Journals Watch - Carotid stenosis, UTIs and stroke

Too busy to keep up with the latest research? Dr Katrina Ford updates you on the latest papers.

Carotid artery stenosis: endarterectomy was found superior to stenting
Carotid artery stenosis: endarterectomy was found superior to stenting

Endarterectomy vs stenting for carotid artery stenosis - BMJ 2010; 340: c467
Carotid artery stenosis causes about 20 per cent of adult strokes. This systematic review and meta-analysis of RCTs compared the short and long-term outcomes of endarterectomy and stenting as treatments for stenosis.

Eleven trials involving 4,796 patients were reviewed to compare the short-term safety (within 30 days), and incidence of stroke or death at least one year after the procedure. Researchers also evaluated the occurrence of MI within 30 days and cranial nerve injuries.

The average incidence of periprocedural death was 5.4 per cent for endarterectomy and 7.3 per cent for carotid artery stenting. These results were not significant, yet the authors claim there is a significant difference in favour of endarterectomy, in terms of odds ratio. The odds of periprocedural MI or cranial nerve injury was higher in the endarterectomy group, but the risk of stroke was significantly lower.

This study suggests carotid endarterectomy is the best procedure for carotid stenosis, at least in terms of stroke.

UTIs in older women - Arch Gerontol Geriatr 2010; 50(2): 132-5
UTIs are one of the most common bacterial infections affecting women, with prevalence increasing with age.

This Scandinavian cross-sectional study looked at 395 women aged 85 or over who had been diagnosed with a UTI in the preceding year or in the preceding five years. Investigators analysed differences in the UTI group to those without UTI.

UTI during the previous year among older women was significantly associated with vertebral fractures, multi-infarct dementia, inflammatory rheumatic disease, stroke and heart failure. These women also suffered more constipation and incontinence and an association with delirium was found. UTI was more common among those in care and a history of falls was more common among women with UTI.

This study highlights how common and debilitating UTI can be and that urinalysis and MSU are important in unwell, elderly, female patients.

Mortality in patients with schizophrenia - Br J Psychiatry 2010; 196: 116-21
Unnatural deaths are common in those with schizophrenia and are best explained by altered exposure to environmental risk factors.

This paper describes the 25-year follow up of a Southampton-based community cohort with schizophrenia. It comprised 370 patients who had contact with NHS psychiatry services in a one year period, of whom 98 per cent were accounted for at the end of the study.

The mean age at death was significantly lower for males (60.4 years versus 67.3 years) and remained when unnatural deaths were excluded.

The standarised mortality rate (SMR) was 289 - a three-fold increase in mortality compared with the general population. SMR was higher (though not statistically significant) in males, the unemployed, the unmarried and those from lower social classes.

Most excess mortality was due to circulatory disease (33 per cent) and respiratory diseases (19 per cent). Of 30 deaths due to cancer, 13 were from lung cancer. SMRs for suicide, diabetes, pneumonia and COPD were strikingly elevated.

Ninety-five deaths were from diseases caused by smoking - 70 per cent of the excess natural mortality in the cohort.

Sleep apnoea, tiredness and obesity in stroke patients - Stroke 2010; 41: 129-34
Obstructive sleep apnoea (OSA) aggravates known risk factors for stroke such as hypertension and diabetes and, after stroke, severe OSA increases risk of stroke recurrence and mortality.

OSA is also associated with worse functional impairment and poorer outcome from rehabilitation. Widely used clinical criteria for the detection of OSA in the general community may not be applicable in patients with stroke.

The researchers hypothesised that patients with stroke report less sleepiness and are less obese than controls with the same severity of OSA.

Polysomnography was performed on 96 patients admitted to a stroke rehabilitation unit and on 1,093 controls without stroke. Subjective sleepiness was assessed with the Epworth scale and BMI was compared between the two groups.

For a given severity of OSA, patients with stroke were less tired and had lower BMI than those without stroke. This makes consideration of the diagnosis more important in stroke patients who may benefit from OSA treatment.

Lasofoxifene in post-menopausal osteoporosis - N Engl J Med 2010; 362(8): 686-96
Lasofoxifene is a selective estrogen receptor modulator (SERM).

The postmenopausal evaluation and risk reduction with lasofoxifene (PEARL) trial was conducted to determine whether it would reduce the risk of fractures, ER-positive breast cancer and cardiovascular disease among postmenopausal women with osteoporosis.

This RCT assigned 8,556 women aged 59-80 years and bone mineral density T-score of -2.5 or less (at femoral neck or spine) to either once daily lasofoxifene (either 0.25 or 0.5mg) or placebo, for five years. The higher dosage was associated with reduced risks of fracture, breast cancer, CHD and stroke.

At the lower dose, lasofoxifene was associated with reduced risks of vertebral fracture and stroke. However, both doses of lasofoxifene were associated with an increased risk of venous thromboembolic events. This increased risk is also seen with raloxifene; and oral estrogen therapies and SERMs seem to increase hot flushes.

Sexual problems and female sterilisation - BJOG 2010; 117(4): 463-8
An Australian telephone survey investigated whether women who have had tubal ligation are more likely to experience sexual problems. Of 2,721 women, 16.4 per cent had undergone tubal ligation and 85 per cent were aged 40-64 years of age.

Researchers asked about experience of sexual problems and ratings of sexual satisfaction, relationship satisfaction and sexual pleasure. This study showed no association between tubal ligation and specific sexual problems such as dyspareunia or anorgasmia.

However, this study was subject to a degree of selection bias.

Women embarrassed about discussing matters of a sexual nature would have been less likely to participate in the study and we know nothing about the degree of sexual satisfaction before tubal surgery.

  • Dr Ford is a locum GP in Worcestershire and a member of our team who regularly review the journals
The Quick Study

Endarterectomy carries a lower risk of periprocedural stroke.

UTIs are common and debilitating in elderly women.

Cardiovascular mortality is higher in patients with schizophrenia than the general population.

Stroke patients with obstructive sleep apnoea report less sleepiness and have a lower BMI.

Fracture risk in osteoporosis may be reduced by lasofoxifene.

Female sterilisation does not cause subsequent sexual problems in women.


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