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Clinical Quickies
- Direct Evidence Showing Nicotinic Acid (NA) Significantly Reduces Carotid Atherosclerosis
- Maintaining Healthy Serum Vitamin D Level May Prevent End-Stage Renal Disease (ESRD)
- Hypercoagulation Associated with More Advanced Stages of Cancer
- IV Infusion of Choline Citrate Could be a Potential Treatment for Multiple Sclerosis
- Be Sure to Monitor Serum CRP Level in Patients with Stents
- When Combined With Statin Drugs, Slow-Release Niacin Significantly Reduced Carotid Intima-Media
Thickness
- Oral Alpha Lipoic Acid Minimizes Subarachnoid Hemorrhage Caused Brain Damage in Rats. Maybe in Humans, Too?
- High Dose Antioxidants Reduced Mortality and Hospital Stay for Acute Trauma Patients
- Correcting Hyperhomocycteinemia and Low Folic Acid Level May Improve Response Rate in Some Erectile Dysfunction Patients
- Melatonin Might Improve Diet-Induced Insulin Resistance
- Direct Acid Erosion May Not Be Cause of Reflux Esophagitis
- Asthmatic Children on Corticosteroids May Benefit from Magnesium Supplementation
- Current Evidence Shows That Antivirals are No Benefit to Bell’s Palsy Recovery
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1. Direct Evidence Showing Nicotinic Acid (NA) Significantly
Reduces Carotid Atherosclerosis
Background: NA raises high-density lipoprotein cholesterol (HDL-C) and reduces low-density lipoprotein cholesterol and is widely used as an adjunct to statin therapy in patients with coronary artery disease. Although changes in plasma lipoproteins suggest potential benefit, there is limited evidence of the effects of NA on disease progression when added to contemporary statin treatment.
Methods: We performed a double-blind, randomized, placebo-controlled study of 2 g daily modified-release NA added to statin therapy in 71 patients with low HDL-C (<40 mg/dl) and either:
1) type 2 diabetes with coronary heart disease; or
2) carotid/peripheral atherosclerosis.
The primary end point was the change in carotid artery wall area, quantified by magnetic resonance imaging, after one year.
Results: NA increased HDL-C by 23% and decreased low-density lipoprotein cholesterol by 19%. At 12 months, NA significantly reduced carotid wall area compared with placebo (adjusted treatment difference:–1.64 mm2 [95% confidence interval: –3.12 to –0.16]; p = 0.03).
Mean change in carotid wall area was –1.1 ± 2.6 mm2 for NA versus +1.2 ± 3.0 mm2 for placebo. In both the treatment and placebo groups, larger plaques were more prone to changes in size (r = 0.4, p = 0.04 for placebo, and r = –0.5, p = 0.02 for NA).
Conclusions: In statin-treated patients with low HDL-C, high-dose modified-release NA, compared with placebo, significantly reduces carotid atherosclerosis within 12 months.
J Lee, et al. Effects of high-dose modified-release nicotinic acid on atherosclerosis and vascular function: a randomized, placebo-controlled, magnetic resonance imaging study. J Am Coll Cardiol. 2009; 54:1787-1794.
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2. Maintaining Healthy Serum Vitamin D Level May Prevent End-Stage Renal Disease (ESRD)
Abstract: Black individuals have lower 25-hydroxyvitamin D [25(OH)D] levels and experience a disproportionate burden of ESRD compared with white individuals. Animal studies suggest that vitamin D has renoprotective effects.
We evaluated the contribution of low 25(OH)D levels on incidence of ESRD using data from the Third National Health and Nutrition Examination Survey-linked Medicare claims files (n = 13,328). We included baseline (1988 through 1994) measurements of 25(OH)D and assessed the incidence of ESRD through July 31, 2001. Overall, 34% of non-Hispanic black individuals had 25(OH)D levels <15 ng/ml compared with 5% of non-Hispanic white individuals (P < 0.001).
During a median of 9.1 yr, 65 participants developed ESRD. After adjustment for demographic, socioeconomic, and clinical and laboratory factors (including diabetes, hypertension, estimated GFR, and albuminuria), participants with 25(OH)D levels <15 ng/ml had a 2.6-fold greater incidence of ESRD than those with levels >/=15 ng/ml (incidence rate ratio 2.64; 95% confidence interval [CI] 1.00 to 7.05; P = 0.05).
