SELECTED ABSTRACTS FROM OTHER JOURNALS

Edited by: Dr. M. Hammoudeh and Dr. A. A. Gehani
Hamad Medical Corporation, Doha, Qatar

Archives of Pediatrics & Adolescent Medicine

A Systematic Review of Nonpharmacological and Nonsurgical Therapies for Gastroesophageal Reflux in Infants

Journal of Anesthesia: 2002; 88: 72-77)

EUROPEAN HEART JOURNAL

Right Ventricular Cardiomyopathy In B-Thalassaemia Major Aims: To evaluate right ventricular function in patients with B-thalassaemia major and congestive heart failure.

Background: 

Nonpharmacological and nonsurgical measures are often recommended for gastroesophageal reflux disease (GERD) in infants, despite ambiguous supporting evidence.
Objective:  To conduct a systematic review of rigorously evaluated nonpharmacological and nonsurgical therapies for GERD in infants.

Design and Methods:

  We searched online bibliographic databases, including MEDLINE, EMBASE, the Cochrane Collaboration and Clinical Trials Database, and alternative medicine databases for the terms gastroesophageal reflux and infants. We selected randomized controlled trials of nonpharmacological and nonsurgical GERD therapies in otherwise healthy infants. Data were extracted from the selected articles regarding reflux, emetic episodes and intraesophageal pH.

Results: 

We identified 43 relevant studies, of which 10 met the selection criteria. These studies examined positioning, pacifier use, and feeding changes. Positioning at a 60° elevation in an infant seat was found to increase reflux compared with the prone position. No significant difference was shown between the flat and head-elevated prone positions. The impact of pacifier use on reflux frequency was equivocal and dependent on infant position. The protein content of formula was not found to affect reflux. Although no study demonstrated a significant reflux-reducing benefit of thickened infant foods compared with placebo, 1 study detected a significant benefit of formula thickened with carob bean gum compared with rice flour (pH<4 for 5% vs 8% of time). Another study showed that if supplementing with dextrose 5% water or dextrose 10% water, the lower-osmolality fluid was associated with less reflux.

Conclusions: 

Many conservative measures commonly used to treat GERD in infants have no proven efficacy. Although thickened formulas do not appear to reduce measurable reflux, they may reduce vomiting. Further studies with clinical outcomes are needed to answer questions about efficacy definitively.

(Arch Pediatr Adolesc Med.2002;156:109-113; Aaron E. Carroll, Michelle M. et al, Robert Wood Johnson Clinical Scholars Program, H-220 Health Sciences Center, Box 357183, Seattle, WA 98195)

Archives of Internal Medicine

Levothyroxine Treatment and Occurrence of Fracture of the Hip

Background:

  Levothyroxine sodium is widely prescribed and has been implicated as a cause of reduction in bone mineral density and, therefore, suggested to be a major contributor to the risk of osteoporotic fractures.
Objective:  To investigate whether levothyroxine use increases the risk of developing osteoporotic fractures.

Methods: 

We conducted a population-based, case-control analysis of the risk of a femur fracture in a large cohort of patients who had been prescribed levothyroxine. We used the United Kingdom General Practice (primary care) Research Database to identify 23 183 patients who had been prescribed long-term thyroid hormone therapy and to identify for each patient taking levothyroxine 4 controls matched for age, sex, primary care practice, and duration of registration on the database. The number of patients who had sustained a fracture of the proximal femur was ascertained for each group, together with drug therapies and medical diagnoses likely to affect fracture risk.

