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BMJ No 7122 Volume 315 Papers - Abstracts Saturday 13 December 1997
Systematic overview of co-proxamol to assess analgesic effects of
addition of dextropropoxyphene to paracetamol Systematic overview of co-proxamol to assess analgesic effects of addition of dextropropoxyphene to paracetamolA Li Wan Po, W Y Zhang
AbstractObjective: To evaluate the comparative efficacy and tolerability of paracetamol-dextropropoxyphene combination and paracetamol through a systematic overview of randomised controlled trials.Design: Systematic retrieval of trials of paracetamol-dextropropoxyphene, paracetamol, and placebo to allow pooling of results from head to head comparison trials and single active placebo controlled trials. Subjects: 2,231 patients with postsurgical pain, arthritis, and musculoskeletal pain reported in 26 randomised controlled trials. Main outcome measures: Sum of difference in pain intensity; response rate ratio and difference in response rate with response defined as moderate to excellent pain relief; and rate ratio and rate difference of side effects. Results: The difference in pain intensity between paracetamol-dextropropoxyphene and paracetamol was 7.3% (95% confidence interval -0.2 to 14.9). The response rate ratio for the combination and paracetamol was 1.05 (0.8 to 1.3) on the basis of the head to head trials. Indirect comparisons produced quantitatively consistent results. Compared with placebo, the combination produced more dizziness (3.1; 1.1 to 8.9) whereas paracetamol resulted in more drowsiness (1.8; 1.1 to 2.9). Conclusion: On the basis of data on analgesic efficacy and acute safety in both head to head and indirect comparisons, there is little objective evidence to support prescribing a combination of paracetamol and dextropropoxyphene in preference to paracetamol alone in moderate pain such as that after surgery.
Centre for Evidence
Based Pharmacotherapy, Correspondence to: Professor Li Wan Po
Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic reviewP M Rothwell, J Slattery, C P Warlow
AbstractObjective: To identify risk factors for operative stroke and death from carotid endarterectomy.Design: Systematic review of all studies published since 1980 which related risk of stroke and death to various preoperative clinical and angiographic characteristics, including unpublished data on 1729 patients from the European carotid surgery trial. Main outcome measure: Operative risk of stroke and death. Results: Thirty six published studies fulfilled our criteria. The effect of 14 potential risk factors was examined. The odds of stroke and death were decreased in patients with ocular ischaemia alone (amaurosis fugax or retinal artery occlusion) compared with those with cerebral transient ischaemic attack or stroke (seven studies; odds ratio 0.49; 95% confidence interval 0.37 to 0.66; P<0.00001). The odds were increased in women (seven studies; 1.44; 1.14 to 1.83; P<0.005), subjects aged 75 years and over (10 studies; 1.36; 1.09 to 1.71; P<0.01), and with systolic blood pressure g180 mm Hg (four studies; 1.82; 1.37 to 2.41; P<0.0001), peripheral vascular disease (one study; 2.19; 1.40 to 3.60; P<0.0005), occlusion of the contralateral internal carotid artery (14 studies; 1.91; 1.35 to 2.69; P<0.0001), stenosis of the ipsilateral internal carotid siphon (five studies; 1.56; 1.03 to 2.36; P=0.02), and stenosis of the ipsilateral external carotid artery (one study; 1.61; 1.05 to 2.47; P=0.03). Operative risk was not significantly related to presentation with cerebral transient ischaemic attack versus stroke, diabetes, angina, recent myocardial infarction, current cigarette smoking, or plaque surface irregularity at angiography. Multiple regression analysis of data from the European carotid surgery trial identified cerebral versus ocular events at presentation, female sex, systolic hypertension, and peripheral vascular disease as independent risk factors. Conclusions: The risk of stroke and death from carotid endarterectomy is related to several clinical and angiographic characteristics. These observations may help clinicians to estimate operative risks for individual patients and will also facilitate more meaningful comparison of the operative risks of different surgeons or at different institutions by allowing some adjustment for differences in case mix. Department of Clinical Neurosciences,
