BMJ family highlights

	Montelukast is a useful adjunct in persistent asthma

Top Montelukast is a useful... Decision making and gut... Home can be dangerous

Two large randomised trials show the value of the leukotriene receptor antagonist montelukast in adults with asthma already treated with inhaled steroids. The Spanish CASIOPEA study group randomised 639 patients receiving budesonide 400-1600 µg daily by Turbuhaler to receive montelukast 10 mg daily or placebo. Patients were followed up for four months: the treated group had 56% more days free of asthma and 35% fewer mild exacerbations than those taking placebo, and they were less likely to wake at night, had a greater improvement in morning peak flow rate, and used less  agonist. The international COMPACT trial looked at adults whose asthma was inadequately controlled with budesonide 800 µg. They were randomised to receive 10 mg of montelukast in addition to their existing treatment or to double their dose of budesonide. After 12 weeks both groups had improved, with fewer symptoms, better quality of life, and less use of  agonists. The montelukast group had a more rapid response. Because of the potential side effects from high doses of inhaled steroids, the authors recommend adding a leukotriene antagonist first. Both studies were aided by grants from the pharmaceutical company manufacturing a proprietary brand of montelukast.

Thorax 2003;58:211-6[Abstract/Free Full Text] ; 217-21 

Does Fusobacterium varium cause ulcerative colitis? Japanese researchers took colonic biopsies from 10 patients with ulcerative colitis. They killed luminal bacteria with the non-absorbable antibiotic imipenem, thereby isolating bacteria present in the inflamed mucosa. Twenty species were isolated but only Fusobacterium varium proved cytotoxic when tested in vitro with vero cells. The culture supernatants were analysed and butyric acid identified as the potentially toxic material. Enemas of butyric acid, in the same concentration, were given to mice, which developed colonic inflammation, ulcers with crypt abscesses, and cell apoptosis. The authors point out that colonocytes from patients with ulcerative colitis oxidise less butyric acid than cells from controls, and hypothesise that this may be important in the pathogenesis of the disease. Gut 2003;52:79-83 [Abstract/Free Full Text] A: Crypt abscess (arrow) in a mouse treated with butyric acid. B: Apoptosis (arrows) in crypts treated with supernatant of F varium. C: Inflammation and gland loss in colon of mouse treated with supernatant of F varium. D: Apoptotic crypt cells with terminal uridine DNA nick end labelling (TUNEL) after butyric acid or culture supernatant

A 35 year old man developed sudden chest pain and haemoptysis while having a drink in a pub. Despite prompt transfer to hospital and competent resuscitation he died a few hours later from torrential haemoptysis. His partner told staff in the emergency department that he had a "hole in the heart" repaired at age 12 and had been discharged from specialist follow up many years before. Postmortem examination showed he had died from rupture of an aortic arch aneurysm at the site of a previous coarctation repair. This, and previous reports, show that general practitioners need to arrange lifelong imaging surveillance for patients on their lists who have had this type of surgery. Emergency Medicine Journal 2003;20:102-3[Free Full Text]

	Decision making and gut feelingsmechanism remains obscure

Top Montelukast is a useful... Decision making and gut... Home can be dangerous

The somatic marker hypothesis states that the decisions we make are coloured by somatic feedback to the brainby our "gut feeling." One way of testing this hypothesis is by using the Iowa gambling task (IGT), in which subjects gamble with four packs of cardstwo of which, they gradually discover, have a high risk of losing. One route for our "gut feelings" might be through the noradrenergic system, as healthy people have a galvanic skin response when about to make a risky choice on the IGT. Thirty undergraduates were given different doses of reboxetine, which enhances central noradrenergic transmission, or placebo. When they played the Iowa gambling task the groups showed no differences in the results. The authors have previously studied patients with total spinal cord transection, who also behaved no more riskily than controls on the IGT. Wherever our gut feelings come from, they don't travel through the spinal nerves or the adrenergic system.

Journal of Neurology, Neurosurgery and Psychiatry 2002;74:376-8 [Abstract/Free Full Text]

	Home can be dangerous

Top Montelukast is a useful... Decision making and gut... Home can be dangerous

An Australian survey found 296 "home duty" deaths over a four year period. Men were most at risk, most commonly while underneath a poorly supported car which they were trying to repair. They also fell off inadequately braced ladders, usually while gardening or undertaking house repairsa particular risk for men over 55. Younger men were likely to receive electric shocks while working with faulty equipment or because they failed to switch off at the mains. Of the 17% of deaths in women, half were in women over 75, most of whom were doing housework. Their commonest problem was burns, often caused by fires that started when they fell asleep while something was cooking or because they forgot to turn off the stove. Even when the far fewer hours men spent in housework were allowed for, men's accident rate was four times higher.

Injury Prevention 2003;9:15-9 [Abstract/Free Full Text]

Harvey Marcovitch. 

BMJ syndication editor
(h.marcovitch{at}btinternet.com)