Consider The Evidence: Med/Peds Journal Roundup

November 9, 2006

SIDS breakthrough? Mittens for stroke rehab

Filed under: JAMA, SIDS, stroke — medblog @ 11:26 am

JAMA (11/1)- An article in last weeks issue by Paterson, et al. is showing up in many news reports as a major advance in the understanding of sudden infant death syndrome (SIDS). The investigators explored the role of seritonergic(5-HT) neurons in the pathogenesis of the syndrome. Frankly, alot of it was basic science gobledygook to me but I got the idea that 1.) seretonin neurons in the medulla oblongata are involved with autonomic and respiratory function, 2.) postmortem exams of the brains of SIDS victims show significant differences in the number and location of 5-HT neurons, as well as lower relative density of seritonin transport protein. With 35% of the SIDS samples coming from premature babies, and the number of controls that were premature not being reported – I was left wondering if this was all confounded by normal developmental differences?

In a more immediately applicable study, Wolf et al. took about 200 stroke patients with hemiparesis and and had half of them put a restraining mitt on their good hand. Its called constraint-induced movement therapy (CIMT). The idea was to reinforce the connections to the affected limb by restricting use of the other limb. The subjects were 3 to 9 months out from the stroke. The CIMT group were supposed to wear the mitt during 90% of waking hours for 2 weeks. In addition they had daily task practice sessions with the paretic limb. The control group had usual care stroke rehab. In the end, the CIMT group had significantly better motor function that persisted at 1 year after therapy.

May 31, 2006

Add Aggrenox? Here we go again. ESPRIT

Filed under: lancet, stroke — medblog @ 12:42 am

Lancet 5/20 – With the growing number of anti-thrombotic drugs, there seems to be a lack of consensus on exactly what anti-thrombotic regimen is to be used after major ischemic events such as stroke.

This weeks Lancet presents information from the ESPRIT trial – the latest study into the value of dipyridamole for treatment after CVA. The study was an RCT which assigned patients who experienced TIA / stroke within the previous 6 months to aspirin + dipyridamole vs aspirin alone.

In the end, the hazard ratio for major ischemic events was 0.81 in an intention to treat analysis. So the addition of dipyridamole to aspirin after an ischemic CVA lowered the risk of a  subsequent major ischemic event by about 20%. In addition the combination group had less (HR 0.67) bleeding complications. Unfortunately, about three times as many patients in the combo group dropped out, mostly due to headache. The effect was robust enough to be significant in an ITT analysis despite the high dropout rate.

Now if I could just get this whole Clodoprigel thing figured out….

April 13, 2006

B12 & Folic Acid, lower homocysteine but not cardiovascular risk

Filed under: CVD, homocysteine, NEJM, stroke — medblog @ 11:11 pm

NEJM 4/13 – After the correlation between high homocysteine levels and disease such as stroke and MI was discovered, there was a flurry of work looking at the connection. The hope was that the effect was causal, and the simple use of B vitamins would lower homocysteine levels and reduce mortality.

The HOPE-2 investigators published an article exploring whether folic acid and B12 supplementation would lower the risk of cardiovascular events via reduction of homocysteine levels. This was a large study including over 5000 patients. Although the treatment group had significantly lower homocysteinie levels, there were no significant differences between the groups in the rates of death from cardiovascular causes or myocardial infarction.

After the failure of HOPE-TOO to show improved outcomes with vitamin E, this is the second vitamin supplementation study that has not shown a benefit. I guess we will have to wait for the next one to come along….

March 30, 2006

Dont count out G-CSF just yet….

Filed under: CMAJ, stem cells, stroke — medblog @ 5:15 pm

CMAJ 3/28 – Well it didnt work for the heart, but can it work in the brain? G-CSF is a promising treatment for the regeneration of infarcted tissues, due to its trophic and chemotactic effects on stem cells. However, in a JAMA article covered earlier this year, the treatment failed to improve outcomes in MI.

This month, Shyu et al. present a phase I study of such treatment for improving stroke outcomes. Although there appeared to be some benefit, the teeny-tiny (n=10) size of the trial precludes any major conclusions. It seems promising, however, that the group treated early with G-CSF achieved higher stroke-scale scores that the ususal care group. The study did also affirm the safety and feasability of the treatment (as is the point of phase I trials). Larger phase II trials are in the works that will hopefully show conclusively that G-CSF can be neuroprotective as well as stimulate new neuron production.


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