In line with current guidelines, doses of inhaled steroid should be "stepped down" once control has been achieved.

Arch Dis Child 2006 doi: 10.1136/adc.2005.087247[Abstract/Free Full Text]

Citalopram may help irritable bowel

Symptoms associated with irritable bowel syndrome were improved with 20-40 mg a day of the selective serotonin reuptake inhibitor citalopram in a crossover trial involving 23 patients with longstanding problems. It was better than placebo at reducing abdominal pain, bloating, and the impact of symptoms on daily life.

No patient was depressed or anxious, so the findings do not seem to be a secondary effect of treating those disorders. However, previous tests on colonic sensitivity and response to feeding in these patients showed no significant effect of the drug. The investigators call for larger scale studies of efficacy.

Gut 2006;55: 1095-103[Abstract/Free Full Text]

Mycoplasma genitalium may cause recurrent urethritis

Men with recurrent or persistent non-gonococcal urethritis may be infected with Mycoplasma genitalium. The organism was detected in 32 of 78 men with non-gonococcal urethritis who returned to a Swedish clinic with symptoms despite standard treatment with doxycycline for nine days. Those who returned represented 27% of all 294 men presenting with non-chlamydial and non-gonococcal urethritis at the clinic. The investigators suggest testing for this organism in men with recurrent or persistent symptoms. Optimal treatment is not yet clear, but in this group azithromycin proved more effective for the men (and infected partners) than either doxycycline or erythromycin.

Sex Transm Infect 2006;82: 276-9[Abstract/Free Full Text]

US physicians may be tempted to overprescribe statins

Family physicians and internists in the United States have responded to a clinical vignette in a manner that suggests they are at risk of overprescribing lipid lowering agents. Over 2000 participants responded to the same scenario presented to them twice, with a two year interval. The hypothetical patient was a 50 year old man with a ratio of (high) total cholesterol to HDL (high density lipoprotein) cholesterol of 4.8. US guidelines do not recommend treatment in such a case, but 39% of those sampled stated initially that they would treat this case; the proportion rose to 51% when the same scenario was presented to them again two years later. "Overprescribers" were more likely to be family physicians, to be in a sole or two person practice, not to be board certified, and to be non-US graduates. They were also likely to spend more time in patient contact (possibly reducing their educational opportunities) and to have a financial inducement because of a greater number of Medicare or Medicaid patients.

The authors recommend that interventions to improve prescribing should consider the role of physician and practice characteristics in determining behaviour.

Qual Saf Health Care 2006; 15: 251-7[Abstract/Free Full Text]

Watch out, Australia

Two elite fast bowlers^* with persistent 11th rib tip pain resulting from the rib's impingement on the 10th rib or iliac crest did not respond to enforced rest, physiotherapy, and modification of bowling technique. After surgical resection of the distal part of the affected rib, both bowlers were able to resume their sport without further symptoms.

^*Bowlers who can propel the ball at 135-150 km/h with an "over the shoulder" straight arm action.

Br J Sports Med 2006;40: 732-3[Abstract/Free Full Text]

Optimistic results for lung cancer surgery

Kaplan-Meier survival plots for all 3211 Norwegian patients with lung cancer who had surgical resection from 1993 to 2002 show survival at 1, 3, and 5 years to be 74.5%, 50.9% and 49.9% respectively. The investigators conclude from their findings that even subgroups such as elderly patients and those with advanced stage tumours, small cell lung cancer, tumours with nodal invasion, or multiple tumours merit surgery where technically possible.

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Thorax 2006;61: 710-5[Abstract/Free Full Text]

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