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mouths than controls.
This week colleagues (p 18) carried out a
population based case-control tell partners about
in the BMJ study with mothers or
caretakers of 185 babies
chlamydia
whose deaths were attributed
Role of to the syndrome and 312
randomly selected controls
gastro-oesophageal matched for race, ethnicity,
reflux treatment and age. After known
confounders were adjusted
for chronic cough for, the odds ratio for SIDS in
may be in doubt infants who used a dummy
during their last sleep was
AJ PHOTO/SPL
0.08 (95% CI 0.03 to 0.21)
compared with infants not
given dummies. Use of a
dummy may reduce the For people with chlamydia
infections diagnosed in
influence of known risk
primary care, a strategy of
factors in the sleep
practice-based partner
environment, say the
VOISIN/PHANIE/REX
notification by trained nurses
authors.
with telephone follow-up by
health advisers may be more
effective than specialist
referral. In a randomised
Interventions to reduce
chronic cough associated with Clarithromycin in controlled trial of 140 adults
gastro-oesophageal reflux with chlamydia infection, Low
may be less beneficial than
stable coronary and colleagues (p 14) found
international guidelines heart disease may that 47 out of 72 participants
whose partners were notified
suggest because trialists may increase mortality by practice nurses had at least
have misdiagnosed chronic
non-specific cough. In a one partner treated,
systematic review and compared with only 39
meta-analysis of randomised partners out of 68
controlled trials, Chang and participants referred to a
colleagues (p 11) found that genitourinary clinic, where 21
this uncertainty sheds doubt participants never turned up.
on the effectiveness of proton The cost was the same for
pump inhibitors for treating both strategies.
cough associated with
JOSH SHER/SPL
gastro-oesophageal reflux
disease.
What works for
Short term treatment with the migraine
Use of a dummy is macrolide antibiotic
Recent advances in clinical
clarithromycin in patients with
associated with stable coronary heart disease
research and basic
reduced risk of neuroscience are improving
may raise the risk of dying of
our understanding of migraine
SIDS cardiovascular causes. In a
and are delivering new
randomised controlled
treatments, says Goadsby on p
multicentre trial by Jespersen 25. Though the future seems
and colleagues (p 22), more positive, some unmet needs
than 4300 patients with remain, such as new preventive
myocardial infarction or therapies, treatments for
angina pectoris received non-vascular acute attack, and
either clarithromycin 500 new strategies to manage
mg/day or placebo for two
patients with intractable
weeks. All cause mortality was migraine. This clinical review
PHOTOS.COM
higher in the clarithromycin summarises developments in
arm (hazard ratio 1.27, 95% diagnosis, classification,
CI 1.03 to 1.54), and patients pathophysiological
Infants who died of sudden in this group were understanding, and treatment
infant death syndrome (SIDS) significantly more likely to strategies for migraine, and
were less likely to sleep with have died from cardiovascular discusses strengths and
dummies (pacifiers) in their causes (1.45, 1.09 to 1.92). weaknesses of current research.
BMJ VOLUME 332 7 JANUARY 2006 bmj.com
 bmjupdates+
New drug for gout shows early promise
Research question Is febuxostat a safe and effective alternative
to allopurinol for patients with gout?
Answer Febuxostat seems better than a fixed dose of
allopurinol at reducing serum concentrations of urate, but not
at improving the clinical symptoms of gout.
Why did the authors do the study? Febuxostat is a new and
potent xanthine oxidase inhibitor, designed to reduce the
production of uric acid in people with gout. Like allopurinol, it
is for preventing, not treating, acute attacks of gout. Febuxostat
is the first new drug in this field for several decades. The
authors wanted to compare the new drug with the current
standard treatment, allopurinol. Their study was funded and
analysed by a company with close links to the manufacturers
of febuxostat.
What did they do? They tested two doses of the new drug
against a fixed dose of allopurinol in a double blind,
randomised trial lasting one year. Of the 760 US adults who
participated in and contributed to the analysis, most were white
men aged > 50 years, all had chronic gout and hyperuricaemia
(mean serum urate concentration 585
mol/l at baseline), and
44% had already tried allopurinol. Participants took 80 mg or
120 mg febuxostat or 300 mg allopurinol daily for 52 weeks.
They also took colchicine or naproxen as prophylaxis against
acute flare ups of gout for the first eight weeks of the trial. The
authors followed up participants regularly and compared their
serum concentrations of urate, and their clinical progress by
recording flare ups of gout and by measuring the size of gouty
tophi in the 156 patients who had them.
