December 22nd, 2014

Selections from Richard Lehman’s Literature Review: December 22nd

CardioExchange is pleased to reprint this selection from Dr. Richard Lehman’s weekly journal review blog at Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.

NEJM 18 December 2014 Vol 371

A Randomized Trial of Intra-arterial Treatment for Acute Ischemic Stroke (OL): Dutch researchers have investigated the effect of removing clot from the blocked cerebral arteries following stroke, usually after initial treatment with alteplase. Collectors of silly acronyms will be pleased to note that this trial was called Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands—MR CLEAN. Intra-arterial thrombolysis, mechanical treatment, or both, was compared with usual care—which could include intravenous alteplase—in patients with a proximal intracranial arterial occlusion of the anterior circulation that was confirmed on vessel imaging. The primary outcome was the score on the modified Rankin scale at 90 days. The modified Rankin scale is a 7 point scale ranging from 0 (no symptoms) to 6 (death). A score of 2 or less indicates functional independence. This score was obtained over the telephone by an assessor blinded to treatment allocation. There was an absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate of functional independence (modified Rankin score, 0 to 2) in favour of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral haemorrhage. Now this is significant news. If you ask any doctor what they would like if they have a stroke, it is either to die or to come out relatively unscathed. This intervention does not reduce your chance of dying but it increases your chance of regaining independent function. So I’d go for it—although the stroke services and delivery times in your part of the world probably aren’t as good as those in the Netherlands.

JAMA 17 December 2014 Vol 312

Effects of High vs Low Glycemic Index of Dietary Carbohydrate on Cardiovascular Disease Risk Factors and Insulin Sensitivity (pg. 2531): A pitifully short trial, with a small sample size, poor completion rate, and entirely surrogate markers. Is this what we need to guide a lifelong intervention for hundreds of millions of people? Alas, it is not. This was an overambitious crossover trial in which 163 overweight adults (systolic blood pressure, 120-159 mm Hg) were given four complete diets that contained all of their meals, snacks, and calorie-containing beverages, each for five weeks. The results were gathered for all who completed at least two diet cycles, and they showed that diets with low glycaemic index of dietary carbohydrate, compared with high glycaemic index of dietary carbohydrate, did not result in improvements in insulin sensitivity, lipid levels, or systolic blood pressure. No matter: I am strongly inclined to believe that a low glycaemic index diet might be beneficial to vast numbers of people, but this is not the way to test it.


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