- Ann Robinson, NHS GP and health writer and broadcaster
S’not what it seems
Can you tell which snotty-nosed children have acute sinusitis rather than a cold or hayfever? If you diagnose acute sinusitis, do you prescribe antibiotics? And is the colour of their snot a factor in your decision?
This useful US primary care study of 515 children aged 2-11 years diagnosed with acute sinusitis based on clinical criteria found a large overlap in symptoms with viral upper respiratory tract infections (no surprise there). Researchers found that 28% of children didn’t grow any pathogenic bacteria from their nasopharynx. The children given antibiotics (amoxicillin and clavulanate for 10 days) had milder illness (mean symptom scores 9 v 10.6) and got better quicker (seven v nine days) than those given placebo. However, antibiotics had only minimal benefit in the 28% of children who didn’t have any bacterial colonisation of their nasopharynx. And kids with yellow or green snot were no more likely to respond than those with the clear sort. Predictably, there was more diarrhoea in the antibiotic group (11.4% v 4.7%) but no serious adverse events in either group. My take home is that we should probably swab and wait for the results before randomly treating.
JAMA doi:10.1001/jama.2023.10854
Missed opportunities in postnatal guidance
It feels unsporting to use a postnatal visit to broach the need for healthy eating, weight loss, and exercise to exhausted, overweight new mums. But poor pre-pregnancy cardiovascular health (such as obesity, diabetes, hypertension) and adverse pregnancy outcomes (such as gestational diabetes, premature birth) are key risk factors for subsequent cardiovascular disease. So it’s a wasted opportunity if doctors don’t offer any effective guidance.
In this US serial cross sectional analysis of nationally representative data, only 60% of those at risk reported that they had received any lifestyle advice at a postpartum consultation. Those with no risk factors were nearly as likely to get advice as those with two or more risk factors (53% v 60%). Overall, rates of women reporting postpartum cardiovascular health advice declined a bit over the study period (2016-2020), possibly as an effect of covid-19. Interestingly, the more socioeconomically deprived patients were most likely to report receiving counselling but that could be because it made a bigger impact on them or that prenatal opportunities had been missed.
JAMA doi:10.1001/jama.2023.11210
Costly quartz
Quartz worktops in kitchens are increasingly popular because they’re durable, easy to clean, low maintenance, and look great. They’re a type of engineered stone made from ground quartz, resins, and polymers. But they are costly in more ways than one.
This case series from California identified 52 men (mainly young Latino immigrants) who developed silicosis after occupational exposure to dust from engineered stone, which is high in silica. The results told a sad story; the median age at diagnosis was 45 years, diagnosis was delayed in 58%, 38% presented with severe fibrosis, and 19% died. On average, the men had been working with quartz for 15 years. Nearly half of them continued to work in the same conditions after their diagnosis. Workers who fashion our worktops need protection from inhaled silica particles and the devastating lung disease that can follow.
JAMA Intern Med doi:10.1001/jamainternmed.2023.3295
Not all are treated equally with statins
The role of statins in preventing cardiovascular disease is based on solid evidence. But not everyone who could benefit from a statin gets one. You’d hope that disparities are based on need, but this cross sectional US study of people eligible for statin therapy found an unexplained lower than expected prevalence of statin use among Black men and Hispanic women for primary and secondary prevention and lower rates of use among women for secondary prevention. The disparities weren’t fully explained by differences in medical appropriateness of therapy, access to healthcare, or socioeconomic factors. It’s possible that other factors that contribute to health inequality are at play here, such as bias among prescribers and mistrust among patients.
Ann Intern Med doi:10.7326/M23-0720
Better out than in: planned delivery in pre-eclampsia
Pre-eclampsia remains a leading cause of maternal and perinatal mortality in low and middle income countries. The question is whether delivering the baby at 34-37 weeks’ gestation saves mothers without compromising babies. Trials in high income countries suggest that planned delivery from 34 weeks is safe and beneficial. But we lack evidence about optimal care in settings where pregnancy related morbidity and mortality are highest.
This CRADLE-4 trial based in India and Zambia found that planned early delivery reduced severe maternal hypertension and other serious complications such as eclampsia and placental abruption, although it didn’t significantly reduce the maternal composite outcome (stillbirth, neonatal death, or neonatal unit admission for >48 hours). There was no increase in caesarean section rate, and the length of hospital stay was shorter. Importantly, the number of stillbirths reduced significantly in the planned delivery group compared with standard expectant care (0 v 10). Being delivered up to 6 weeks early had no detrimental effect on the newborns; there was no significant difference in rates of jaundice, encephalopathy, or respiratory problems between the two groups.
Lancet doi:10.1016/S0140-6736(23)00688-8