Neurology
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Editorial Comment
Still an elusive target: guiding practice for epilepsy surgery.
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Randomized Controlled Trial Multicenter Study
Lithium carbonate in amyotrophic lateral sclerosis: lack of efficacy in a dose-finding trial.
A neuroprotective effect of lithium in amyotrophic lateral sclerosis (ALS) has been recently reported. We performed a multicenter trial with lithium carbonate to assess its tolerability, safety, and efficacy in patients with ALS, comparing 2 different target blood levels (0.4-0.8 mEq/L, therapeutic group [TG], vs 0.2-0.4 mEq/L, subtherapeutic group [STG]). ⋯ The study provides Class II evidence that therapeutic (0.4-0.8 mEq/L) vs subtherapeutic (0.2-0.4 mEq/L) lithium carbonate did not differ in the primary outcome of efficacy (survival/loss of autonomy) in ALS. Both target levels led to dropouts in more than 30% of participants due to patient-perceived lack of efficacy and AEs.
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To quantify the accuracy of commonly used intracerebral hemorrhage (ICH) predictive models in ICH patients with and without early do-not-resuscitate orders (DNR). ⋯ ICH prognostic model performance is substantially impacted when stratifying by early DNR status, possibly giving a false sense of model accuracy when DNR status is not considered. Clinicians should be cautious when applying these predictive models to individual patients.
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Multicenter Study Comparative Study
Pretreatment ASPECTS on DWI predicts 3-month outcome following rt-PA: SAMURAI rt-PA Registry.
To evaluate whether the pretreatment Alberta Stroke Programme Early CT Score (ASPECTS) assessed using diffusion-weighted imaging (DWI) predicts stroke outcomes at 3 months following IV recombinant tissue-type plasminogen activator (rt-PA) therapy. ⋯ ASPECTS on DWI was independently predictive of functional and vital outcomes at 3 months, as well as sICH within 36 hours, following rt-PA therapy for stroke patients.
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Comparative Study
Invited article: comparative effectiveness research, evidence-based medicine, and the AAN.
Comparative effectiveness research (CER) is the study of the relative effects of treatments to determine which will be most likely to improve overall health for a specific condition. This area has received a great deal of political focus, and substantial funding for CER is included in the American Reinvestment and Recovery Act of 2009. The results of CER are intended to inform evidence-based guidelines and to improve the quality and effectiveness of medical care. ⋯ Specifically, individual patient characteristics must be taken into account, study endpoints must approximate the most important patient outcomes, therapies must be used optimally within the studies, and the most relevant therapies for a given indication must be included for comparison. CER that is not performed or interpreted correctly could have the potential to affect negatively our choices of therapies. The neurology community must help inform the process of CER to ensure the highest-quality research, which in turn will result in the most valid outcomes.