NEUROLOGICAL EVIDENCE

The impact of increased duration of exercise therapy on functional recovery following stroke: what is the evidence?
Author's objectives
To examine the effect of increased duration of exercise therapy compared to routine formal exercise on functional recovery after stroke.
Author's conclusions
The authors concluded that increased duration of exercise therapy, when compared to standard exercise regimes, improved functional outcome, as measured by the Barthel Index, in patients with stroke both post-treatment and at six months follow-up. They also indicated that their findings supported a positive effect on lower extremity impairment and walking speed.
Bibliographic details
Galvin R, Murphy B, Cusack T, Stokes E. The impact of increased duration of exercise therapy on functional recovery following stroke: what is the evidence? Topics in Stroke Rehabilitation, 2008; 15(4): 365-377
Status
This record is a structured abstract written by CRD reviewers. The original has met a set of quality criteria.
CRD commentary
This review had a clear aim and inclusion criteria and adequate details of studies included were provided. The literature search covered several databases but no attempt was made to uncover unpublished or non-English language studies, leaving the review open to possible publication and language bias. Only one reviewer assessed the references for retrieval, but full papers were screened by two reviewers, limiting possible reviewer bias. Quality assessment was performed independently by two reviewers, but it was not clear whether data extraction was performed in the same way. A relatively thorough quality assessment appeared to have been performed, although details of the process and criteria used to assess studies for the PEDro database would have added to this. The choice of statistical synthesis and method used was appropriate. Only results for trials reporting the same outcome measure were pooled, but given that results using different scales were converted to standardised mean differences, results could have been pooled across scales giving the analyses greater power, although this might have been at the expense of meaningful results if the scales were not assessing sufficiently similar outcomes. No details of the heterogeneity assessment were provided and no graphical presentation of trial results was given to allow the reader to assess the similarity of included trials. This was a reasonable well-conducted review and the authors' conclusions with respect to functional outcome are an accurate and reliable reflection of the results of the review, although the authors did not indicate that the actual observed effect was small in magnitude. The conclusions relating to lower extremity impairment and walking speed are not based on the results of the review and cannot be regarded as reliable.
Publication Date: 23 Dec 2009
Publication Type: Structured Abstract
Publisher: Centre for Reviews and Dissemination
Source: Database of Abstracts of Reviews of Effects
Creator: Centre for Reviews and Dissemination

Botulinum toxin treatment for spasticity following stroke
Bibliographic details
Botulinum toxin treatment for spasticity following stroke. HAYES, Inc, 2008; Directory Publication
URL of original report http://www.hayesinc.com/
Status
The HTA database is produced by the Centre for Reviews and Dissemination (CRD), York and the International Network of Agencies for Health Technology Assessment (INAHTA), Sweden. The HTA database contains information on publications and projects from nationally funded health technology assessment organisations. The abstracts in this database are descriptive only, and the original reports have not been evaluated by reviewers from the CRD
Publication Date: 23 Dec 2009
Publication Type: Review
Source: CRD Health Technology Assessment Database

Antidepressants and stroke
“Postmenopausal women who take antidepressants may be increasing their chance of suffering a stroke and dying prematurely,” reported the Daily Mail. It said a six-year study found a 45% increase in risk of strokes for women who used antidepressants compared to women who did not use them.
As the newspaper also reported, the absolute increase in risk of stroke (the number of women who might be affected) was small, equating to an increase of about 13 additional women in every 10,000 (0.43% of women on antidepressants compared to 0.3% of women not on them). In addition, depression itself is a known risk factor for stroke, so it is not clear how much of the increase was due to depression rather than the drugs.
Overall, this increase in risk was small and may not be attributable solely to the drugs themselves. Taking any medication involves weighing up the pros and cons of taking the drug compared to the prospects of leaving the disease untreated. As the British Heart Foundation said, “it is important to weigh up any small increase in the risk of stroke with the benefits of treating depression".
What does NHS Choices make of this study?
This study has collected and pooled a large amount of data from several studies of postmenopausal women. In the full journal article, the researchers are cautious in their interpretations of their results, discussing the issue of residual confounding and other limitations in four pages of comments.
See the entire NHS Choices commentary on this news item.
Citation of original study
Smoller JW, Allison M, Cochrane BB, et al. Antidepressant Use and Risk of Incident Cardiovascular Morbidity and Mortality Among Postmenopausal Women in the Women's Health Initiative Study. Arch Intern Med 2009; 169: 2128-2139

