BMJ  2004;329:1208 (20 November), doi:10.1136/bmj.329.7476.1208

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What's new this month in BMJ Journals

Three weeks of prednisolone offers short term benefit for frozen shoulder

A randomised placebo controlled trial in patients with adhesive capsulitis of the shoulder (frozen shoulder) has shown that 30 mg of oral prednisolone daily for three weeks reduced pain and disability for up to six weeks, but the improvement was lost by 12 weeks. This suggests a rebound effect after stopping treatment, particularly for pain. Questions arise as to whether a longer course of treatment or gradual withdrawal would be more effective. The authors also found that 25 of the 80 patients referred to them had been wrongly diagnosed, suggesting either that general practitioners were poor at recognising the condition or that they were taking advantage of the researchers' short waiting time for an appointment.

Ann Rheum Dis 2004;63: 1460-9[Abstract/Free Full Text]

Half of children with asthma do not outgrow it

Ninety four of a cohort of 119 children diagnosed as having asthma in 1966-9 have been followed up to age 32-42. Twenty were in complete remission and a further 27 had no symptoms nor used inhaled steroids but had bronchial hyperresponsivenss or an abnormal forced expiratory volume in one second, or both. Twenty six patients still had symptoms, and a further 20 did not report symptoms but still took inhaled steroids. Better lung function at age 5-14 was associated with eventual complete or clinical remission. Paradoxically, heavier smokers were more likely to be symptom free. The authors say this might be because those with more susceptible airways did not take up smoking or quit early.

Thorax 2004;59: 925-9[Abstract/Free Full Text]

Defining who will not survive an out of hospital cardiac arrest

Ambulance paramedics in Sweden prospectively surveyed 38 750 out of hospital cardiac arrests from 1990 to 2001. In 16 712 patients who were in non-shockable rhythm (that is, not ventricular fibrillation) and in whom cardiopulmonary resuscitation was attempted before the paramedics' arrival, overall survival to one month was 1% compared with 8% in patients in a shockable rhythm. None of the non-shockable group survived if the arrest was at home and not witnessed, if there was no bystander cardiopulmonary resuscitation, and if it took more than 12 minutes for the ambulance to arrive. No patient over 80 survived when the delay was more than eight minutes. The authors say their findings provide evidence on which to base non-resuscitation protocols, and they note the possible adverse psychological impact on families of any such lack of action.

Heart 2004;90: 1114-8[Abstract/Free Full Text]

GP cooperatives reduce A&E workload in the Netherlands

In the Netherlands, reorganising out of hours primary care through large general practice cooperatives replacing practice rotas has reduced pressure on hospital emergency services. After adopting this UK model of care, demand for emergency services fell by 8.9% despite an overall increase in contacts with patients. The reduction is probably due to a fall in self referred patients with non-urgent problems.

Emerg Med J 2004;21: 722-3[Abstract/Free Full Text]

Probiotic helps maintain remission in ulcerative colitits

The probiotic E coli Nissle 1917 (Mutaflor) has proved equivalent to mesalazine in preventing relapse in patients with ulcerative colitis. A multicentre blinded randomised controlled trial investigated 327 patients over 12 months. About a third relapsed, with no difference in the two treatment arms. The arms were similar for a clinical activity index, endoscopic findings, quality of life scoring, voluntary discontinuation of medication, and adverse effects. Probiotics may help by provoking production of antibacterial agents, inhibiting adhesion of pathogens, or changing mucosal barrier function. The authors state that as mesalazine is the current "gold standard" for maintaining remission, E coli Nissle 1917 may be an alternative management option.

Gut 2004;53: 1617-23[Abstract/Free Full Text]

Calcinosis may complicate end stage renal disease A 48 year old woman who had had dialysis for five years for end stage renal disease presented with enlarging non-tender nodules of her hands. She had raised concentrations of calcium phosphate product and serum parathyroid hormone but normal urate concentrations. Radiography showed heavy calcification, which was confirmed by aspirating a nodule. Treatment is by controlling secondary hyperparathyroidism and increasing dialysis. Postgrad Med J 2004;80: 601[Free Full Text]

A 50 year bullet point Fifty years after he was shot in the neck during the second world war, a 68 year old man had presented with complete heart block, and chest radiography had shown a bullet within his heart. Treatment was with a permanent pacemaker. X ray films taken in 2003, when he was 79, show the pacing electrode (*) and a bullet, revealed by echocardiography as within the cavity of the right ventricle. Heart 2004;90: 1298[Free Full Text]

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