After adjustment for clinical covariates but not 25(OH)D levels, non-Hispanic black individuals had a 2.83-fold (95% CI 1.03 to 7.77) higher risk for developing ESRD compared with non-Hispanic white individuals. Additional adjustment for 25(OH)D levels reduced the risk by 58% (incidence rate ratio 1.77; 95% CI 0.38 to 8.21). In summary, low 25(OH)D levels associate with development of ESRD even after adjustment for multiple risk factors. Low 25(OH)D levels may account for a substantial proportion of the increased risk for ESRD experienced by black individuals.
Melamed ML, et al. 25-hydroxyvitamin D levels, race, and the progression of kidney disease. J Am Soc Nephrol. 2009 Dec;20(12):2631-9.
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3.Hypercoagulation Associated with More Advanced Stages of Cancer
Abstract: Cancer produces a hypercoagulable state, which might lead to thrombosis, and on contrary, unprovoked venous thromboembolism might be the manifestation of an occult cancer. In this pilot case-control study, we assessed the risk of gynecological malignant diseases related to the presence of the factor V Leiden and prothrombin G20210A polymorphisms.
Fifty-two women underwent an operation for gynecological malignancy and were enrolled in the study. Women who underwent an operation for gynecological nonmalignant disease in the same days of cases were considered as controls. The presence of factor V Leiden and prothrombin G20210A was assessed in case and control groups. In all, 7 out of 52 cases were carriers of the 2 polymorphisms compared with 20 out of 198 controls (odds ratio = 1.3; 95% confidence interval, 0.6-3.0).
The results were also similar when the risk was considered separately for the site of cancer. As for advanced and metastatic malignancies, the odds ratios were 2.3 (95% confidence interval, 0.96.0) and 3.3 (95% confidence interval, 1.0-11), respectively, compared to noncancer patients. When these two groups were compared to nonadvanced cancer group, the odds ratios for carriers of polymorphisms were 2.7 (95% confidence interval, 0.7-11.0) and 3.9 (95% confidence interval, 0.8-18.6) for advanced cancer and metastatic malignancies, respectively.
Women with factor V Leiden or prothrombin G20210A polymorphisms who developed gynecological malignancy might present with a higher stage of cancer at the time of surgery. Larger case-control studies in similar cohort of patients are needed to confirm these findings.
Tormene D, et al. The Risk of Cancer Progression in Women With Gynecological Malignancies and Thrombophilic Polymorphisms: A Pilot Case-Control Study. Clin Appl Thromb Hemost. 2009 Oct;15(5):535-9.
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4. IV Infusion of Choline Citrate Could be a Potential Treatment for Multiple Sclerosis
Abstract: The efficacy of intravenous choline citrate infusions was investigated in 34 patients with multiple sclerosis (MS) by clinical evaluation and by monitoring of lymphocyte proliferation in vitro against fragments of myelin basic protein (MOG-35-55, MBP15-31, PLP 39-15) over a period of 12 weeks. Patients have been diagnosed with MS at least one year before entering the study and suffered from mild relapsing/remitting course to long-term chronic progressive disease.
Twenty one patients exhibited positive lymphocyte proliferation to myelin fragments prior to treatment and were
therefore selected for further studies. Choline citrate was administered with a dosage of 1200mg/ 2x week for a period of three months.
This treatment resulted in a significant decrease of lymphocyte proliferation to neural fragments (MOG- 35-55, MBP15-31) in lymphocyte transformation test (LTT). There was no significant SI change of PLP Peptide (PLP 39-15) LTT found after treatment with choline citrate.
During the three month observation period, patients remained stable and no side-effects of the treatment were observed. In addition, some patients reported long-lasting improvement (less paresthesia and increase of muscle strength in lower extremities) which was demonstrated up to three years later. In one spectacular case a commercial pilot was able to return to duty again after treatment. This pilot was allowed back in to his position as a commercial flying cockpit member and is on duty for more than four years now.
Muss C, et al. The effectiveness of choline citrate infusions monitored by lymphocyte transformation test (LTT) in multiple sclerosis. A new approach to the diagnosis and treatment of the disease. Neuro Endocrinol Lett. 2009 Aug 26;30(3):331-334.
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5.Be Sure to Monitor Serum CRP Level in Patients with Stents
Background: Although C-reactive protein (CRP) has been proposed as a useful biomarker for predicting atherothrombosis, the association between CRP and stent thrombosis after drug-eluting stent implantation has not been defined.
Methods and Results: We prospectively evaluated 2,691 patients treated with drug-eluting stents who had a baseline CRP measurement. The primary outcome was stent thrombosis; secondary outcomes were death, myocardial infarction (MI), death or MI, and target vessel revascularization.
