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First validated treatment for idiopathic intracranial hypertension

MD-FM Thursday April 24, 2014

 

 

SARAH:

MD-FM: the latest Medical News from around the world, here’s Peter Goodwin.

 

 

SEGMENT 1: Idiopathic Intracranial Hypertension: adding acetazolamide is more effective than weight-loss diet alone in patients with mild vision loss

 

PETER:

Hello, and to begin with: for patients with idiopathic intracranial hypertension (IIH) and mild-vision loss, the diuretic agent acetazolamide improved visual field function. Here’s Sarah Maxwell with the details…

 

SARAH:

Yes, that’s according to the first randomized trial, published in JAMA, that’s shown this commonly used agent given in combination with a low-sodium weight-reduction diet was more effective than dieting alone. Study author Michael Wall:

 

WALL:

We had improvement of a variety of things: we had improvement of vision, there was improvement of quality of life, there was an improvement in the severity of the optic nerve swelling and there was an improvement in the intracranial pressure. All of the side effects were reversible –we had no long-term morbidity.

 

SARAH:

Dr. Wall noted that the overall median improvement in vision was only “modest” in the trial. That’s because they only included patients with vision loss –measured using the criterion known as “perimetric mean deviation” –between minus two and minus seven decibels:

 

WALL:

So if they only had 2 decibels loss, they didn’t have much room to improve and most patients had 3.5 decibels or less so, again, there wasn’t a lot of room for improvement although there was a tremendous improvement in patients that had high-grade optic nerve swelling or high-grade papilledema. So you definitely want to use it if there’s high-grade papilledema –if you have grade 3, 4 or 5 papilledema –even if you don’t have vision loss, I would recommend using this because you’re at a high risk for getting worse.

 

SARAH:

Dr. Wall said another trial should begin shortly to test acetazolamide in patients with severe vision loss, so more than seven decibels:

 

WALL:

What we really don’t know are people with worse vision loss: would acetazolamide be effective in these people or do they need a surgical procedure to either protect the optic nerve or lower intracranial pressure and that’s the focus of the trial we are submitting.

 

SARAH:

That was Dr. Michael Wall, from the University of Iowa.

 

 

SEGMENT 2: Strategies for improving time to rescue treatment in patients with ischemic stroke

 

PETER:

Two studies in JAMA show, it’s possible to drastically reduce the delay in providing rescue treatment for patients who’ve just had a stroke…

 

SARAH:

Yes, time to treatment with intravenous tissue plasminogen activator (tPA) was significantly reduced in both studies and many patients actually got their tPA treatment within the recommended 60 minutes of hospital arrival. Gregg Fonarow, first author of one of the studies, described current pitfalls:

 

FONAROW:

The benefits of tPA are highly time-dependent however, despite that evidence, there has been over a decade’s worth of data, at least for United States hospitals, showing that less than one third of patients had door to needle times within 60 minutes and there was a lot of variation by hospital and very little progress over the last decade.

 

SARAH:

That was Dr. Gregg Fonarow from Ahmanson-UCLA Cardiomyopathy Center, in Los Angeles. His team used the American Heart Association’s ‘Target: Stroke’ initiative, which sets out 10 steps to streamline the way stroke teams work inside the hospital. More than 50 percent of patients got tPA within one hour with this approach.

 

FONAROW:

These improvements in the door-to-needle time for tPA actually translated into clinically meaningful improvements in outcomes. We really feel that this is generalizable, sustainable and scalable to improve the timeliness of acute ischemic stroke care and clinical outcomes worldwide.

 

SARAH:

In the other study, which was also positive, the team used a CT scan inside the ambulance –so bypassing the Emergency Room and bringing the stroke team to the patient. James Grotta wrote an editorial on the study:

 

GROTTA:

You know we spend a lot of time trying to think of how we can find better drugs that tPA, and we spend a lot of time doing imaging to try to identify the rare patients at the delayed time window –4, 5, 6 hours after the onset of symptoms –who may benefit.. In my mind, we will make more of a difference by getting more patients treated in that first hour –so driving the system to get more patients treated more quickly, for me, is the best way to, on a population-basis, make a bigger impact. And so these two articles point the way on how to do that.

 

SARAH:

That was Dr. James Grotta, from Memorial Hermann Hospital in Texas.

 

SEGMENT 3: Conservative management of brain arteriovenous malformations is safer than interventions in the long-term

 

PETER:

Patients with brain arteriovenous malformations that haven’t ruptured, have a lower risk of stroke or death for up to 12 years if they receive conservative management compared to interventions, including neurosurgical excision, endovascular embolization or stereotactic radiosurgery. That’s the conclusion of an observation study, published in JAMA, that’s confirmed previous findings from a randomized trial comparing both approaches. But, it’s worth bearing in mind that the authors did not provide information on the size of the patients’ unruptured malformations.

 

SEGMENT 4: First agent to reduce cartilage loss in knee osteoarthritis

 

PETER:

For patients with knee osteoarthritis a pharmacological agent has been shown to reduce cartilage loss, for the first time.

 

SARAH:

Yes, sprifermin –a growth factor present naturally in the body –was shown to reduce total femorotibial cartilage loss at 12 months. That was in a study, published in Arthritis and Rheumatology, that compared intra-articular injections of spirfermin with placebo jabs in 168 patients with knee osteoarthritis. Lead author Stefan Lohmander:

 

LOHMANDER:

There have been many attempts over the years to develop what we call disease-modifying agents to try to stop or slow this joint destruction by inhibiting the various enzymes that are active in the osteoarthritis joint, but they have so far not been successful... And this is a new approach, trying to stimulate repair and regeneration.

 

SARAH:

That was Pr. Stefan Lohmander, from the University of Lund in Sweden. He said although they didn’t notice any change in cartilage thickness in the central medial area of the joint, which they’d chosen as their primary outcome endpoint, they did see improvements in the lateral compartment and in the total amount of cartilage in the joint.

 

LOHMANDER:

It’s the first clinical trial in humans where we have actually used this sub-compartmental analysis and we will need to continue studies to see if we can repeat these positive effects and the issue is trying to focus on which particular area of the knee joint is the most important one.

 

SARAH:

Stefan Lohmander, from Sweden.

 

IN BRIEF 1: solid evidence to show a single dose of IV-administered ketamine can rapidly reduce symptoms of post-traumatic stress disorder

 

 PETER:

Finally, in brief: For patients with chronic post-traumatic stress disorder, a single, sub-analgesic, intravenous dose of ketamine, rapidly reduced symptoms and, apparently, much faster than with other pharmacotherapies, like selective serotonin re-uptake inhibitors and serotonin nor-epinephrine re-uptake inhibitors. This is the finding of the first randomized placebo-controlled trial to date, reported in JAMA Psychiatry, testing the efficacy of ketamine in PTSD.

 

IN BRIEF 2: Position of newborn babies before cord clamping does not seem to affect volume of placental transfusion

 

PETER:

Placing a newborn baby on the mother’s abdomen or chest before its umbilical cord is clamped doesn’t seem to affect the volume of placental transfusion. It’s also safe and it could reduce iron deficiency in infancy. These are the findings of a study, published in The Lancet, that compared this approach with “delayed cord clamping” at the currently recommended, but more awkward, “introitus” position, that’s level with the vagina. The volume of blood transferred from the mother’s placenta to the child was similar in both positions but immediate skin-to-skin contact between mother and baby could enhance maternal-infant bonding.

 

PETER:

That's all from MD-FM for now. Sarah Maxwell and I will be back with more soon so, until then from me, Peter Goodwin, goodbye!

 

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