Alex Nowbar’s journal reviews—10 May 2021

Alex Nowbar reviews the latest research from the top medical journals

Maternal covid-19 infection

A nationwide Swedish cohort study found increased rates of some neonatal morbidities, including respiratory distress, with maternal covid-19 infection. However, the increased risk was minimal, and, given the multiplicity of data (lots of different outcomes were looked at), it’s hard to know how genuine these findings are. The authors looked at 88 000 infants, of whom 1.6% were delivered by mothers who tested positive covid-19. Infants were matched by maternal characteristics, and the neonatal outcomes were compared between infants of covid-positive and covid-negative mothers. Confounding cannot be eliminated as these are observational data. So we do not know if covid-19 itself mediated the difference, or if it could have been due to the mothers with covid-19 being treated differently, or that factors that made the women more likely to get covid-19 also influenced the neonatal outcome. Generally these data are reassuring that covid-19 isn’t upping neonatal risk too dramatically.

JAMA doi:10.1001/jama.2021.5775

Education to reduce upper GI endoscopies for dyspepsia

De Jong and colleagues randomised 119 patients with uninvestigated dyspepsia to health education or usual care. I find this interesting given that usual care would, I imagine, include a level of education, or at least explanation. A year on, the proportion of patients having upper GI endoscopies was 39% in the education group and 82% in the usual care group. This is an impressive reduction in rates of a procedure with a low diagnostic yield (gastroscopy for dyspepsia) without compromising symptoms and quality of life. So what exactly was the education intervention, and can it be implemented widely? It was a web based tool with videos and 3D animations, so yes probably. I wonder what other procedures this approach could be applied to, because it sure sounds good. One slight caveat is that the results may only be generalisable to the type of patient who was prepared to participate in research rather than all comers. But even if there was some reduction in effectiveness, it would still be worth implementing to avoid gastroscopies that are unlikely to benefit patients.

JAMA Intern Med doi:10.1001/jamainternmed.2021.1408

Sexual acceptability of contraception

Higgins and colleagues explored the association of sexual function, satisfaction, and self reported sexual acceptability with continued contraception use over time in over 2000 women in Utah, USA. Contraception needs to be adhered to if it’s going to be any good to anyone, so it’s vital that factors affecting adherence are understood. Interestingly, more than half of the women felt that the contraception had improved their sex life. Contraception making their sex life worse was strongly associated with stopping the contraception method at six months. Sexual acceptability turns out to be really important. This is therefore an important topic to cover in contraception decision-making conversations—just as much as mood, weight gain, and blood pressure get covered.

JAMA Intern Med doi:10.1001/jamainternmed.2021.1439

Immunological intrigue with paediatric brain tumours

Immunovirotherapy is not my bread and butter, but it seems to do something for high grade paediatric gliomas (a condition with poor survival) in a single arm trial of 12 patients. The therapy is a genetically engineered oncolytic herpes simplex virus (G207). It is designed to selectively infect and lyse tumour cells. It is also supposed to reverse tumour immune evasion. It is adminstered directly into the tumour and supplemented with radiation to enhance the efficacy of G207. The results of this phase I trial were favourable in terms of clinical response and safety. Hopefully, phase II will be promising too. 

N Engl J Med doi:10.1056/NEJMoa2024947

Tranexamic acid for C-section

The era of randomised obstetric research is in full swing. In this trial, 4551 women undergoing caesarean delivery were randomised to tranexamic acid or placebo in a double blind fashion. All participants received uterotonic agents prophylactically. The primary outcome was postpartum haemorrhage (defined as >1000 mL estimated blood loss or receipt of transfusion within two days of delivery). The trial showed that tranexamic acid reduced this primary outcome compared with placebo (26.7% versus 31.6%). But the haemorrhage-related secondary outcomes (gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion) were not reduced, which calls into question whether the treatment makes a clinically significant difference. Thromboembolic event rates were very low but numerically higher in the treatment group. A quarter of participants did not receive the tranexamic acid or placebo within three minutes of delivery as required by the protocol—one of the realities of trial conduct. This probably wasn’t the reason for a lack of greater efficacy, though. This is an excellent trial. The resounding evidence for tranexamic acid that was expected (given that it is already in widespread use) did not come.

N Engl J Med doi:10.1056/NEJMoa2028788

Alex Nowbar is a clinical research fellow at Imperial College London.