Results: 

Of the 23 183 patients prescribed thyroid hormone, a mean ± SE of 1.61% ± 0.08% had sustained a fracture of the femur, compared with 1.44% ± 0.04% of 92 732 controls (P = .06). When analyzed according to sex, a significant difference in rate of fracture between patients taking levothyroxine and controls was found in males (P = .008). Compared with controls, patients taking levothyroxine had higher reported rates of medical diagnoses and therapies, potentially confounding the fracture risk. Independent predictors of the occurrence of fracture after adjustment for other factors were age (adjusted odds ratio [AOR], 1.11; 95% confidence interval [CI], 1.10-1.11; P<.001), medical diagnoses including rheumatoid arthritis (AOR in females, 1.69; 95% CI, 1.27-2.26; P<.001), excessive use of alcohol (AOR in females, 3.05; 95% CI, 1.94-4.76; P<.001), and prescription of drugs (eg, anticonvulsants; AOR in females, 2.49; 95% CI, 2.00-3.09; P<.001). Prescription of levothyroxine was an independent predictor of fracture occurrence in males (AOR, 1.69; 95% CI, 1.12-2.56; P = .01) but not females (AOR, 1.03; 95% CI, 0.92-1.16; P =.60).

Conclusions: 

The lack of association between fracture and levothyroxine prescription in the whole cohort is reassuring, although an independent association between levothyroxine prescription and fracture occurrence in male patients suggests that levothyroxine may contribute to fracture risk in this specific group.

(Arch Intern Med. 2002;162:338-343; Michael C. Sheppard, Roger Holder, Jayne A. Franklyn, Departments of Medicine, The University of Birmingham, Queen Elizabith Hospital, Edgbaston, Birmingham B15 2TH, UK)

Archieves of Neurology

Reduction of Plasma 24 S-Hydroxycholesterol (Cerebrosterol) Levels Using High-Dosage Simvastatin in Patients with Hypercholes-terolemia
Evidence That Simvastatin Affects Cholesterol Metabolism in the Human Brain

Background: 

Previous studies have shown that patients with early onset of Alzheimer disease and vascular dementia have higher levels of circulating brain-derived 24S-hydroxycholesterol (cerebrosterol).Two recent epidemiological studies indicated that treatment with inhibitors of cholesterol synthesis (statins) reduces the incidence of Alzheimer disease.

Objective: 

To test the hypothesis that treatment with high-dosage simvastatin reduces circulating levels of 24S-hydroxycholesterol.

Design: 

Prospective, 24-week treatment trial for lowering of cholesterol levels. We conducted assessments at baseline, week 6, and week 24.

Setting: 

An academic outpatient clinical study.

Patients: 

Eighteen patients who met the criteria for hypercholesterole-mia.
Intervention  Treatment with 80 mg/d of simvastatin at night.
Main Outcome Measures  Plasma lipoprotein levels were measured enzymatically; lathosterol, by means of gas chromatography; and 24S-hydroxycholesterol, by means of gas chromatography–mass spectrometry.

Results: 

Simvastatin reduced total plasma cholesterol levels by 36% and 35% after 6 and 24 weeks, respectively (P<.001). Lathosterol levels were reduced by 74% and 72%, respectively, and the ratio of lathosterol to cholesterol, an indicator of whole-body cholesterol synthesis, was reduced by 60% and 61%, respectively (P<.001). Plasma 24S-hydroxycholesterol levels were lowered by 45% and 53%, respectively (P<.001). The ratio of 24S-hydroxycholesterol to cholesterol also decreased significantly (-12% [P= .01] and -23% [P<.002], respectively). The further reduction of 24S-hydroxycholesterol levels and its ratio to cholesterol from weeks 6 to 24 was also significant (P= .02 for both).

Conclusions: 

The greater reduction of plasma concentrations of 24S-hydroxycholesterol compared with cholesterol indicates that simvastatin in a dosage of 80 mg/d reduces cholesterol turnover in the brain. The present results might describe a possible mechanism of how long-term treatment with statins could reduce the incidence of Alzheimer disease.

(Arch Neurol. 2002;59:213-216, Sandra Locatelli, Dieter Lütjohann, et al, Department of Clinical Pharmacology, University of Bonn, Bonn, Germany)

LANCET

Clinical Efficacy of 3 Days Versus 5 Days of Oral Amoxicillin for Treatment of Childhood Pneumonia: A multicentre double-blind trial.