During follow-up (median, 3.9 years), 32 patients had definite or probable stent thrombosis, 137 patients died, 227 had an MI, and 195 underwent target vessel revascularization. In multivariable Cox proportional-hazards models, elevated levels of CRP were significantly associated with increased risk of stent thrombosis (hazard ratio, 3.86; 95% confidence interval, 1.82 to 8.18; P<0.001).
Elevated CRP levels also significantly predicted the risks of death (hazard ratio, 1.61; 95% confidence interval, 1.13 to 2.28; P=0.008), MI (hazard ratio, 1.63; 95% confidence interval, 1.25 to 2.12; P=0.001), and death or MI (hazard ratio, 1.61; 95% confidence interval, 1.29 to 2.00; P<0.001) but not target vessel revascularization
(hazard ratio, 1.20; 95% confidence interval, 0.90 to 1.61; P=0.21). The incorporation of CRP into a model with patient, lesion, and procedural factors resulted in a significant increase in the C statistic for the prediction of stent thrombosis, MI, and the composite of death or MI.
Conclusions: Elevated CRP levels were significantly associated with increased risks of stent thrombosis, death, and MI in patients receiving drug-eluting stents, suggesting the usefulness of inflammatory risk assessment with CRP. Given the relatively infrequent occurrence of stent thrombosis, death, and MI, larger studies with longer-term follow-up are required to confirm the novel relationship.
Park DW, et al. C-Reactive Protein and the Risk of Stent Thrombosis and Cardiovascular Events After Drug-Eluting Stent Implantation. Circulation. 2009 Nov 17;120(20):1987-95.
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6. When Combined With Statin Drugs, Slow-Release Niacin Significantly Reduced Carotid Intima-Media Thickness
Background: Treatment added to statin monotherapy to further modify the lipid profile may include combination therapy to either raise the high-density lipoprotein (HDL) cholesterol level or further lower the low-density
lipoprotein (LDL) cholesterol level.
Methods: We enrolled patients who had coronary heart disease or a coronary heart disease risk equivalent, who were receiving long-term statin therapy, and in whom an LDL cholesterol level under 100 mg per deciliter (2.6 mmol per liter) and an HDL cholesterol level under 50 mg per deciliter for men or 55 mg per deciliter for women (1.3 or 1.4 mmol per liter, respectively) had been achieved. The patients were randomly assigned to receive extended-release niacin (target dose, 2000 mg per day) or ezetimibe (10 mg per day).
The primary end point was the between-group difference in the change from baseline in the mean common carotid intima-media thickness after 14 months. The trial was terminated early, on the basis of efficacy, according to a prespecified analysis conducted after 208 patients had completed the trial.
Results: The mean HDL cholesterol level in the niacin group increased by 18.4% over the 14-month study period, to 50 mg per deciliter (P<0.001), and the mean LDL cholesterol level in the ezetimibe group decreased by 19.2%, to 66 mg per deciliter (1.7 mmol per liter) (P<0.001). Niacin therapy significantly reduced LDL cholesterol and triglyceride levels; ezetimibe reduced the HDL cholesterol and triglyceride levels. As compared with ezetimibe, niacin had greater efficacy regarding the change in mean carotid intima-media thickness over 14 months (P=0.003), leading to significant reduction of both mean (P=0.001) and maximal carotid intima-media thickness (P</=0.001 for all comparisons).
Paradoxically, greater reductions in the LDL cholesterol level in association with ezetimibe were significantly associated with an increase in the carotid intima-media thickness (R=-0.31, P<0.001). The incidence of major cardiovascular events was lower in the niacin group than in the ezetimibe group (1% vs. 5%, P=0.04 by the chi-square test).
Conclusions: This comparative-effectiveness trial shows that the use of extended-release niacin causes a significant regression of carotid intima-media thickness when combined with a statin and that niacin is superior to ezetimibe.
Taylor AJ, et al. Extended-Release Niacin or Ezetimibe and Carotid Intima-Media Thickness. N Engl J Med. 2009 Nov 26;361(22):2113-22.
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7. Oral Alpha Lipoic Acid Minimizes Subarachnoid Hemorrhage Caused Brain Damage in Rats. Maybe in Humans, Too?
Abstract: The neuroprotective effect of alpha lipoic acid (ALA; 100 mg/kg, po), a dithiol antioxidant, on experimentally induced subarachnoid hemorrhage (SAH) was assessed in Wistar albino rats.
