Journals Watch - Aortic stenosis, PFOs and diets

Too busy to keep up with the journals? Allow Dr Raj Thakkar to be your guide to the latest findings.

Aortic stenosis and statins
Heart 2006; 92: 729-34

Degenerative calcific aortic stenosis (AS) is the commonest form of valvular lesion in Western societies. With an ageing population, the prevalence of AS and its co-morbidities is set to grow. Once breathlessness, chest pain, syncope or severe outflow tract obstruction develop, mortality may reach 50 per cent at two years.

This editorial discusses the possible medical treatments of AS. There is histological evidence that the development of AS has some similarities to that of vascular atherosclerosis. Observational studies have indicated that statins may lead to regression of early aortic disease, although the SALTIRE trial did not show regression in established disease.

The editorial also commented on the use of ACE inhibitors and the potential over-concern with these drugs in AS. The evidence regarding the benefits of ACE inhibitors in AS is conflicting and further work is required.

Community care benefits elderly patients
JAMA 2006; 295: 2,503-10

Removal from a familiar environment and concern about dying are among the factors that make elderly patients feel vulnerable and reluctant to be transferred to hospital.

Community care may reduce the risk of confusion and nosocomial infection, and is cheaper than secondary care.

This Canadian study of 680 patients over the age of 65 assessed a clinical care protocol including oral antibiotics, portable chest radiography, O2 saturation monitoring, fluid management and monitoring by a research nurse against usual care. Hospital admissions, length of stay, mortality, health-related quality of life, functional status and cost were measured among both groups.

A 12 per cent reduction in admissions was demonstrated when the protocol was applied. When these patients were admitted they had a reduced length of stay in hospital.

PFO and cerebrovascular disease
Mayo Clin Proc 2006; 81: 602-8

We are taught in medical school that patent foramen ovale (PFO) is a risk factor for cerebrovascular disease. This case-controlled study aimed to determine whether PFO is a risk factor for stroke.

The study involved just over 2,000 patients and adjusted for classical risk factors for cerebrovascular disease. The research group concluded that the link with PFOs has been over-estimated.

Is this ground breaking or a classic case of do not believe everything you read in the journals? It would be a brave clinician to ignore a PFO in a stroke patient.

Infection rates and miscarriage
BMJ 2006; 332: 1235-1237

This study aimed to assess differences in infection rate between expectant, medical and surgical management modalities for miscarriage. The UK based study involved seven hospitals and 1,200 women under 13 weeks gestation experiencing missed (early foetal demise) or incomplete miscarriages.

Outcomes measured were infection rates at 14 days, unplanned admission or further surgical intervention. Infection rates at 14 days were around 2-3 per cent across all three groups. Unplanned admissions were higher in the expectant (49 per cent) and medical (18 per cent) groups. The duration of bleeding was the least in the surgical group.

Admissions were mainly due to failure to expel the products of conception or failure of medical management, requiring curettage. A small number (3 per cent) required emergency surgery.

Expectant management is more appropriate for incomplete miscarriages and should be undertaken in selected patients who have 24-hour access to healthcare professionals.

- Dr Raj Thakkar is a GP in Woodburn Green, Buckinghamshire and a member of our team who regularly review the journals

INFORMING PATIENTS

Aortic stenosis is increasing in prevalence but more research on treatment is needed.

Community care reduces elderly patients' hospital stay.

Risk of stroke from PFO has been overstated.

Expectant management is more appropriate for incomplete miscarriages.

RESEARCH OF THE WEEK
Supported diets could work
BMJ 2006; 332: 1,309-11

Obesity is the new epidemic

This interesting UK-based study compared Dr Atkin's New Diet Revolution, the Slim-Fast plan, Weight Watchers and Rosemary Conley's regime to a control group. Weight loss, body fat indices and waist circumference were monitored over six months.

Reductions in all three measures were comparable in the four diet regimes, although the rate of weight loss varied. Average weight loss and fat loss at six months were 5.9kg and 4.4kg respectively.

At 12 months, those taking part in the unsupported regimes (Atkins and Slim-Fast) were more likely to have withdrawn. Supported weight loss on a population-wide scale could have major public health and cost benefits.

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