What did they find? After 52 weeks treatment, 62% (154/250)
of participants taking 120 mg febuxostat, 53% (136/255) of
those taking 80 mg febuxostat, and 21% (53/251) of those
taking allopurinol had reached the treatment goal of a serum
urate concentration of < 357
mol/l for the last three months
of the trial. On this measure, both doses of febuxostat worked
significantly better than allopurinol. In clinical terms, however,
the three treatments were similar: tophi shrank substantially in
all three groups, and about two thirds of participants in each
group had at least one flare up of gout (70% (150/215) in the
febuxostat 120 mg group, 64% (147/228) in the febuxostat 80
mg group, and 64% (150/234) in the allopurinol group).
Side effects were also similar, although participants taking
120 mg febuxostat were significantly more likely to drop out of
the trial than those taking allopurinol (98/251 v 66/254,
P = 0.003), and the commonest adverse event leading to
withdrawal was abnormal liver function (7/251 of those taking
120 mg febuxostat v 1/254 of those taking allopurinol,
P = 0.04).
What does it mean? Febuxostat may prove a reasonable
alternative to allopurinol for people with gout, but its too early
to say for certain. The favourable laboratory results in this trial
did not translate to a better clinical outcome for patients,
worries remain about febuxostats long term safety, and it has
not yet been tested against the commonest dose schedule for
allopurinol (titrated against serum urate concentration rather
than fixed).
Becker et al. Febuxostat compared with allopurinol in patients with
hyperuricemia and gout. New England Journal of Medicine 2005;353:2450-61
This summarises a paper that has been selected by bmjupdates. To
register for bmjupdates (free email alerts about high quality new papers in
your favourite subjects) go to http://bmjupdates.com/
BMJ VOLUME 332 7 JANUARY 2006 bmj.com
Editors choice
Doing things differently
The beginning of a new year is a time to think about
doing things differently. The first BMJ of the new year
has several suggestions.
If fear of precipitating acute glaucoma has
prevented you from dilating a patients pupils before
checking for diabetic retinopathy, stop worrying and
get out the mydriatic eye drops. Gerald Liew and
colleagues (p 3) tell us that you are twice as likely to
spot retinopathy through a dilated pupil and there is
very little chance of precipitating acute angle closure
glaucoma, though they do say you should warn the
patient to seek medical attention if symptoms
develop.
If you have been following guidelines on treating
chronic cough with empirical treatments for
gastro-oesophageal reflux disease, stopA B Chang
and colleagues systematic review suggests you should
first check that the patient has GORD (p 11). If you
have ever thought of giving clarithromycin to patients
with stable coronary heart disease, dont (p 14).
And if you have ever frowned on a mother whose
baby sucks a dummy or pacifier, think again. De-Kun
Li and colleagues case-control study indicates that
sleeping with a dummy/pacifier cuts the risk of
sudden infant death by more than 90% (p 18). The
authors acknowledge the limitations of their study
and that only half of eligible women agreed to take
part. They dont claim that dummies prevent sudden
infant death, but its a hypothesis worth testing.
Any day now we expect the UK government to
announce its plans for reforming primary care, so we
have asked some thoughtful people for their vision
for primary care in 2015. Most are surprisingly
utopian. Despite talking of patients being utterly
bemused, Peter Lapsely (p 43) sees out of hours work
being made more attractive, linkage to the by now
excellent NHS Direct telephone and internet advice
service, and patients acknowledging that they have
responsibilities as well as rights. Dougal Jeffries (p 44)
sees recovering morale and an end to competition:
the ruinously costly choose and book fiasco is a
fading memory. Providers will relearn the simple
lessons of cooperation and coordination. Like others,
he sees most care happening outside hospitals and
lots of patients availing themselves of alternative
therapies provided within the NHS. Carol Black (p 47)
and Mayur Lakhani and Maureen Baker (p 41) are
aspirational: strong clinical and professional
leadership and medical professionalism will ensure
high levels of public trust.
Alone among our visionaries, Hamish Meldrum is
underwhelmed by life in 2015 (p 46): Tesco Health
has taken over the failing NHS Direct; Connecting for
Health finally integrates the NHS computing systems
eight years late and 25bn over budget; patients have
less choice because hospitals have closed and local
treatment centres offer only a limited selection of
treatments, and patients are charged for non-essential
services including hotel care in hospital. Why is it I
find Meldrums vision the most convincing? Note to
self for 2006: try to look on the bright side.
Fiona Godlee editor (fgodlee@bmj.com)