eMJA: In Other Journals, 5 May 2008

Probiotics should probably not be used in patients with predicted severe acute pancreatitis, according to the results of a randomised, double-blind, placebo-controlled trial.1 Within 72 hours of symptom onset, 298 people with predicted severe acute pancreatitis were randomly assigned to receive an enterically administered probiotic preparation or a placebo for 28 days. Although there was no significant difference in the rate of infectious complications between the two groups, nine patients in the probiotic group developed bowel ischaemia (compared with none in the control group) and 24 died (compared with nine in the control group). These results appear to be at odds with the published literature, which has not shown an increase in mortality with the use of probiotics. The authors speculate that the bowel ischaemia may have been a side effect of increased bacterial load, leading to inflammation and a reduction in capillary blood flow.

An accompanying commentary2 advises caution in the interpretation of the results, pointing out that the selection process may have been skewed, with more people in the probiotic group having organ failures at the time of randomisation. The possibility of contamination of the probiotic mixture or interaction with the enteric feeding formula is raised as a possible confounder. The authors of the commentary also discuss the thorny question of safety in clinical therapeutic trials, and contemplate whether earlier cessation of the trial may have saved some patients.

Thank you for not smoking

We know that smoking and exercise have opposite effects on coronary risk factors, but can smoking negate the advantage conferred by regular exercise on the prevention of coronary heart disease? A large Japanese study involving over 76 000 people appears to have found a worrying answer. Among non-smokers, people who participated in sports for 5 hours or more a week had a 50%-80% lower age-adjusted risk of mortality from coronary heart disease compared with those who exercised 1-2 hours a week. For smokers, no association was found between exercise and reduced risk. Adjustment for known cardiovascular risk factors did not appear to alter these associations. The authors comment that although the study had some limitations, including a lack of data on the history of dyslipidaemia, there is strong evidence that smoking may reduce the beneficial effects of sports participation for the reduction of coronary heart disease.

Heart 2008; 94: 471-475

Why not vaccinate?

The vaccination rate for the combined measles-mumps-rubella vaccine (MMR) declined worldwide after reports of a possible association with autism and bowel disease in 1998. A UK study has explored factors associated with the uptake of MMR, which reached a low in that country of 79% in 2003. In a cohort study of over 14 000 children born between 2000 and 2002, immunisation status with MMR or a single antigen vaccine at 3 years of age was recorded. Overall, 88.6% of children were immunised with MMR and 5.2% with a single antigen vaccine. Children were more likely to be unimmunised if they lived in a household with other children or a lone parent, or if their mother was under 20 or over 34 years of age at the time of the child’s birth, more highly educated, or not employed. Nearly three-quarters of parents who did not immunise made a “conscious decision” not to do so. The authors comment that social differentials appear to play an important part in vaccine uptake, and these factors could be used to target interventions aimed at increasing uptake.

BMJ Online, 28 February 2008

Apgar may equal intelligence

Infants with a low Apgar score (< 7) at birth appear more likely to have low intelligence quotients (IQ) in their late teens, according to a large study of Swedish children. Data on the Apgar scores at birth were gathered for over 170 000 male infants born between 1973 and 1976 and correlated with educational achievement and IQ in the teenage years. Infants with a brief (< 5 minutes) or prolonged (> 5 minutes) low Apgar score were more likely to have a low IQ at age 18. Additionally, there was an increased risk of a low IQ the longer it took for the infant to achieve a normal Apgar score. The authors suggest that mild perinatal hypoxia may be sufficient to cause neuronal damage and affect cognition, supporting the concept of a “continuum of reproductive risk”.

Arch Dis Child Fetal Neonatal Ed 2008; 93: F115-F120

Penalties and panic in a pandemic

As the risk of pandemics looms in the wake of the severe acute respiratory syndrome (SARS) epidemic and with the rise of avian influenza, renewed discussion has arisen in medical communities around the obligations of health care professionals (HCPs) to work during a pandemic. A recent commentary by health and law policy experts calls for a rational approach to the conundrum, advocating that HCPs who refuse to work during a pandemic should not be penalised by loss of licence or jailing. The authors argue that penalties for HCPs who refuse to work in a pandemic should be limited to those dealt out in a non-pandemic situation where a HCP refuses to treat a patient with an infectious disease. They conclude that instead of relying on punitive measures, incentives to become involved in such situations should be implemented, including hazard pay for those who volunteer to work.

JAMA 2008; 299: 1471-1473

Dr Tanya Grassi, MJA

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