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Carphology by Rajendra

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Whole body hypothermia (33.5°C for 72 hours) reduces the risk of death or disability in infants with moderate or severe hypoxic-ischaemic encephalopathy. This is the finding of a randomised trial in 239 infants who were admitted to hospital at or before six hours of age with severe acidosis or perinatal complications, resuscitation at birth, and who had moderate or severe encephalopathy. Other studies have used selective head cooling whereas this study used whole body cooling.

Small surveys are not rocket science, but here is something to keep in mind when you are next on an ego trip. A survey of 100 patients on the internal medicine and neurology services at a large teaching hospital in Brooklyn, NY, found that of patients initially tested, 15% correctly stated their physician’s name and 21% correctly stated their nurse’s name. After being given the name of their physician in writing and being asked to remember it, 76% of a different group of patients correctly stated their physician’s name. This probably means that almost a quarter of patients you treat can’t be bothered to know who you are.

Most systematic reviews find insufficient evidence for the interventions they are studying and a recent Cochrane review, which looks at the treatment of epileptic absences, is no exception. The authors conclude: “Although ethosuximide, lamotrigine and valproate are commonly used to treat people with absence seizures we have insufficient evidence to inform clinical practice, and the few trials included in this review were of poor methodological quality and did not have sufficient number of participants. More trials of better quality are needed.” This review might not have much impact on how neurologists treat patients with absences—but it might have an impact on how they look at systematic reviews.

Some patients with an initial diagnosis of conversion symptoms later turn out to have an organic disease that explains their initial presentation. A systematic review of 27 studies found a significant decline in the rate of misdiagnosis of conversion symptoms from the 1950s to the present day, but the rate has been steady at around 4% since 1970. According to the authors the decline is probably due to improvements in the quality of studies rather than improved diagnostic accuracy due to computed tomography of the brain—because the decline began before scanning became generally available.

Erudite collectors of rare syndromes will already know that Williams-Beuren syndrome is a sporadically occurring deletion disorder involving chromosome 7 (7q11.23), which is characterised by “a velocardiofacial syndrome” and behavioural attributes. Children with this disorder show considerable strength in expressive language and can be loquacious but have a low overall level of intellectual ability. Although deletion disorders of this chromosomal area have been known, the predicted duplication disorder remained elusive until a recent case report was published. The patient had severe difficulties with expressive language suggesting that the affected gene is indeed concerned with language. Our understanding of the genetic basis of language is poor, and finding a second language gene could be an important step forward.

Some resident doctors working nights will have experienced excessive sleepiness during night work and insomnia when attempting to sleep during the day. A double blind, randomised trial on 209 subjects with well defined shiftwork sleep disorder finds that modafinil reduced the extreme sleepiness associated with the disorder and resulted in a small but significant improvement in performance compared with placebo. The authors say that more effective interventions are still needed because some patients treated with modafinil had residual sleepiness.

A meta-analysis of risks and benefits of sedative hypnotics in people aged 60 or older with insomnia looked at 24 studies including 2417 participants and found that sleep quality improved marginally with use of a sedative as did total sleep time and the number of night time awakenings compared with placebo. But the risk of adverse events was also higher with sedative treatment. The authors conclude that in people over 60, the benefits associated with sedative use are marginal and are outweighed by the risks, particularly if patients are at high risk for falls or cognitive impairment.

Patients with stroke have a higher prevalence of obstructive sleep apnoea syndrome but this could be because of confounding factors such as hyper-lipidaemia, diabetes mellitus, obesity, and smoking. Now a large observational cohort study in 1022 patients referred to a sleep centre finds a significant association between the syndrome and stroke or death (hazard ratio, 1.97; 95% CI 1.12 to 3.48) after adjusting for several confounders. The authors say that the association is unlikely to be due to residual confounders.

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