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CARPHOLOGY by Rajendra

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A population based study in Oxfordshire looks at underinvestigation of older patients with transient ischaemic attack and stroke and comes to predictable but important conclusions. The incidence of symptomatic carotid stenosis increases steeply with age, but in routine clinical practice older patients, especially those aged 80 or older, are substantially underinvestigated. Unfortunately, this is despite good evidence of major benefit from carotid endarterectomy in these patients and their willingness to have surgery.

Pressure ulcers are unwelcome and theories on how best to avoid them plentiful. So a meta-analysis of the evidence is timely. Using support surfaces, repositioning the patient, optimising nutritional status, and moisturising sacral skin are all appropriate strategies to prevent pressure ulcers. Unsurprisingly, many of the 59 randomised trials had important methodological limitations.

Neurostimulation of the subthalamic nucleus was more effective than medical management alone in patients with advanced Parkinson’s disease and severe motor complications. This was the conclusion of a multicentre trial, which included 156 patients in a randomised pairs design. Neurostimulation resulted in improvements of 24–38% in the PDQ-39 (Parkinson’s disease questionnaire) subscales for mobility, activities of daily living, emotional wellbeing, stigma, and bodily discomfort. Serious adverse events were more common with neurostimulation than with medication alone (13% v 4%, p<0.04) and included a fatal intracerebral haemorrhage. The overall frequency of adverse events was also higher in the medication group (64% v 50%, p=0.08). No change was seen in cognition, mood, and overall psychiatric functioning.

For mild head injury, brain CT and early discharge is no worse for outcome and is less expensive than observation in hospital, finds a multicentre, pragmatic, non-inferiority, randomised trial including over 2600 patients in 39 acute hospitals in Sweden. In the patients admitted for observation, a considerable delay occurred in time to treatment in those who required surgery. None of the patients with a normal immediate CT had complications later, and patient satisfaction was similar in the two groups.

The Chinese medical literature may be a rich source of evidence to inform clinical practice and other systematic reviews, say the authors of a meta-nalysis of 20 trials of treatment of hypoxic-ischaemic encephalopathy with hyperbaric oxygen. Admittedly, the reporting quality of trials was poor by Western (CONSORT) standards. Treatment with hyperbaric oxygen gave better outcomes than the comparator in almost all trials. The odds ratios of the meta-analyses were 0.26 (95% CI 0.14 to 0.46) for mortality and 0.41 (0.27 to 0.61) for neurological sequelae.

In patients with recent stroke or transient ischaemic attack (TIA) daily atorvastatin reduced the overall incidence of stroke (adjusted hazard ratio 0.84 (95% CI 0.71 to 0.99) and of cardiovascular events (hazard ratio 0.80 (0.69 to 0.92). However, there was a small increase in the incidence of hemorrhagic stroke (adjusted hazard ratio 1.66 (1.08 to 2.55)). These were the findings of a placebo controlled, double blind, randomised controlled trial including 4731 patients who had a TIA or stroke within one to six months before entering the study, low density lipoprotein cholesterol levels of 2.6 to 4.9 mmol/l, and no known coronary heart disease. The patients were followed up for a median of 5 years.

A population based prospective study of 1836 dementia-free Japanese Americans from King County, Washington, compares people who drank fruit and vegetable juices at least three times per week with those who drank these juices less often. The researchers find that the hazard ratio for probable Alzheimer’s disease was 0.24 (95% CI 0.09 to 0.61) for those who drank juices at least three times a week compared with those who drank less often than once per week. The researchers did adjust for potential confounders, but how many confounders can one adjust for? And can you ever be sure that none has escaped your list? So I will continue to drink what I drink, and anyway, I am not Japanese American from King County, Washington.

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