Efrain Salgado

Amyotrophic lateral sclerosis Effects of acute intravenous and chronic subcutaneous administration of thyrotropin‐releasing hormone in controlled trials

We performed double-blind crossover trials to assess the effects of thyrotropin-releasing hormone (TRH) on amyotrophic lateral sclerosis patients. For acute intravenous trials, 500 mg TRH or placebo with norepinephrine was given at 1-week intervals (16 patients). CSF TRH concentration increased, and clinical side effects appeared with TRH. For chronic studies, 25 mg TRH and a saline placebo were given subcutaneously every day for 3 months (25 patients). CSF TRH level increased 29-fold after a single TRH injection, and mild transient side effects occurred. Vital signs, respiratory function, semiquantitative and quantitative neurologic function, muscle strength by manual and dynamometer testing, and EMG were studied. With daily TRH, 10 patients noted subjective improvement without objective evidence, and 10 patients complained of worsening of the disease with objective decline after TRH was stopped. Statistical analysis, however, showed no beneficial effects from either acute or chronic TRH trials.

Prevalence and control of stroke risk factors in a South Florida population.

ABSTRACT Objective: To assess the prevalence and control of stroke risk factors in our South Florida service population. Methods: We obtained data from the 2006–2010 Cleveland Clinic Florida annual “stroke prevention screening” questionnaires. Participants responded to questions regarding demographic information and stroke risk factors including pertinent comorbidity, alcohol consumption, and smoking. Onsite weight, height, blood pressure, and cholesterol levels were obtained. Our hospitals Director of Research did not identify any issues requiring formal institutional review board evaluation. Those with three or more modifiable risk factors breaching recommended targets met criteria for “poorly controlled.” Results: There were 298 participants, average age: 62.5 years, 65% were females. 36.9% had hypercholesterolemia, 32.9% hypertension, 14.4% diabetes mellitus, 8% transient ischemic attack/stroke, 7% coronary artery disease, 5.7% atrial fibrillation, and 2.7% carotid artery disease. 81.8% had a BMI of 25 or more and 37.8% had inadequate exercise. 38.3% had elevated cholesterol levels, 26.4% had blood pressures of 140/90mmHg or more, 6% were smokers, and 2.1% had excessive alcohol intake. 29.1% of the composite sample met the criteria outlined for “poorly controlled” stroke risk factors. Conclusion: Control of stroke risk factors especially obesity was worse compared to United States national data. Additionally, there is a higher prevalence of hypercholesterolemia and physical inactivity compared to statewide data. There is a definite need for local healthcare professionals to disseminate more stroke risk factor information. However, health promotion at the public policy or patient level should advocate personal responsibility especially pertaining to lifestyle and behavioral changes necessary for stroke prevention.

Letter by Govindarajan and Salgado Regarding Article, “Risk of Bleeding With 2 Doses of Dabigatran Compared With Warfarin in Older and Younger Patients With Atrial Fibrillation: An Analysis of the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) Trial”

To the Editor: We read with interest the article by Eikelboom et al1 on the subgroup analysis of bleeding complications with the 2 doses of dabigatran and coumadin in the RE-LY trial. It is interesting to note that the bleeding risk was the same for both doses. This was irrespective of whether patients were taking aspirin alone or a combination of aspirin and clopidogrel, whether they had renal failure, and even their age, although the higher dose (D150) had an increased trend toward major bleeding compared with the lower dose (D110).1 Atrial fibrillation is a disease of the old (>75 years), and older patients are more likely to be taking aspirin and/or …

Dabigatran and thrombolysis: A therapeutic dilemma

We read with interest the article by Pfeilschifter et al. on the safety of thrombolysis with dabigatran (DB) in a mouse model of experimental stroke. The authors have shown that recombinant tissue plasminogen activator (rt-PA) might be safe with DB at clinically significant serum concentrations of DB. But it remains unclear as to what were the actual DB levels in the mouse population at the time when rt-PA was administered. Further routinely measured anticoagulant parameters such as activated partial thromboplastin time (aPTT) and international normalized ratio are not reported at the time when rt-PA was given. Although thrombin time is a reliable marker for DB activity, it is not widely available, thus limiting its use. DB has a nonlinear relationship with aPTT. The primary utility of aPTT is in its negative predictive value, as a normal aPTT suggests little anticoagulant activity. Whether rt-PA would have been safe with a normal aPTT in this experimental model remains unknown.

Closed loop communication to prevent delay in recombinant tissue plasminogen activator administration

We read with interest the article by Walter et al entitled ‘‘Pointof-care laboratory halves door-to-therapy decision time in acute stroke.’’ We have sometimes noted a delay in obtaining results from our central laboratory. Emergency room (ER) personnel who draw the blood sample often wait for samples from other patients to be collected so they can tube all samples together. Once the sample reaches the laboratory, technicians are either not immediately available to process them or do not prioritize. There may be a delay from the time the results are actually released into the data pool to the time of posting in the electronic medical record (EMR). The point-of-care (POC) laboratory was discussed as an alternative, but the following drawbacks were noted: