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<\/a>Annals of Internal Medicine<\/b>\n<\/b><\/strong><\/p>\n
Renal transplant for patients with lupus nephritis improves survival<\/u><\/b><\/p>\n
Patients with end-stage renal disease due to lupus nephritis have high rates of premature death and these haven\u2019t improved in the past 20 years. In the past, these patients weren\u2019t usually offered renal transplantation because of fears of recurrence of the nephritis, complications such as thrombosis, and rejection of the transplant. But is it better to go ahead with renal transplant, despite the risks? Opinion has changed, but concerns remain and transplant is often held as a last resort. This US study<\/a> shows that transplant improves survival compared to dialysis, primarily due to fewer deaths from cardiovascular disease and infection. The authors urge \u201ctimely referral\u201d for transplant.<\/span><\/p>\n NEJM<\/b><\/p>\n Levodopa\u2014when\u2019s the best time to start?<\/u><\/b><\/p>\n Levodopa remains the main treatment for symptoms of Parkinson\u2019s disease. Traditionally, neurologists have held off using it until symptoms such as bradykinesia and rigidity become troublesome because of its unwanted effects of involuntary movements (dyskinesia), fluctuations of motor control, and because its effect starts to wear off with time. But is it better to start levodopa as early as possible? Could it have a disease-modifying effect? This double-blind, placebo-controlled<\/a>, delayed-start trial, randomly assigned patients with early Parkinson\u2019s disease to levodopa with carbidopa for 80 weeks (early start group), or placebo for 40 weeks and then levodopa and carbidopa (delayed-start group.) There was no significant difference in progression of Parkinson\u2019s disease\u00a0between the two groups, which suggests that there\u2019s no point in starting levodopa before it\u2019s needed to treat symptoms.<\/span><\/p>\n Endometrial scratching doesn\u2019t improve success of IVF<\/u><\/b><\/p>\n Endometrial scratching involves making superficial scratches in the endometrium in an attempt to improve the receptivity of the uterus to embryo implantation. This open-label, randomized, controlled trial<\/a> followed 1364 women undergoing in vitro fertilization. Half had endometrial scratching performed in the cycle before embryo transfer and half didn\u2019t. 26.1% had a live birth (comparable with the 21% overall rate and 29% for under 35\u2019s in the UK), with no difference between the groups. It\u2019s not clear how scratching works and this study suggests that it doesn\u2019t.<\/span><\/p>\n The Lancet<\/b><\/p>\n Early calcium doesn\u2019t prevent pre-eclampsia<\/u><\/b><\/p>\n Why are pre-eclampsia and eclampsia so prevalent in low-income countries? One theory is that low levels of calcium in the diet may be part of the problem. There is evidence that calcium supplementation in the second half of pregnancy reduces the severity of pre-eclampsia. But do calcium supplements given in the first half of pregnancy have a similar protective effect? This study, conducted in South Africa, Zimbabwe, and Argentina<\/a>, compared the outcome in pregnant women who had previously had pre-eclampsia and eclampsia and took 500mg calcium a day in the first half of pregnancy, compared to similar women who took placebo. All these high risk women took calcium in the second half of pregnancy as there\u2019s already good evidence for that. This study didn\u2019t show a similar benefit in early pregnancy though. there was no significant difference in the incidence of pre-eclampsia between the two groups (23% in the calcium group, 29% in the placebo group). The trial was only powered to detect a large effect size, so some individuals or sub-groups may benefit, but that would need a different type of study to explore further. <\/span><\/p>\n JAMA<\/b><\/p>\n Daily aspirin for healthy people?<\/u><\/b><\/p>\n Should healthy people take an aspirin a day? Do the pros outweigh the cons? It\u2019s a question that crops up frequently and help is at hand from this meta-analysis of 13 trials with 164 225 participants<\/a> with no known cardiovascular disease. Median age was 62, minimum follow up time was 1 year, and the baseline cardiovascular risk was 9.2%. It found that aspirin was associated with a lower risk of cardiovascular events (number needed to treat of 265) and an increased risk of major bleeding (number needed to harm of 210) compared to those on placebo or no aspirin. So if 1000 healthy people take a daily aspirin, approximately four will benefit from a cardiovascular point of view and a similar number will have a major bleed. This doesn\u2019t take into account any other possible advantages of aspirin such as cancer prevention, but on the basis of this study, it doesn\u2019t seem worth taking a daily aspirin on spec.