SEX MATTERS

Arch Intern Med 26 Oct 2009 Vol 169

1767 In the 1990s, the sex difference in mortality following myocardial infarction was a common topic of debate. Women were much less likely than men to get heart attacks, but nearly twice as likely to die from them in 1994. This reassuring study from the USA shows that in-hospital death rates from MI have fallen markedly in all patients but especially in women, so that the sex difference in mortality is now a third of what it was.
http://archinte.ama-assn.org/cgi/content/abstract/169/19/1767

ELECTRIC SHOCKS

NEJM 8 Oct 2009 Vol 361
1427 Most of us have an internal electric shock machine which often goes off just as we are going to sleep, reminding us of referral letters we meant to do or a job we promised for somebody. That’s bad enough: but a real electric shock machine is worse, and there have been several tirades against implantable defibrillators over recent weeks, as evidence has emerged that they do not improve mortality in women with advanced heart failure or men with marked systolic dysfunction but few symptoms. The latest group to demonstrate that these machines are shockingly ineffective are patients following myocardial infarct who show evidence of ventricular instability. Nearly 900 patients with reduced ejection fraction and tachycardia were selected to have an ICD or no ICD, so the trial was unblinded, but death is a reasonably objective end-point, and occurred equally in the two groups.
http://content.nejm.org/cgi/content/abstract/361/15/1427

JOURNAL SNIPS

NEJM 1 Oct 2009 Vol 361
1329 Cardiac resynchronisation therapy (dual chamber pacing) is a good intervention for about two thirds of patients with heart failure due to systolic dysfunction. We’ve known that for a while, and it’s worth repeating because it’s an under-used treatment in the UK and one that’s worth fighting for in a time of financial restraint. Implantable cardioverter-defibrillators, on the other hand, are of dubious value to most heart failure patients, especially women, and at the end stage prevent sudden painless death at the shocking (literally) cost of repeated firings and drowning from pulmonary oedema. So I have grave misgivings about the design of this trial to prevent overt heart failure in patients with minimal breathlessness but severely impaired systolic function, either due to ischaemia or non-ischaemic cardiomyopathy. They were relatively young (mean 64) and nearly asymptomatic despite having a mean LVEF of 24%. They were all fitted with ICDs; half of them also with dual chamber pacemakers. The trial was stopped early as the paced group had 41% fewer episodes of overt heart failure. These are not the kind of heart failure patients you see much of in primary care, so it doesn’t get us all that far. However, it’s consistent with my headline message: think biventricular pacing for all your appropriate real-life HF patients, think ICD for very few. http://content.nejm.org/cgi/content/abstract/361/14/1329

1368 One patient I remember was a sculptor who ended an anecdote with the words “I nearly killed him with my bare hands!” The great surgeon moved on, laughing grimly, “I’ve killed plenty of people with my hands”. Hospital mortality associated with inpatient surgery in the USA shows a twofold variation between the lowest and the highest quintiles, which surprisingly is not related to complication rates. Rather it is related to the way complications are managed. Surgeons, it seems, kill more patients after their operations than during. http://content.nejm.org/cgi/content/abstract/361/14/1368

Lancet 3 Oct 2009 Vol 374
1171 Of all the things to UPLIFT sales for Boehringer Ingelheim and Pfizer Pharmaceuticals, a disease-modifying agent for chronic obstructive pulmonary disease would have to come top. They ran a trial of this name for tiotropium in various grades of COPD, carefully prespecifying their subgroups so they could not be accused of cheating if one of them turned out to have a good result. In patients with stage II COPD using the GOLD classification this proved to be the case – a reduction in decline of postbronchodilator FEV1 and better ratings on the St George’s Respiratory Questionnaire compared with placebo. So for patients with early and mild symptoms, tiotropium may have a place. But whether this really warrants a population-wide effort to identify early COPD, as the editorial states, is more debatable. There is still a lot more to be done in promoting smoking cessation, the only intervention that will really affect COPD, plus cardiovascular disease, plus lung cancer; and a lot else.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61298-8/abstract

NHS EVIDENCE - neurological conditions

Centre for Reviews and Dissemination (CRD)
Cerebral blood flow threshold of ischemic penumbra and infarct core in acute ischemic stroke: a systematic review

Topic highlights
Migraine and risk of cardiovascular disease in women: learning about relative and absolute risk

Review: Blood pressure as a prognostic factor after acute stroke