Journal of the New Zealand Medical Association, 20-April-2012, Vol 125 No 1353
Atrial fibrillation is a significant risk factor in the aetiology of strokes. It can be effectively treated with drugs such as warfarin, but evidence indicates that up to half of patients who could benefit from treatment are not receiving it. This issue was addressed by UK stroke specialists at a 2-day consensus conference organised by the Royal College of Physicians of Edinburgh.
The conclusion reached by conference members was—“Screening for AF (atrial fibrillation) in people of 65 or older satisfies the UK National Screening Committee criteria for a screening programme and such a national screening programme should be undertaken in the UK.” The consensus noted that the most cost-effective screening method would be opportunistic pulse-checking of people over 65 by GPs, followed by electrocardiogram examination for those with an irregular pulse. When such patients were detected, the consensus recommended treatment with warfarin rather than low-dose aspirin which has proved to be ineffective.
This paper is based on the premise that different arm blood pressures of 10 mmHg or more may predict widespread vascular disease. The researchers included 20 reports in their meta-analysis. They note that a 15 mmHg or more difference was associated with peripheral vascular disease in 9 cohorts, pre-existing cerebrovascular mortality in 5 cohorts and increased cardiovascular mortality in 4 cohorts. A difference of 10 mmHg or more was associated with peripheral vascular disease in 5 studies.
They advocate blood pressure reading in both arms and further vascular assessment in those with such findings. An editorial writer concurs but points out that ideally the blood pressure readings should be simultaneous as sequential pressure reading doubles the prevalence of difference.
Lancet 2012;379:905–14 and 872–3.
Preclinical studies have shown that laquinimod reduces inflammatory cell infiltrates in the central nervous system, decreases demylination, and prevents axonal loss. This report concerns a randomised double-blind trial conducted in 24 countries, involving 1106 patients with relapsing–remitting multiple sclerosis. They were randomly assigned in a 1:1 ratio to receive oral laquinimod at a dose of 0.6 mg once daily or placebo for 24 months. The primary end-point was the annualised relapse rate during the 24-month period.
Those patients assigned to laquinimod 0.6 mg daily did better than those receiving placebo. They had a modest reduction in relapse rate (p=0.002), a reduction in disability progression (p=0.01) and less new or enlarging lesions noted on their gadolinium MRI images (p<0.001). There were no significant adverse events noted.
N Engl J Med:366:1000–9.
Hypertension is a common comorbidity of gout, affecting up to 74% of patients with gout. Some antihypertensives drugs are associated with elevation of serum uric acid and therefore may increase the risk of gout. On the other hand, calcium channel blockers and losartan are known to lower serum uric acid levels and so possibly lower the risk of gout. This nested case–control study from a large UK general practise database investigated this matter. They report the relative risk of incident gout associated with the use of various antihypertensive drugs. The relative risk for diuretics was 2.36, β-blockers 1.48, calcium channel blockers 0.87, ACE inhibitors 1.24, losartan 0.81, and non-losartan angiotensin-2 receptor blockers 1.29.
So calcium channel blockers and losartan might be the best treatment for the hypertensive patient with gout or hyperuricaemia.
Smoking cessation post-discharge following nicotine replacement therapy use during an inpatient admission
This study involved 123 smokers who elected to stop smoking during their hospital admission. All were given supportive management and the choice of 2 nicotine replacement therapies (NRT)—a nicotine patch or an inhaler formulation.
37 elected to use the inhaler, 50 the patch, and 36 no NRT. At 12 months continuous abstinence rates were 38%, 38%, and 25% respectively. All adverse effects were mild and transient and no subjects withdrew from their treatment as a result of toxicity. The cessation rates achieved were similar to those reported in the community setting.
The researchers recommend that such cessation policies should be used in hospitals generally. The predominant cost would be the employment of a dedicated professional.
Internal Medicine Journal 2012;42:154–9.
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