<\/span><\/p>\n JAMA Intern Med<\/b><\/p>\n Best practice for liver transplants<\/u><\/b><\/p>\n Footballer George Best generated headlines when he went on an alcohol-fuelled binge within a couple of years of a liver transplant for alcohol-associated liver disease. Alcohol-associated liver disease used to be a reason not to offer a transplant, but is now the main reason to offer a liver transplant in the US. An expert panel in 1983 recommended that a six month period of abstinence should be a requirement for transplant to see if disease would stabilise without a transplant and improve public perception that donated organs weren\u2019t being wasted. Since then studies have shown that the chances of reverting to alcoholism after a transplant for alcohol-associated liver disease is linked to many factors, but not specifically to the period of abstinence prior to the transplant. This prospective, national (US) cohort study looked at why transplant for alcohol-associated liver disease has doubled in recent years<\/a> and what the long term survival rates are. Nearly half of the increase in transplants for alcohol-associated liver disease is attributed to the decrease in liver transplants needed for hepatitis C (as other treatments have become available.) People with alcohol-associated liver disease did less well after transplant in the long term (cumulative unadjusted 10-year posttransplant survival was 63%), than people who had a transplant for other reasons (cumulative unadjusted 10-year posttransplant survival was 68%) \u00a0The excess deaths were mostly due to cancer and infections and linked to a return to alcohol abuse and lower socio-economic status. What\u2019s not clear is whether the previous requirement to abstain from alcohol prior to transplant, for at least six months, should be reinstated and what other measures are needed to support those with alcohol-associated liver disease to improve their survival after transplant, or find ways to obviate the need for a new liver altogether.<\/span><\/p>\n BMJ<\/b><\/p>\n Rheumatoid arthritis\u2014which non-TNF drug is best?<\/u><\/b><\/p>\n Many people living with rheumatoid arthritis find that tumour necrosis factor (TNF) \u03b1 inhibitors vastly improve their quality of life. But as many as a third of people with rheumatoid arthritis don\u2019t respond to anti-TNF drugs. Three non-TNF targeted biologic agents<\/span>\u2014<\/span>rituximab (a B lymphocyte depleting agent), abatacept (targets T cell co-stimulation), and tocilizumab (an interleukin 6 receptor inhibitor) are available for these non responders and all perform better than placebo in trials. But which of the three is safest and most effective? This population-based prospective French study<\/a> followed 3162 adults who had refractory rheumatoid arthritis, but were otherwise healthy. Drug retention is used as a surrogate marker for effectiveness and safety. The assumption is that if you stay on the drug, you\u2019re probably deriving net benefit. By that (indirect) measure, patients treated with rituximab or tocilizumab fared better at 24 months than those on abatacept.<\/span><\/p>\n Frying tonight?<\/u><\/b><\/p>\n Up to a third of Americans eat food from fast food outlets every day and most of the food is fried. It\u2019s safe to assume that the UK is catching up fast and the consensus is that it\u2019s a bad thing. But hard evidence of the effect of a fast food habit on mortality is thin on the ground. This prospective cohort study<\/a> drawn from the estimable Women\u2019s Health Initiative used data from nearly 2 million person years of follow up and found that frequent consumption of fried foods (especially chicken and fish\/shellfish) were associated with a higher risk of all-cause and cardiovascular mortality among postmenopausal women. The underlying mechanisms are unclear and require further study. On the plus side, there was no increase in cancer mortality (the heart attack gets you first, presumably.) I would quibble with the sunny optimism of the authors who say \u201cwe have identified a risk factor for cardiovascular mortality that is readily modifiable by lifestyle and cooking choices.\u201d Personal choices are rarely \u201creadily modifiable\u201d in my experience.\u00a0<\/span><\/p>\n