Background:

For most infections, especially acute respiratory infections (ARIs), the recommended duration of therapy is not based on strong scientific or clinical criteria. Shorter courses of antibiotics for non-severe pneumonia would result in lower costs, enhance patient compliance, and might help to contain antimicrobial resistance. We aimed to compare the clinical efficacy of 3-day and 5-day courses of amoxicillin in children with non-severe pneumonia.

Methods:

We recruited 2000 children, aged 2-59 months, with non-severe pneumonia (WHO criteria) diagnosed in the outpatient departments of seven hospitals. Patients were randomly assigned to 3 days or 5 days of treatment with oral amoxicillin. The primary outcome was treatment failure. Analyses were by intention to treat.

Findings:

We allocated 1000 children to 3 days of treatment and 1000 to 5 days. Treatment failed in 209 (21%) patients in the 3-day group, and in 202 (20%) in the 5-day group (difference 0·7%; 95% CI -1·8 to 3·2). In 12 (1%) children in the 3-day group and in 13 (1%) in the 5-day group the disease relapsed (difference 0·1%; -0·6 to 0·8). Treatment was more likely to fail in children who did not adhere to treatment (p<0·0001), in those younger than 12 months (p<0·0001), in those whose illness lasted for 3 days or longer (p=0·004), in those whose respiratory rate was more than 10 breaths/min above the age-specific cut-off (p=0·004), and in those with vomiting (p=0·009). Non-adherence was also associated with failure of treatment in the 5-day group (p<0·0001).

Interpretation Treatment with oral amoxicillin for 3-days was equally as effective as treatment for 5 days in children with non-severe pneumonia. The most important risk factor for treatment failure was non-compliance, which was also associated with longer duration of therapy.

(Lancet 2002; 360: 835-841, Pakistan Multicentre Amoxicillin Short Course Therapy (MASCOT) pneumonia study group, Correspondence to: Dr Shamim Qazi, Department of Child and Adolescent Health and Development, World Health Organization, 20 Avenue Appia, CH 1211, Geneva-27, Switzerland)

Annals of Surgery

Etiology, Diagnosis, and Treatment of Failures After Laparoscopic Heller Myotomy for Achalasia

Objective:

To assess the causes of failure of laparoscopic Heller myotomy and to verify whether endoscopic pneumatic dilation is a feasible treatment.

Summary Background Data:

Laparoscopic Heller myotomy has proved an effective treatment for esophageal achalasia, with good or excellent results in 90% of patients. The treatment of failures remains controversial, however.

Methods:

From 1992 to 1999, 113 patients underwent laparoscopic Heller myotomy for esophageal achalasia. Ten patients (8.7%) reported dysphagia (n = 7) or chest pain (n = 3) a median of 5 months after surgery (range 1-12) and were considered surgical failures. Pre- and postoperative radiologic, manometric, and 24-hour pH monitoring findings in patients with achalasia recurrence were compared with those of 74 asymptomatic subjects.

Results:

The preoperative characteristics of the two groups were comparable. After surgery, a decrease in resting lower esophageal sphincter pressure was observed in both groups, whereas the abdominal and overall lengths were significantly shorter among the asymptomatic patients. No patients with recurrence had abnormal gastroesophageal reflux. Based on time to recurrence and manometric and fluoroscopic findings, the etiology of the recurrences was classified as incomplete myotomy upward (n = 1), incomplete myotomy or sclerosis of the myotomy downward (n = 7), or sigmoid megaesophagus (n = 1); in one patient the authors could not establish the etiology. Seven of nine patients were effectively treated with endoscopic pneumatic dilations (median 2 dilations, range 1–4); one refused to undergo further treatment. Two patients underwent redo surgery.

Conclusions:

Recurrence of symptoms after myotomy is mainly related to incomplete myotomy or sclerosis of the distal site of the myotomy; it can be treated by dilations after surgery.

(ANNALS OF SURGERY 2002;235:186-192, Giovanni Zaninotto, Mario Costantini, Giuseppe Portale, et al, Department of Medical and Surgical Sciences, Clinica Chirurgica IV, University of Padova School of Medicine, Padova, Italy)