Ending with a CRASH

The CRASH (Corticosteroid Randomisation After Significant Head injury) trial, a multi-centre international collaboration involving 239 hospitals in 49 countries, including Australia, has been stopped early because of an unexpected and alarming result.1,2 In CRASH, patients aged 16 years or older, with a head injury and a Glasgow coma score of 14 or less within 8 hours of injury (and who did not have a clear indication or contraindication for corticosteroid use) were randomised to receive an early 48-hour infusion of either methylprednisolone or placebo. It became apparent, when only halfway to the planned recruitment target of 20 000, that the corticosteroid group had an 18% increase in the relative risk of death from all causes in the first two weeks after treatment. The mechanism responsible for this increase in deaths was not known; however, it was not influenced by injury severity or time since injury. German commentators suggested that, during the 1980s and earlier, about 10 000 patients with brain injury could have lost their lives because of the then wide use of corticosteroid treatment.2

1. Lancet 2004; 364: 1321-1328
2. Lancet 2004; 364: 1291-1292

Stop the chocolate

An Australian resident of two years’ standing has called for schools and education departments to take action to prevent school fund-raising campaigns that involve selling chocolates. Given the rapid increase in childhood obesity in our society, Gunatilaka suggests that, rather than promoting poor dietary habits, schools should instead use a child’s eagerness to support his or her school as an opportunity for promoting healthy food habits. Healthier alternatives to chocolate could include dried fruits and long-life milk packets.

Aust N Z J Public Health 2004; 28: 494

Here, kitty kitty . . .

Tasmanian authors say that empirical antibiotic therapy should be commenced for minor infections following cat bites of the hand, rather than waiting for microbiological results. Mitnovetski and Kimble reported a series of 41 patients treated for cat bites of the hand in which five required surgery, mainly for drainage of deep infection. The use of prophylactic antibiotics for small wounds following cat bites to the hand has previously been shown to reduce the infection rate from 28% to 2%.

Aust N Z J Surg 2004; 74: 859-862

Tako-tsubo

Emotional stress can trigger an acute myocardial infarction in the absence of significant coronary artery disease, say Australian authors. Connelly and colleagues reported three women, aged 40, 49 and 58 years, who had a myocardial infarct shortly after experiencing emotional distress related to a minor road crash, a heated meeting about a case of sexual harassment and an argument leading to a permanent family break-up, respectively. On angiography, none of the women had serious coronary heart disease, but all showed temporary left ventricular wall motion abnormalities. The angiogram pattern was first described by Japanese authors in 1991 as tako-tsubo, as it resembles the shape of the instrument used to trap octopuses in Japan (tako = octopus, tsubo = pot).

Heart 2004; 90: e52

Cochrane report

The Cochrane Collaboration has come a long way in its first 10 years, but has further to go, according to a Canadian expert. The Collaboration is a unique, worldwide, not-for-profit organisation that aims to help people make well-informed decisions about healthcare through its core business of producing systematic reviews which are regularly updated and published quarterly. The Cochrane Library (2004, Issue 3) presented 2074 systematic reviews authored by about 7000 volunteers worldwide, including reviews relevant to the top 10 causes of disability in both developed and developing countries. However, as the reviews are often interest-driven rather than priority-driven, the Collaboration has not been sufficiently responsive to the immediate needs of policy-makers; further, the reviews have not adequately assessed the potential harms of healthcare interventions.

CMAJ 2004; 171: 747-749