Humans

Surgery versus corticosteroid injection for carpal tunnel syndrome (DISTRICTS): an open-label, multicentre, randomised controlled trial

Author/s: 
Wijnand A C Palmbergen, Roy Beekman, A Marijne Heeren, Bart F L van Nuenen, Tim W H Alleman, Esther Verstraete, Korné Jellema, Wim I M Verhagen, Leo H Visser, Godard C W de Ruiter, Diederik van de Beek, Corianne A J M de Borgie, Johannes A Bogaards, Rob M A de Bie, Camiel Verhamme, Dutch CTS study group

Background: Surgery and corticosteroid injections are established treatments for carpal tunnel syndrome, but the optimal treatment strategy remains unclear. This study aimed to compare starting treatment with surgery versus starting with a corticosteroid injection.

Methods: We conducted an open-label, randomised controlled trial across 31 hospitals in the Netherlands. Eligible patients, diagnosed with carpal tunnel syndrome for at least 6 weeks and confirmed by electrophysiological or sonographic testing, were randomly assigned (1:1) to start treatment with either surgery or an injection via a web-based system. Randomisation was stratified by unilateral or bilateral symptoms, carpal tunnel syndrome with or without concomitant disease as risk factor, and previous ipsilateral injections. If needed, additional treatments were allowed, such as additional injections or surgery. The primary outcome, assessed in the intention-to-treat population, was the proportion of patients who were recovered (defined as a score of less than eight points on the six-item carpal tunnel syndrome scale) at 18 months. The trial was preregistered with the ISRCTN Registry (ISRCTN13164336) and is now completed.

Findings: From Nov 7, 2017, to Nov 4, 2021, 934 participants (545 female and 389 male participants) were included. 468 were randomised to the surgery group and 466 to the injection group. At 18 months, 805 (86%) of 934 participants had primary outcome data. In the surgery group, 243 (61%) of 401 participants had recovered, significantly higher than the 180 (45%) of 404 participants recovered in the injection group (relative risk 1·36; 95% CI 1·19-1·56; p<0·0001). One or more adverse event occurred in 376 (86%) of 436 participants in the surgery group and in 384 (85%) of 453 participants in the injection group. One participant in the surgery group was hospitalised due to complications. No treatment-related deaths were reported.

Interpretation: In patients with carpal tunnel syndrome, initiating treatment with surgery offers a higher chance of recovery after 18 months compared with starting with a corticosteroid injection, even with the possibility of additional interventions.

Funding: The Netherlands Organization for Health Research and Development and Zorgverzekeraars Nederland.

Gold 2023: Highlights for Primary Care

Author/s: 
Alvar Agustí, Antoni Sisó-Almirall, Miguel Roman, Claus F. Vogelmeier

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has issued its 2023 annual report1. Compared with former versions, it has been significantly updated. Here, we summarize the most relevant changes for a Primary Care audience. The complete document can be downloaded for free from the GOLD web page (www.goldcopd.org), together with a “pocket guide” and a “teaching slide set”.

Parkinson disease primer, part 1: diagnosis

Author/s: 
Frank, C., Chiu, R., Lee, J.

Objective To provide family physicians an updated approach to the diagnosis of Parkinson disease (PD).

Sources of information Published guidelines on the diagnosis and management of PD were reviewed. Database searches were conducted to retrieve relevant research articles published between 2011 and 2021. Evidence levels ranged from I to III.

Main message Diagnosis of PD is predominantly clinical. Family physicians should evaluate patients for specific features of parkinsonism, then determine whether symptoms are attributable to PD. Levodopa trials can be used to help confirm the diagnosis and alleviate motor symptoms of PD. “Red flag” features and absence of response to levodopa may point to other causes of parkinsonism and prompt more urgent referral.

Conclusion Access to neurologists and specialized clinics varies, and Canadian family physicians can be important players in facilitating early and accurate diagnosis of PD. Applying an organized approach to diagnosis and considering motor and nonmotor symptoms can greatly benefit patients with PD. Part 2 in this series will review management of PD.

Parkinson disease (PD) is the fastest growing neurodegenerative condition, with prevalence predicted to double from more than 6 million globally in 2015 to more than 12 million by 2040.1 Recognizing parkinsonism and having knowledge of the presentation, diagnosis, and management of motor and nonmotor symptoms of PD are increasingly important, particularly as access to neurologists and specialized clinics is limited in many parts of Canada.2 Family physicians are well placed to identify symptoms, participate in diagnosis, and collaborate with specialty clinics in management of patients through the course of the disease.

Snake Envenomation

Author/s: 
Seifert, S. A., Armitage, J. O., Sanchez, E. E.

Snake envenomation represents an important health problem in much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms.1 However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma.2,3 In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago.4 For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.

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