Journals watch: Carpal tunnel syndrome, BP treatment and alcohol

Too busy to read all of the journals? Dr Simon Hunter reviews some papers of interest to GPs.

Carpal tunnel syndrome: if conservative measures fail, surgery is an option
Carpal tunnel syndrome: if conservative measures fail, surgery is an option

Steroid injections for patients with carpal tunnel syndrome

Ann Intern Med 2013; 159: 309-17

For patients who have carpal tunnel syndrome, if conservative measures such as a splint fail, surgery is often the next option.

Although usually successful, this is not without its problems, such as the length of time needed off work.

This study looked at the medium to long-term effectiveness of a steroid injection in carpal tunnel syndrome.

Previous studies had only been blinded for one month. This was a double-blinded placebo-controlled study with either 40mg or 80mg methylprednisolone or saline injected by an orthopaedic surgeon.

All of the patients recruited to the study had been unsuccessfully treated with splintage.

There was good relief from both strengths of steroid injection at 10 weeks' follow-up, but by one year, 73%, 81% and 92% of patients had received surgery in the 80mg, 40mg and placebo groups respectively.

The difference between the 80mg and the placebo was significant. It seems that a steroid injection can reduce the need for surgery, but the effects are relatively modest.

Shock-absorbing flooring

Age Ageing 2013; 42: 641-5

Falls in the elderly can have serious consequences. There are various interventions to stop falls or prevent injury should a fall occur.

This study assessed the cost-effectiveness of a shock-absorbing floor on elderly care wards as an injury prevention measure.

Four hospital sites had one ward bay fitted with a shock-absorbing floor and four sites had standard flooring. There was a non-significant increase in the number of falls in the intervention group (incidence rate ratio 1.07) and a non-significant decrease in the number of injuries (incidence rate ratio 0.58).

The researchers calculated that the flooring was likely to be a cost- saving measure, but further study was needed. The floor is not cheap, but is a novel way of thinking about preventing injury.

Educating adolescents on alcohol

Arch Dis Child 2013; 98: 672-5

Alcohol use and abuse is a concern because it can lead to dangerous behaviour and is associated with preventable mortality.

Adolescent drinking can lead to alcohol-related problems in later life. It is also very common; 25% of UK 15-year-olds drink weekly.

In this study in Israel, a group of 16to 17-year-old students took part in a one-day alcohol course, including a lecture on the risks of alcohol, meeting someone disabled in an alcohol-related accident, an enacted violent scene and a discussion on two videos about excess alcohol.

They filled in a pre-programme questionnaire, a feedback questionnaire at the end of the day and another after three months.

After the course, most students felt it had increased their knowledge of alcohol and said they would think differently about alcohol. The most appreciated part of the day was the enacted violent scene.

In the three-month follow-up questionnaire, a quarter of the students said they had reduced the amount of alcohol they drank and 88% felt the day should be part of the curriculum.

Incentivising BP treatment

JAMA 2013; 310(10): 1042-50

This US study of incentives in BP treatment looked at numbers of patients achieving the recommended BP, appropriate response to high BP readings and how clinicians followed guidelines.

The incentives went to the clinician or the team, or the clinician received an incentive and a share of the team payment. The control group received no incentive. The only method that made a significant difference from the control was the individual physician payment.

In this group, more patients were treated to target and more uncontrolled patients were identified and treated. There was no additional hypotension in this group, suggesting overtreatment.

Once payments stopped, the level of treatment returned to the same as the non-incentivised group. Payments to the team made no difference to quality of care. There was no greater adherence to guidelines in the incentivised groups.

Tolerance after cow's milk allergy

J Pediatr 2013; 163: 771-7

Cow's milk allergy is very common in infants, with an incidence of 3%. This study compared the rate of acquiring oral tolerance to cow's milk after 12 months of various milk alternatives.

Compared with the other groups, significantly more infants on extensively hydrolysed casein formula and extensively hydrolysed casein formula plus Lactobacillus rhamnosus GC had acquired tolerance of 44% and 79% respectively.

The rate of tolerance in the other groups was rice formula, 33%, soy formula, 24%, and amino acid based formula, 18%. This difference was repeated equally in IgE and non-IgE mediated intolerance.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Dr Hunter is a GP in Bishop's Waltham, Hampshire, and a member of our team who regularly review the journals

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Set up a meeting with local care homes to discuss falls prevention.
  • Consider asking about alcohol and adding a brief intervention on alcohol to adolescents when asking about smoking.
  • Audit 20 random patients with hypertension to find out if prescribing guidelines are being followed.

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