Surgery plus medical treatment of Parkinson's disease
Lancet Neurol 2010; doi:10.1016/S1474-4422 (10) 70093-4
Surgical treatment for advanced Parkinson's disease may be an option if medical treatment alone fails to control symptoms adequately. This study looked at the efficacy of surgery in this situation.
At 13 neurosurgical centres in the UK, 366 patients whose symptoms were inadequately controlled with medical treatment alone were randomly assigned to receive immediate surgery in the form of lesioning or deep brain stimulation in addition to medical treatment, or to best medical treatment alone.
The primary endpoint was patients' self-reported quality of life issues on a 39-item Parkinson's disease questionnaire.
It was found that at one year, surgery plus best medical treatment patients reported improved quality of life over those on medical treatment alone. These differences were clinically meaningful.
This trial is ongoing. It was noted, however, that surgery is not without risk, but the findings could offer hope to some Parkinson's disease patients.
Role of HPV testing in low grade cervical abnormalities
Br J Obstet Gynaecol 2010; 117 (6): 645-59
How useful is HPV testing in the diagnosis of cervical abnormalities? In this study from the UK, Ireland and Canada, 4,439 women with low grade cervical abnormality showing borderline nuclear changes or mild dyskaryosis underwent HPV testing.
The women were randomised to receive either six monthly follow-up cervical screening in primary care or immediate colposcopy and were followed up for three years.
It was found that there was no advantage of immediate colposcopy over cytological surveillance in those who were HPV positive.
In younger women with low grade abnormality, a single HPV test was not useful in determining who should be referred for colposcopy or most effective management at colposcopy.
However, one positive finding was that in women aged over 40 years, a negative HPV test could be used to rule out the need for any further investigation. This might reduce the numbers being referred to colposcopy clinics.
Obstructive sleep apnoea
Br J Gen Pract 2010; 60 (574): 325-8
Obstructive sleep apnoea affects 5 per cent of adults and its links to hypertension are well known.
Sleep apnoea is known to contribute to elevated BP in a large proportion of hypertensive patients. It is thought to be frequently underdiagnosed but to screen all patients with hypertension for sleep apnoea would be a huge challenge due to the numbers involved.
In this study from Italy, obese hypertensive patients were recruited and their degree of sleepiness by the Epworth sleepiness scale was measured.
Obstructive sleep apnoea was identified in about 10 per cent of these patients and the diagnosis confirmed by polysomnography in all but one patient. The use of nasal continuous positive airway pressure (CPAP) machines in these patients greatly improved BP control in all cases on 24-hour BP monitoring.
This simple screening strategy may therefore improve BP control for our patients.
Further pregnancy after perinatal death
Am J Obstet Gynecol 2010; 202 (4): 357
After a stillbirth or early infant death, which is fortunately an uncommon event, upset parents are often very keen to conceive soon and I have certainly been asked how long parents should wait before trying for another pregnancy.
Multiple studies have shown that a waiting time of six to 18 months between pregnancies reduces adverse outcomes, including prematurity and intra-uterine growth retardation. But what advice is given to parents in these circumstances?
A total of 1,500 American obstetricians were randomly selected to be asked about their advice to parents.
Of these, almost 70 per cent endorsed a waiting time of less than six months with 27 per cent advising parents to try 'as soon as they feel ready' and 10 per cent even advising only a single normal period before trying to conceive again.
I shall certainly advise a six-month wait after reading this article.
Knowledge about IUDs
J Fam Plann Reprod Health Care 2010; 36(1): 73–8
The use of IUDs as long-acting methods of contraception is to be encouraged according to NICE guidelines, but I certainly encounter resistance to their use in my practice from some patients, mainly due to concerns about infection and future fertility.
In addition, many patients have little or no knowledge of IUDs. As a result, IUDs remain underused in many countries, including the UK, although they are an effective method of contraception.
I was interested to read this study from South African family planning clinics involving a cross-sectional survey.
It was found that awareness of IUDs among women attending the clinics was only 41 per cent. Those who had used an IUD in the past accounted for only 4 per cent and only 1 per cent were current users of IUDs.
These figures seem very low and it would be interesting to see what the figures are for the UK. There is definitely scope for further education about all methods of contraception.
- Dr Lewis is a GP in Windsor, Berkshire, and a member of our team of regular research reviewers.
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