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CARPHOLOGY by Rajendra

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Topiramate may have another use. It was found to reduce heavy drinking days in a 14-week double blind, randomised, placebo controlled trial including 371 men and women with alcohol dependence (mean difference 8.44%; 95% CI 3.07% to 13.80%; p = 0.002). The primary outcome measure was self-reported heavy drinking days, but plasma gamma-glutamyltransferase was also measured. Adverse events included paraesthesias, taste perversion, anorexia, and difficulty with concentration. The authors (one of whom is a consultant to the manufacturers of topiramate) say that the results of the trial may not be generalisable to patients outside the trial, who may be less healthy than those in the trial.

JAMA 2007;298:1641–51.


A systematic review of observational studies finds no strong evidence to associate amateur boxing with chronic traumatic brain injury. A total of 36 papers had extractable data, but most studies were of poor quality. Only four of 17 better quality studies found any indication of chronic traumatic brain injury in a minority of boxers. Systematic reviews, however, can only be as good as the studies they combine, so the lack of strong evidence seems impossible to interpret to this carphologist.

BMJ 2007;335:809–12.


Here is a trial with disappointing results. It finds that donepezil is no better than placebo in controlling agitation in patients with Alzheimer’s disease. Donezepil 10 mg was given over 12 weeks to 128 of 272 patients. The primary outcome was a change in the score on the Cohen-Mansfield agitation inventory (CMAI). Although a few patients on donepezil showed some reduction in agitation so did a comparable number of patients on placebo. No significant differences were seen between the groups in scores for the neuropsychiatric inventory, the neuropsychiatric inventory caregiver distress scale, or the clinician’s global impression of change. So neither the patients, nor the doctors, nor the caregivers were happy with the drug.

N Engl J Med 2007;357:1382–92.


Reassuringly, a randomised controlled trial with about 500 participants finds that in patients with Bell’s palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. Among patients treated within 72 h, 10 days of prednisolone 50 mg increased the chances of full recovery at three months from 64% to 83%, compared with placebo (p<0.001). Surprisingly, it also finds that giving acyclovir alone or in combination with prednisolone provides no additional benefit.

N Engl J Med 2007;357:1598–607.


Thiomersal, a mercury-containing preservative used in vaccines, has had its fair share of controversy and scares, which will hopefully be put to rest. A recent study looks at 42 neuropsychological outcomes in over 1000 children between the ages of 7 and 10 years and finds no evidence to link thiomersal with neurological damage. Only a few significant associations were found, and these showed some beneficial and some harmful effects. For example, higher prenatal mercury exposure was associated with better performance on one measure of language and poorer performance on one measure of attention and executive functioning. Furthermore, increasing mercury exposure from birth to 28 days was associated with poorer performance on one measure of speech articulation and better performance on one measure of fine motor coordination.

N Engl J Med 2007;357:1281–92.


See them quickly and treat them as soon as possible. This was the approach used by doctors in a dedicated clinic in Oxford to manage patients with transient ischaemic attacks or minor strokes. They report their before and after study, which shows an 80% reduction in the incidence of stroke. In the before phase, 10.3% (32/310) of patients sent to the clinic had a stroke within 90 days. In the after phase, only 2.1% (6/281) had a stroke (adjusted hazard ratio 0.2 (95% CI 0.08 to 0.49)). Thus doing away with the appointment system can save lives.

Lancet 2007;370:1432–42.


The seven recommendations in the joint clinical practice guideline from the American College of Physicians and the American Pain Society make sensible reading. For example, they tell clinicians not to obtain imaging or other diagnostic tests routinely in patients with non-specific low back pain (strong recommendation, moderate quality evidence). For most patients, first-line medication options are paracetamol or non-steroidal anti-inflammatory drugs. And for patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacological therapy with proven benefits. Clinicians should use MRI (preferred) or CT only in patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis, and only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate quality evidence). The next job is to get doctors to follow the guidelines.

Ann Intern Med 2007;147:478–91.

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