Journals watch: TIA, carpal tunnel syndrome and anaemia

Too busy to read all of the journals? Dr Lizzie Croton selects papers of interest to primary care.

Aspirin plus clopidogrel may be superior in reducing stroke risk after TIA
Aspirin plus clopidogrel may be superior in reducing stroke risk after TIA

Clopidogrel and aspirin after TIA

N Engl J Med 2013; 369: 11-19

In this double-blind, placebo-controlled, multicentre trial in China, 5,170 patients assessed within 24 hours of a TIA were randomly assigned to receive clopidogrel plus aspirin or placebo plus aspirin.

Clopidogrel was given at an initial dose of 300mg followed by 75mg daily for 90 days; aspirin was given at 75mg daily for the first 21 days.

In the placebo plus aspirin group, aspirin was given at 75mg daily for 90 days.

Stroke occurred in 11.7% of the aspirin/placebo group and 8.2% of the clopidogrel/aspirin group, a statistically significant reduction.

Moderate or severe haemorrhage rates were similar in both groups, suggesting aspirin/clopidogrel is superior to aspirin alone in reducing stroke risk after TIA.

NSAIDs and cardiovascular risk

Ann Rheum Dis 2013 doi:10.1136/annrheumdis-2013-203137

Patients with rheumatoid arthritis (RA) have an increased cardiovascular risk owing to chronic systemic inflammation and classic cardiovascular risk factors.

NSAIDs are often used in RA and are associated with increased risk of cardiovascular death, MI and stroke.

In this longitudinal cohort case-control study, 17,320 patients with RA were matched with 69,280 controls.

During follow-up, 6,283 cardiovascular events occurred.

The cardiovascular risk associated with NSAID use in patients with RA was modest and significantly lower than in the non-RA controls.

Only diclofenac and rofecoxib (the latter now withdrawn) were associated with an increased cardiovascular risk in patients with RA. It is possible the benefit of NSAID use in RA may reduce cardiovascular effects, through improved pain relief and increased mobility.

Carpal tunnel syndrome

Occ Environ Med 2013 doi:10.1136/oemed-2012-101287

Little is known about the level of physical activity in the workplace that might lead to carpal tunnel syndrome (CTS).

This prospective study over two years selected three workplaces (healthcare and manufacturing) on the basis of hand activity level and forceful exertion.

The incidence of dominant hand CTS was 5.11 per 100 person-years.

The results suggested CTS is more common in those with high job demands and more time spent in forceful exertion.

People who are overweight or who have had CTS in the non-dominant hand are more likely to experience CTS with high job demands.

Organisational factors, such as workers' ability to choose when to have breaks, may play a part.

Doctors at risk of complaints

BMJ Qual Saf 2013; 22: 532-40

This study in Australia used a national sample of 18,907 formal patient complaints filed with health service ombudsmen over an 11-year period.

The authors found that 3% of Australia's medical workforce accounted for 49% of complaints. A total of 61% of the complaints concerned clinical care, most commonly treatment (41%) and medications (8%).

A quarter of complaints addressed communication problems, including attitude or manner (15%) or quality of information provided (6%).

Seventy-nine per cent of doctors named in complaints were male, 47% were GPs and 14% were surgeons.

The number of prior complaints received by a doctor was a strong predictor of subsequent complaints.

Doctors with two complaints had nearly double the risk of recurrence compared with those with one complaint. Doctors aged >35 years had more complaints than younger ones.

Anaemia in pregnancy

BMJ 2013; 346: f3443

This large systematic review and meta-analysis of women using iron prenatally revealed a linear decrease in maternal anaemia with higher doses of iron (up to 66mg per day).

Doses of iron >66mg per day were associated with a linear increase in birthweight and a decrease in the risk of low birthweight. Using iron at doses of up to 66mg per day was associated with a linear reduction in the risk of low birthweight.

Higher mean Hb concentrations prenatally increased birthweight with a dose-response relationship.

There was, however, no evidence of a reduction in the risk of preterm birth as a result of iron use.

  • Dr Croton is a GP in Birmingham 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.

  • Take a thorough, focused occupational history with the next patient you see with carpal tunnel syndrome. Are there any modifiable work risk factors that could prevent the condition getting worse?
  • The next time you hold a practice review of complaints, look at the nature of the complaints (clinical, attitudinal and so on) and see how they compare to the figures from the study. Are there any changes the practice can implement as learning points?
  • Perform an audit of compliance of all pregnant women at your practice who have been prescribed iron tablets.

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