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…and what about the other half? ▸

Investigation of iron deficiency anaemia (IDA) constitutes a significant proportion of a gastroenterologist’s workload and many recent studies have examined the management and outcome of such patients referred to gastroenterologists. However, general practitioners do not refer all of their IDA patients, presumably only those in whom they suspect investigation will be fruitful. This valuable paper analyses the investigation and outcome of IDA presenting in primary care. Cases were identified from the records of two hospital laboratories covering a population of 0.5 million. Over 10 months 431 new cases (men aged >20 years with haemoglobin level <120 g/l; women >50 years with haemoglobin <110 g/l and MCV <78) were identified, of whom only 47% were investigated; 13% were deemed unfit, 8% refused, and for the remainder no reason was evident. At one year, 263 of the 365 cases still alive had no clear diagnosis: two thirds underwent no investigation and in at least 40% anaemia was still evident during follow up. Over the next four years remarkably few (43) had further investigations but in 24 there was a new diagnosis, including seven found to have gastrointestinal cancers (four with colorectal cancers of whom two had previously had negative barium enemas). Overall the prevalence of gastrointestinal cancer (11%) was as high as in recent hospital based series, with colorectal cancer being found in 18% of men but in only 3% of women.

Clearly if all patients with IDA had been investigated, the endoscopic workload would have been even greater, emphasising our need for less invasive methods of identifying that subset in whom invasive investigation is worthwhile.

Does acid suppression increase the risk of pneumonia? ▸

Antisecretory therapies are useful in the management of upper gastrointestinal symptoms and are the second most expensive drug category on the UK National Formulary. These drugs have an excellent side effect profile although they are associated with an increased risk of developing infective diarrhoea, possibly due to reduced gastric acid defence against pathogens. This may also increase the risk of respiratory infections if colonised gastric juice regurgitates into the oesophagus and upper respiratory tract. This hypothesis was tested by Laheij et al in a Dutch study using the Integrated Primary Care Information database. They identified 364 683 individuals with 5551 first occurrences of community acquired pneumonia. Acid suppression was associated with an unadjusted relative risk (RR) of 4.47 (95% confidence interval (CI) 3.82–5.12)) of developing pneumonia with proton pump inhibitor (PPI) and H2 receptor antagonist therapy (H2RA), both having a similar effect. The authors then performed a nested case control study to adjust for potential confounding factors and found that PPI therapy (RR 1.89 (95% CI 1.36–2.62)) and H2RA (RR 1.63 (95% CI 1.07–2.48)) were still associated with an increased risk of pneumonia. The relative risk increased with increasing dose of PPI.

The authors estimated that 1 case of pneumonia per 100 person years of acid suppression could be directly attributable to the drug. This effect is small and should be interpreted cautiously as there was a large reduction in the effect size once there was adjustment for confounding factors. The results may therefore be due to residual confounding. For example, those with severe gastro-oesophageal reflux may be more likely to be prescribed acid suppression, and reflux itself may be a risk factor for pneumonia, regardless of the acid suppression received (

). Nevertheless, these data remind us that we should only prescribe antisecretory therapy for those that really benefit and at the lowest dose needed to control symptoms.

Saving live(r)s, legally ▸

On 16 September 1998, legislation was introduced in the UK to reduce the size of packs of paracetamol and salicylates as well as to limit their sales. Using multiple data sources (Office for National Statistics, six liver transplantation centres, five general hospitals, Intercontinental Medical Statistics Health UK), Hawton et al have evaluated the long term effects of the legislation on poisonings.

Legislation did not have any lasting effect on the total number of paracetamol (or paracetamol compounds) sold whereas the number of aspirin tablets sold halved by 2002. Large overdoses due to paracetamol reduced by 20% (95% confidence interval (CI) 9–29%)) and those due to salicylates by 39% (14–57%). Admissions to the liver units and liver transplantations for acute hepatic failure due to paracetamol overdose were reduced by 30% in the four years after legislation. Suicide deaths from paracetamol and salicylates were reduced by 22% (11–32%) while smaller overall reduction in suicide rates was observed in England and Wales during this period (11.8% in males and 7% in females). Ibuprofen overdoses increased by 27% (11–44%) but there was no significant change in the frequency of large ibuprofen overdoses and consequent deaths. In all cases of deaths from ibuprofen overdoses, other drugs were involved.

This study indicates that suicide attempts are often impulsive and the legislation limiting the sales of analgesics has been effective in reducing morbidity and mortality due to overdoses. Authors recommend a further reduction in pack sizes of paracetamol and salicylates. Success of this legislation in the UK has stimulated debates in other countries regarding the use of similar measures to reduce serious overdoses.

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