eMJA: In Other Journals, 6 November 2006

Combining low-dose aspirin with another antithrombotic agent, such as clopidogrel, dipyridamole or a vitamin K antagonist, greatly increases the risk of serious upper gastrointestinal (GI) bleeding, say Danish researchers. They conducted a case-control study, involving 1443 cases of serious upper GI bleeding and 57 720 age- and sex-matched controls, and measured exposure to low-dose aspirin, antithrombotic agents and some other drugs. They found that combination therapy was associated with higher rates of bleeding. The greatest risk came from combining aspirin with clopidogrel (odds ratio [OR], 7.4), followed by aspirin with a vitamin K antagonist (OR, 5.3). The researchers said that this effect reflected a true synergism as the effect of combined treatment was more than a simple addition of the effects of the individual drugs.

It’s time to “parachute”

How much evidence is needed to move from research to practice? According to US experts, the answer need not always be a randomised controlled trial — especially when the matter under consideration is a simple, life-saving intervention in a resource-poor setting. Using three examples, Potts and colleagues make their case for an alternative “parachute” approach to evidence-based medicine in such settings — where policies are still set on good science, albeit without randomised trials. They say that for oral rehydration therapy for child diarrhoea, for male circumcision to prevent HIV infection, and for misoprostol in postpartum haemorrhage, the local risks and benefits would support adoption of these practices well before the availability of robust trial results, with many lives (potentially) being saved.

BMJ 2006; 333: 701-703

Bottled water warning

If your primary water source is bottled water, then you may be at increased risk of dental caries, warn Melbourne researchers. Noting that recent surveys have suggested the incidence of dental caries in school children is increasing for the first time in decades, Cochrane and colleagues assayed the fluoride content of 10 popular brands of bottled water. For all brands, the fluoride concentration was less than 0.08 parts per million (ppm); the local tap water was found to be fluoridated at 1.02 ppm. According to the NHMRC, the minimum concentration required for a protective effect against dental caries is approximately 0.50 ppm.

Aust Dent J 2006; 51: 242-244

Risky mismatch?

In a survey of more than 4000 New York City men, researchers were surprised to find that nearly one in 10 of the men who said they were “straight” reported having sex in the previous year with at least one man but no women. This apparent discordance between sexual identity and sexual behaviour is greater than has been previously noted. The researchers were concerned that HIV risk in these men may be inadequately assessed if doctors only asked about their sexual identity; instead, doctors should specifically ask about sexual behaviour.

Ann Intern Med 2006; 145: 416-425

Elbowing out steroids?

The short-term benefits of corticosteroid injection for tennis elbow are paradoxically reversed after 6 weeks, with high subsequent recurrence rates, according to Brisbane researchers. They say physiotherapy may be of superior benefit to steroid injections in the long term. Bisset and colleagues randomised 198 adults with tennis elbow to one of three groups: a corticosteroid injection group (one or, if needed, two injections); a physiotherapy group (eight sessions; elbow manipulation and exercise); or a “wait and see” group (advice on how to avoid aggravating the pain while being as active as possible, with heat, cold and braces permitted). All study participants were given ergonomic and self-care advice and allowed to use analgesics, as needed. At 6 weeks, corticosteroid injection showed the best effect, with physiotherapy better than “wait and see”. However, at 52 weeks, physiotherapy and “wait and see” gave the best results. Of the three groups, the physiotherapy group used fewer additional treatments.

BMJ Online, 29 September 2006

Anti-diabetes DREAM

In high-risk patients, rosiglitazone may help to reduce the development of diabetes; it can also induce a return to normoglycaemia, according to an international study group. The DREAM (Diabetes REduction Assessment with ramipril and rosiglitazone Medication) trial investigators studied 5269 adults aged 30 years or older with impaired fasting glucose levels and/or an impaired glucose tolerance test from 191 sites in 21 countries, including Australia. After an average of 3 years of treatment with rosiglitazone, 8 mg daily, or placebo, the rosiglitazone group was about 60% less likely to develop diabetes or die, and 70%-80% more likely to regress to normoglycaemia. However, there was a small excess in non-fatal congestive heart failure in those patients receiving rosiglitazone.

Lancet 2006; 368: 1096-1105

Dr Ann Gregory, MJA

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