Ann Robinson’s journal review—7 November 2019

Ann Robinson reviews the latest research from the top medical journals


Prevalence of survival without major comorbidities in adulthood and premature birth

This Swedish population-based cohort study of more than 2.5 million people born over 25 years (1973-1997), found that health outcomes in adulthood (ages 18-43 years) are strongly related to gestational age at birth. The prevalence of survival without any major comorbidities was 63% in those born at full term (39-41 weeks), 61.2% for early term (37-38 weeks), 58% at late preterm (34-36 weeks), 48.5% at very preterm (28-33 weeks), and only 22.3% in those born extremely preterm (22-27 weeks). More than 95% of preterm infants in developed countries now survive into adulthood. This survival has previously come at the cost of an increased risk of cardiometabolic, respiratory, and neuropsychiatric ill health. This study showed that the absolute risk of complications is low, although extreme prematurity does still mean that survival tends to come at a price. Comparing the health outcomes with siblings showed that the findings were attributable to the degree of prematurity rather than shared genetic or environmental factors. One limitation is that follow up was only until the age of 43, so any impact on later adult life couldn’t be assessed.

Levothyroxine for older people with subclinical hypothyroidism

Subclinical hypothyroidism (raised TSH levels, normal T4) is a common finding in people over 80 years old. Should we prescribe levothyroxine in such cases? This pooled analysis of data from two randomised clinical trials, with a total of 251 participants, found no significant improvement in thyroid-related patient-reported quality of life outcomes (ThyPRO), hypothyroid symptoms, or tiredness in those given levothyroxine compared with placebo. Previous studies have shown similar results, but people aged 80 and over, who are generally underrepresented in trials, hadn’t been specifically studied, and nobody had asked about their quality of life and whether it improved once subclinical hypothyroidism was treated. It’s possible that individuals who are more symptomatic, have higher TSH levels, or are at greater risk of developing frank hypothyroidism may benefit from treatment, but this study wasn’t powered to examine those subgroups. 

JAMA Internal Medicine

Doctors experience of patient bias

How do doctors respond when patients use racist, sexist, homophobic or generally abusive language? This US qualitative study of  focus groups with 50 trainees, physicians and medical students found that “biased patient behavior” caused pain, upset, exhaustion, self doubt, cynicism, and confusion about how to respond. About half of those interviewed were non-white and half were women. This was a convenience sample-researchers recruited those most available-and we don’t know what non participants feel. All participants came from a single medical school in California with a diverse population of patients and doctors; other areas may have less of a problem or recognition of personal abuse. The study was qualitative which gives a flavour of experiences, but doesn’t quantify how often these events occurred. Participants wanted more training and better institutional support to guide responses. Just putting up a sign saying “We will not tolerate abuse towards our staff” in the waiting room isn’t enough.

Banning sugary drinks in the workplace

Does banning the sale of sugar sweetened beverages in the workplace reduce consumption and improve employees’ cardiometabolic health? This study found that a 10 month workplace ban on selling sugar sweetened beverages reduced consumption and waist circumference, but not body mass index or insulin sensitivity, among 214 employees who were drinking on average over 1 litre of sugar sweetened drinks a day. Half of the participants were randomised to a brief “motivational intervention” in addition to the sales ban to see if this provided added benefit. This was a 15 minute face to face talk with a health educator and three follow-up phone calls. The additional intervention led to a substantial fall in consumption in those who were most overweight. Intake was self-reported, although measured blood biomarkers suggest that reporting was broadly accurate. There was a variable and ultimately net neutral effect on blood biochemistry, lipids (total cholesterol actually rose in the lean group), and weight. Banning sugary drinks is an attractive idea, but the evidence of impact from this limited study is not very strong.

Annals of Internal Medicine

Drugs versus cognitive behavioural therapy for major depression

What is more cost effective in the initial treatment of newly diagnosed major depression—a second generation antidepressant such as venlafaxine, trazodone, bupropion, or mirtazapine; or cognitive behavioral therapy? Most trials have suggested that they work equally well, but this US study found that cognitive behavioral therapy produced higher quality adjusted life years (3 days more at 1 year and 20 days more at 5 years). The cost of cognitive behavioural therapy was higher at 1 year, but lower at 5 years. However, we can’t answer the question of cost effectiveness reliably, because longer term data, including risk of relapse, are not available. Many patients prefer talking therapy to drugs, and that should be taken into account.


Nintedanib in progressive fibrosing interstitial lung diseases

The INBUILD randomised multicentre trial found that nintedanib, a tyrosine kinase inhibitor, slowed the loss of lung function in people with progressive fibrosing interstitial lung disease (rate of decline in forced vital capacity -80.8 mL/year v -187.8 mL/year with placebo). Diarrhoea and abnormal liver function tests were common side effects. The fact that this seemingly heterogenous group of conditions—including chronic hypersensitivity pneumonitis, autoimmune interstitial lung diseases, and idiopathic pulmonary fibrosis—responded similarly lends weight to the concept that they share a common pathophysiology. Unfortunately, despite slowing the progression of fibrosis, there was no substantial improvement in quality of life.


Plaques matter

Lipid-rich plaques in coronary arteries, that appear to be non or only mildly obstructed, are associated with acute coronary syndromes and myocardial infarction. Do lipid-rich plaques detected by near-infrared spectroscopy imaging correlate with subsequent major coronary events in unstented areas? This study found that near-infrared spectroscopy imaging can be used as a tool to identify high risk patients and non-culprit arteries at high risk for future events on the basis of characteristics of the lipid-rich plaques. It’s important because 9% of patients with stable and acute coronary syndrome, who presented for cardiac catheterisation for possible percutaneous coronary intervention and were treated medically, went on to have non-culprit events within the next two years. Using multivessel near-infrared spectroscopy imaging during cardiac catheterisation and percutaneous coronary intervention may reduce this risk, but further studies are needed.

Ann Robinson is an NHS GP and health writer and broadcaster