Volume 194 - Issue 4
In Other Journals
Author: Peter Lavelle
Med J Aust 2011; 194 (4): 203. || doi: 10.5694/j.1326-5377.2011.tb03774.x
Published online: 21 February 2011
Published online: 21 February 2011
Stemming the flow
The antifibrinolytic drug tranexamic acid (TXA) is best known for preoperative prophylaxis to prevent haemorrhage during and after surgery, and for treating excessive blood loss in women with heavy menstrual periods. It is also likely to be effective in another context — to prevent deaths from bleeding after trauma, according to an updated Cochrane Database review. A systematic review in 2004 of randomised trials in which TXA was given to patients with bleeding following severe injury was inconclusive, but two trials of TXA have been conducted since then. The 2011 review shows that TXA reduces the risk of death from bleeding by 10%-15% compared with patients who receive no treatment with TXA, without causing adverse events.
Cochrane Database Syst Rev 2011; (1): CD004896
Progesterone for brains?
Progesterone is known to reduce brain tissue oedema and the release of inflammatory mediators that follow brain injury. Should it be a routine treatment after brain injury? Authors of a Cochrane review identified three small randomised controlled trials comparing progesterone with placebo or no treatment. Progesterone showed a modest beneficial effect on mortality and disability; but given the modest number of trial participants, 315 in total, further multicentre randomised controlled trials are required before progesterone should be recommended as a routine treatment for brain injury.
Cochrane Database Syst Rev 2011; (1): CD008409
No tip required
“Pay for performance” schemes, such as Medicare’s Practice Incentives Program, link a portion of doctors’ payments to measures of health care quality, so as to encourage best practice. But are they efficacious? Serumaga and colleagues reviewed the effect of one such scheme, the Quality and Outcomes Framework, which targeted several chronic diseases including hypertension in primary care in the UK, and evaluated its impact. In a group of 470 725 patients with hypertension, over a 7-year period, a pay-for-performance bonus had no effect on the control of patients’ hypertension, or on clinical outcomes such as myocardial infarction and stroke. It is likely that treatment for hypertension was close to optimal or improving anyway over this period, so the scheme had no effect, the authors say. Other interventions such as educational outreach programs or case management by a team of health professionals may be more worthwhile. At least, pay for performance appears to cause no harm.
BMJ 2011; 342: d108
The hard sell
The more aggressively drug companies market their product, the less benefit and the more harm those drugs will cause. So say American academics Brody and Light. This “inverse benefit law”, as they term it, is the result of drug companies seeking to extend the market for drugs such as cyclooxygenase-2 inhibitors, statins, and bisphosphonates by exaggerating safety and efficacy claims and by encouraging off-label use. The effect is to increase side effects and costs, and to decrease therapeutic benefits. They say drug trials should be independently designed, funded and conducted; and doctors should view commercial marketing by pharmaceutical companies with scepticism.
Am J Public Health 2011. Epub Jan 13
Online rehab
Patients who undergo a total knee replacement but who live in rural or remote areas are at a disadvantage; access to high-quality rehabilitation services is not always possible. A solution might be “telerehabilitation” — an internet-based postoperative rehabilitation program conducted in the patient’s own home. Russell and colleagues studied a group of 65 patients who received 6 weeks of either traditional outpatient rehab services or rehab through real-time (live video and audio) interaction with a physical therapist via an internet-based system. The telerehabilitation patients did just as well; indeed, some experienced less stiffness than the traditional rehab patients. The technology is simple and easy to use, and could be the solution to the tyranny of distance, say the researchers.
J Bone Joint Surg Am 2011; 93: 113-120