Correspondence to: Dr P M Rothwell, email: peter.rothwell@clneuro.ox.ac.uk The West of Scotland coronary prevention study: economic benefit analysis of primary prevention with pravastatinJ Caro, W Klittich, A McGuire, I Ford, J Norrie, D Pettitt, J McMurray, J Shepherd for the West of Scotland Coronary Prevention Study GroupAbstractObjective: To estimate the economic efficiency of using pravastatin to prevent the transition from health to cardiovascular disease in men with hypercholesterolaemia.Design: Economic benefit analysis based on data from the West of Scotland coronary prevention study. Treatment specific hazards of developing cardiovascular disease according to various definitions were estimated. Scottish record linkage data provided disease specific survival. Cost estimates were based on extracontractual tariffs and event specific average lengths of stay calculated from the West of Scotland coronary prevention study. Subjects: Men with hypercholesterolaemia similar to the subjects in the West of Scotland coronary prevention study. Main outcome: Cost consequences, the number of transitions from health to cardiovascular disease prevented, the number needed to start treatment, and cost per life year gained. Results: If 10,000 of these men started taking pravastatin, 318 of them would not make the transition from health to cardiovascular disease (number needed to treat, 31.4), at a net discounted cost of £20m over 5 years. These benefits imply an undiscounted gain of 2460 years of life, and thus £8121 per life year gained, or £20 375 per life year gained if benefits are discounted. Restriction to the 40% of men at highest risk reduces the number needed to treat to 22.5 (£5601 per life year gained (undiscounted) and £13 995 per life year gained (discounted)). Conclusions: In subjects without evidence of prior myocardial infarction but who have hypercholesterolaemia, the use of pravastatin yields substantial health benefits at a cost that is not prohibitive overall and can be quite efficient in selected high risk subgroups. Caro Research, City University, University of Glasgow, Bristol-Myers
Squibb Outcomes Research, University of Glasgow, Department of Pathological Biochemistry, Correspondence to: Dr Caro email: jcaro@caroresearch.com Epileptic seizures after a first stroke: the Oxfordshire community stroke projectJohn Burn, Martin Dennis, John Bamford, Peter Sandercock, Derick Wade, Charles WarlowAbstractObjective: To describe the immediate and long term risk of epileptic seizures after a first ever stroke.Design: Cohort study following up stroke survivors for 2 to 6.5 years; comparison with age specific incidence rates of epileptic seizures in the general population. Setting: Community based stroke register. Subjects: 675 patients with a first stroke, followed up for a minimum of 2 years. Main outcome measures: Occurrence of single and recurrent seizures. Results: 52 patients had one or more post stroke seizures; in 25 the seizures were recurrent. The 5 year actuarial risk of a post stroke seizure in survivors (excluding19 patients with a history of epilepsy and 3 patients in whom the seizure occurred shortly before death from another cause) was 11.5% (95% confidence interval 4.8% to 18.2%). The relative risk of seizures, in comparison with the general population, was estimated at 35.2 in the first year after stroke and 19.0 in year 2. The risk of seizures was increased in survivors of subarachnoid and intracerebral haemorrhage (hazard ratio for intracranial haemorrhage v cerebral infarction 10.2 (3.7 to 27.9)). The risk of seizures after ischaemic stroke was substantial only in patients presenting with severe strokes due to total anterior circulation infarction. Only 9 of 295 patients (3%) independent one month after stroke suffered a seizure between 1 month and 5 years (actuarial risk 4.2% (0.1% to 8.3%)). Conclusion: Stroke patients have about an 11.5% risk of single or recurrent seizures in the first 5 years after a stroke. Patients with more severe strokes or haemorrhagic strokes are at higher risk.
Rehabilitation
Research Unit, Department of Clinical
Neurosciences, Department of Neurology, Rivermead Rehabilitation Centre, Correspondence to: Dr Burn email: rehab@soton.ac.uk
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