Journals Watch - Parkinson's, clopidogrel and cancer

Too busy to catch up on the research? Let Dr Suzanne Hunter guide you through the latest papers.

Deep brain stimulation: X-ray showing electrodes positioned in the brain to treat Parkinson’s disease
Deep brain stimulation: X-ray showing electrodes positioned in the brain to treat Parkinson’s disease

Deep brain stimulation for Parkinson's disease
JAMA 2009; 301: 63-73

Deep brain stimulation is essentially a pacemaker for the brain with an electrode implanted to the subthalamic nucleus or globus pallidus. It is used for the treatment of advanced Parkinson's disease.

This study compared deep brain stimulation with 'best medical therapy' controlled by a consultant neurologist.

Deep brain stimulation showed tremendous benefits giving an extra 4.6 hours a day on average of 'on' time (good motor control) and significantly better quality of life. However, this improvement came with risks.

There were more adverse effects reported, especially from the surgical procedure, and there was one death from a cerebral haemorrhage.

This study does show that the treatment has a future, if used cautiously.

Maternal depression, violence and smacking
Arch Dis Child 2009; 94: 138-43

The use of smacking as a punishment is controversial and there is a wide body of opinion that it is wholly inappropriate.

This study examined the relationship between maternal depression, in-house violence (between adults) and the incidence of smacking.

They found a clear correlation, with the risk of smacking 1.59 times as likely in the presence of maternal depression, 1.48 times as likely in the presence of in-house violence and if both were present (and sadly they often co-exist) the risk increased 2.51 times.

The incidence rose no matter whether the child was well- or badly behaved.

More ICE, less scrips
Br J Gen Pract 2008; 58: 29-36

It is difficult to imagine a more appetising piece of research for the RCGP.

This Belgian study looked at GP trainees' consultations to see if they elicited ideas, concerns and expectations and the impact it had on prescribing.

Not surprisingly, the discovery of ideas, or concerns or expec- tations was associated with lower prescribing rates.

More surprisingly maybe was that although this was a one-day study and the doctors knew they were being observed, in 22 per cent of consultations, none of the triumvirate were elicited.

This indicates that it is not always that easy to elicit these factors, even more so when consultation success is measured in quality framework points.

Perhaps our masters need to decide whether it is more important for us to enquire about ethnicity or expectation.

Variable response to clopidogrel
Lancet 2009: 373; 309-17

The best evidence indicates that the combination of aspirin and clopidogrel is the treatment of choice for preventing recurrences following an acute coronary syndrome or a percutaneous coronary intervention. Yet, despite this, patients still continue to have thrombotic events.

Clopidogrel is a prodrug with the cytochrome P450 2C19 enzyme key to its activation. However, there is a polymorphism that affects its function.

This study examines the effect of this polymorphism on patients under 45 who had survived a first MI and received clopidogrel for at least a month.

The researchers found those with the polymorphism were over 3.5 times more likely to have an event than those without, and it appears to be the only independent predictor of cardiovascular events. The future seems to be more tailored treatments.

Weight loss improving incontinence
N Engl J Med 2009; 360: 481-90

Urinary incontinence has an association with obesity.

This study took two groups of overweight and obese women with at least 10 episodes of urinary incontinence. The control group had four one-hour sessions on weight loss and healthy living. The intervention group met weekly with experts in nutrition, were given diets and encouraged to exercise.

Both groups had advice on urinary incontinence. After six months the intervention group had a weight loss of 8 per cent compared with the control group's loss of 1.6 per cent, and had a reduction in incontinent episodes of 47 per cent compared with 28 per cent in the control group.

This demonstrates a relatively modest degree of weight loss can have a marked effect and should be recommended to patients.

Locally advanced prostate cancer
Lancet 2009; 373: 301-8

There is an accepted wisdom for the treatment of locally advanced prostate cancer to be either radiotherapy or endocrine treatment.

This 10-year study compared endocrine therapy with and without local radiotherapy. It was found that the mortality from prostate cancer was 23.9 per cent and all-cause mortality was 39.4 per cent in a group of patients with locally advanced prostate cancer treated with endocrine manipulation alone.

The group treated with endocrine manipulation and local radiotherapy had mortalities of 11.9 per cent and 29.6 per cent.

As the cancer-specific mortality was half with acceptable side-effects they recommend this combination therapy be the gold standard.

The Quick Study
  • Deep brain stimulation offers significantly better quality of life for patients with Parkinson's disease.
  • Smacking a child is associated with maternal depression and in-house violence.
  • Ideas, concerns or expectations, when elicited by a GP, were associated with lower prescribing rates.
  • Cardiovascular events were 3.5 times more likely in MI patients with the cytochrome p450 2C19 polymorphism.
  • Incontinence can be improved by weight loss in overweight women.
  • Cancer-specific mortality was reduced in prostate cancer patients treated with endocrine manipulation and local radiotherapy.
  • Dr Hunter is a GP in Bishops Waltham, Hampshire and a member of our team who regularly review the journals.

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