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Crimmins and Palmer1 highlight the variations in clinical practice in the use of hyperventilation, anti-oedema agents, anticonvulsant drugs, and prophylactic antibiotics in patients with head injury. Although some of this may be due to variations in the standard of clinical care, at least some of the variation may be attributable to lack of really reliable randomised evidence. For example, in the 1980s there was very substantial variation in the proportion of patients with carotid territory transient ischaemic attacks referred for angiography and for carotid surgery in the United Kingdom.2 This variation highlighted uncertainties about the value of carotid surgery and led to the initiation of the European Carotid Surgery Trial. In this context it is interesting that the authors concluded that “there is class one data (randomised, controlled respective studies) that show there is no evidence of benefit of steroids in acute head injury”. They cited a non-systematic review published in 1993. However, the authors confuse lack of evidence of benefit with evidence of lack of benefit. A recent systematic review shows that clinically worthwhile benefit from corticosteroids in acute severe head injury is plausible and well worth evaluating.3 A large scale randomised controlled trial (corticosteroid randomisation in acute severe head injury—CRASH) is now under way and seeks to evaluate the balance of risk and benefit from corticosteroids in acute head injury in 20 000 patients world wide. We hope that the other interventions which are widely practicable in head injury, yet are so variably used, might also in future be submitted to similar large scale trials. Reliable evidence from these trials might help to reduce the variation in clinical practice in the treatments used for head injury.
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