QJM : monthly journal of the Association of Physicians
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Review
Oximes in acute organophosphorus pesticide poisoning: a systematic review of clinical trials.
Acute organophosphorus (OP) pesticide poisoning is widespread in the developing world. Standard treatment involves the administration of intravenous atropine and an oxime to counter acetylcholinesterase inhibition at the synapse, but the usefulness of oximes is uncertain. ⋯ The RCT authors must be congratulated for attempting important studies in a difficult environment. However, their studies did not take into account recently clarified issues regarding outcome, and their methodology is unclear. A generalized statement that pralidoxime should not be used in OP poisoning is not supported by the published results. Oximes may well be irrelevant in the overwhelming self-poisoning typical of the tropics, but a large RCT comparing the current WHO-recommended pralidoxime regimen (>30 mg/kg bolus followed by >8 mg/kg/h infusion) with placebo is needed for a definitive answer. Such a study should be designed to identify any patient subgroups that might benefit from oximes.
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Randomized Controlled Trial Clinical Trial
A pilot study of N-acetylcysteine as adjunctive therapy for severe malaria.
The case fatality rate of severe malaria remains unacceptably high. N-acetylcysteine (NAC) is a safe compound that inhibits tumour necrosis factor (TNF) and impedes cytoadherence, both of which have been implicated in the pathogenesis of malaria complications. ⋯ NAC's mechanism of action in malaria is unclear, since it did not markedly alter plasma cytokine profiles. Trials of NAC adjunctive therapy for complicated malaria, with mortality as an endpoint, appear to be warranted.
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Comparative Study
A comparison of lorazepam and diazepam as initial therapy in convulsive status epilepticus.
Previous trials have suggested lorazepam may be superior to diazepam as first-line treatment of convulsive status epilepticus (CSE), with improved seizure outcome, and a lower incidence of side-effects. Many published guidelines however still recommend diazepam. ⋯ We recommend that lorazepam be the first-line therapy in preference to diazepam in adults with CSE.
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Randomized Controlled Trial Clinical Trial
Survival of unselected stroke patients in a stroke unit compared with conventional care.
Recent meta-analyses have reported a beneficial effect of stroke units compared with traditional care, both on patient survival and on dependency after one year. ⋯ In this, the largest single-centre study to evaluate the survival benefit of a stroke unit, survival at 30 days was increased, although not significantly so. Survival at one year was unchanged.