This month (July) Eyes on Evidence highlights new evidence in emergency stroke treatment, lifestyle measures to reduce cardiovascular risk and effective ways to put evidence into practice.NHS Evidence provides access to more than 150 reliable evidence sources. This month we focus on UK Database of Uncertainties about the Effects of Treatments (UK DUETs), explaining how to use it and what kind of information you can expect to find.The current economic climate has focused our minds on the need for increased financial efficiency. The QIPP collection highlights practical examples of how NHS organisations are both cutting costs and improving quality. It showcases what the NHS is already doing well, allowing colleagues to share best practice and deliver successful improvements without having to reinvent the wheel. Each month in Eyes on Evidence we will showcase an outstanding example of local best practice. To start us off we look at the success of Oxford Radcliffe Hospitals' electronic blood transfusion system. To find out how to share your success stories visit NHS Evidence. As always, user feedback is central to the future development of NHS Evidence, so if you have any comments let us know.
Examining the window for emergency stroke treatment
Examining the window for emergency stroke treatment
Overview: Stroke is a major health problem in the UK and is estimated to cost the economy around £7 billion per year. Most people survive a first stroke, but often have significant morbidity. More than 900,000 people in England are living with the effects of stroke, with half of these being dependent on other people for help with everyday activities.
Current treatment: Early management of stroke aims to avoid or minimise damage to the ischaemic brain. Intravenous recombinant tissue plasminogen activator (rt-PA) after ischaemic stroke can improve outcome. NICE recommends alteplase (rt-PA) should be considered for thromobolysis within 3 hours of symptom onset (in line with its marketing authorisation). However, it has been suggested that there is potential benefit of starting alteplase beyond 3 hours from onset.
New evidence: This pooled analysis by Lees et al (Lancet 2010; 375: 1695–703) re-examined the effect of time to treatment with alteplase on therapeutic benefit and clinical risk by adding recent trial data from ECASS III and EPITHET to pooled data from six other trials of alteplase for acute stroke. Treatment was started within 6 hours of stroke onset in 3,670 patients randomly allocated to alteplase or to placebo. Results indicated that treatment should be initiated as soon as possible to maximise benefit. Favourable 3-month outcome was significantly more likely with a shorter interval between symptom onset and treatment. There was no benefit of starting alteplase treatment after 4.5 hours and mortality significantly increased with a longer interval between symptom onset and treatment. 
Commentary: "Lees et al confirm the view that treatment benefit outweighs risk beyond the current 3 hour window from stroke onset, to 4.5 hours. After 4.5 hours, mortality rises with treatment, a fact not wholly explained by intracranial haemorrhage. The evidence favours extending the treatment licence to 4.5 hours, as this will increase the probability of a good outcome and potentially increase the number of patients who might benefit. But the authors rightly emphasise the point that such an extension in the 'time window' for thrombolysis should not lead to a more relaxed approach to hyper-acute stroke management. Their analysis shows that the greatest benefit comes from earlier treatment – 'time is brain'." - Dr Lionel Ginsberg, Clinical Lead, NHS Evidence – neurological; and Prof Tom Quinn, Clinical Lead NHS Evidence - cardiovascular, stroke and vascular.For more information on evidence relating to stroke visit NHS Evidence – stroke.
Can brushing teeth cut your cardiovascular risk?
Overview: In the UK, nearly three million women and three million men are living with the disabling effects of cardiovascular disease, which includes heart disease and stroke. More than 40,000 people die from premature cardiovascular disease each year. Overall, cardiovascular disease costs the UK approximately £30 billion annually.
Current treatment: Cardiovascular disease is a largely preventable condition that can be effectively tackled by making simple changes to diet, stopping smoking and increasing physical activity. NICE has recently published public health guidance on 'Prevention of cardiovascular disease', which aims to tackle this issue using a population-based approach.
New evidence: A study by de Oliveira et al. (BMJ 2010;340:c2451 doi:10.1136/bmj.c2451) examined if self-reported toothbrushing behaviour was associated with cardiovascular disease and markers of inflammation (C-reactive protein) and coagulation (fibrinogen).A population-based survey drew a nationally representative sample of nearly 12,000 people in Scotland, with an average age of 50. Oral hygiene was assessed using self-reported frequency of toothbrushing and surveys were linked prospectively to clinical hospital records. There were 555 cardiovascular disease events over an average 8 years follow-up, with coronary heart disease thought to be responsible for about three out of four of these. Poor oral hygiene seemed to be associated with higher levels of risk of cardiovascular disease and low grade inflammation. Participants who never or rarely brushed their teeth had a significantly greater risk of a cardiovascular disease event and higher concentrations of C-reactive protein and fibrinogen.
Commentary: "It is important for dental health that people brush their teeth regularly. A recent study in the BMJ suggests that those people who brush their teeth regularly are also less likely to suffer from cardiovascular disease in the future. However, there is no evidence of a causal link between teeth brushing and the development of cardiovascular disease. As the authors themselves discuss, residual confounding by social class and/or healthy lifestyle is likely to have had a major impact on the results." - Dr Jackie Price, Clinical Senior Lecturer in Epidemiology and Public Health, University of Edinburgh.
Commentary: "It is important for dental health that people brush their teeth regularly. A recent study in the BMJ suggests that those people who brush their teeth regularly are also less likely to suffer from cardiovascular disease in the future. However, there is no evidence of a causal link between teeth brushing and the development of cardiovascular disease. As the authors themselves discuss, residual confounding by social class and/or healthy lifestyle is likely to have had a major impact on the results." - Dr Jackie Price, Clinical Senior Lecturer in Epidemiology and Public Health, University of Edinburgh.
For more information on evidence relating to cardiovascular health visit NHS Evidence - cardiovascular.
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