Neurological examination scores recorded at the 48th h of SAH induction were increased in SAH groups, which were accompanied with significant increases in the formation of reactive oxygen species, DNA fragmentation ratios, malondialdehyde levels and myeloperoxidase activity, while significant decreases in the brain glutathione content and Na(+), K(+)-ATPase activity were observed. On the other hand, ALA treatment reversed all these biochemical indices as well as SAH-induced histopathological alterations. Increased brain edema, impaired blood-brain-barrier permeability and neurological scores were also improved by ALA treatment.
The results demonstrate that ALA exerts neuroprotective effects via the enhancement of endogenous antioxidant enzyme activity, the Clinical Quickies continued from page 5inhibition of neutrophil accumulation and free radical generation, suggesting a therapeutic potential in reducing secondary injury after SAH in patients.
Ersahin M, et al. Alpha Lipoic Acid Alleviates Oxidative Stress and Preserves Blood Brain Permeability in Rats with Subarachnoid Hemorrhage. Neurochem Res. 2010 Mar;35(3):418-28.
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8. High Dose Antioxidants Reduced Mortality and Hospital Stay for Acute Trauma Patients
Background: The profound oxidative stress that occurs following injury results in significant depletion of many endogenous antioxidants (vitamin C, E, selenium).
Increasing evidence suggests antioxidant supplementation reduces infectious complications and organ dysfunction following injury and hemorrhagic shock. The purpose of this study was to evaluate the impact of high-dose antioxidant administration on the mortality rate of acutely injured patients.
Methods: In October 2005, we implemented a 7-day high-dose antioxidant protocol for acutely injured patients admitted to our trauma center. A retrospective cohort study, evaluating all patients admitted to the trauma service between October 2005 and September 2006 following protocol implementation (AO+), was performed. The comparison cohort (AO-) was made up of those patients admitted in the year prior to protocol implementation.
Results: A total of 4,294 patients met criteria (AO+, N = 2,272; AO-, N = 2022). Hospital (4 vs 3 days, P < .001) and ICU (3 vs 2 days, P = .001) median length of stays were significantly shorter in the AO+ group. Mortality was significantly lower in the AO+ group (6.1% vs 8.5%, P = .001), translating into a 28% relative risk reduction for mortality in patients exposed to high-dose antioxidants.
After adjusting for age, gender, and probability of survival, AO exposure was associated with even lower mortality (OR 0.32, 95% CI 0.22-0.46). Patients with an expected survival <50% benefited most (OR 0.24, 95% CI 0.15-0.37).
Conclusions: A high-dose antioxidant protocol resulted in a 28% relative risk reduction in mortality and a significant reduction in both hospital and ICU length of stay. This protocol represents an inexpensive intervention to reduce mortality/morbidity in the trauma patient.Collier BR, et al. Impact of high-dose antioxidants on outcomes in acutely injured patients.
JPEN J Parenter Enteral Nutr. 2008 Jul-Aug;32(4):384-8.
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9.Correcting Hyperhomocycteinemia and Low Folic Acid Level May Improve Response Rate in Some Erectile Dysfunction Patients
Introduction: Epidemiological studies conducted on erectile dysfunction (ED) have demonstrated its close correlation with cardiovascular disease. Since hyperhomocysteinemia is considered an important cardiovascular risk factor, it could also be involved in the pathogenesis of ED.
Aim: To study the role of the C677T MTHFR mutation with subsequent hyperhomocysteinemia in the determination of ED.Methods: We studied 75 consecutive patients presenting with ED. Patients were interviewed using the International Index of Erectile Function. Blood samples were drawn for determination of MTHFR gene C677T mutation, homocysteine (Hcy) and folate levels. Penile color Doppler was also performed.
Main Outcome Methods: Patients were administered sildenafil citrate for two months. The nonresponders were treated with combination of sildenafil, vitamin B6, and folic acid for six weeks. Patients were split into three groups, A, B, and C on the basis on their MTHFR genotype, and in a further group defined as “sildenafil nonresponders” (NR).
Results: We found 20 patients homozygous for mutant MTHFR 677T, 36 heterozygous, and 19 wild type. Difference in baseline values for Hcy and folic acid was found between groups A and B, and A and C. The NR group (18 patients from group A and B), presented high levels of Hcy and low levels of folic acid. After combination treatment 16 of them (88.9%) revealed an improvement in the IIEF questionnaire. Moreover, it was measured a significant difference between the values of Hcy and folic acid at the baseline and at the end of the study for the nonresponders.
Conclusions: Hyperhomocysteinemia in patients homozygotes for the C677T mutation may interfere with erection mechanisms and thus be responsible for ED. In case of hyperhomocysteinemia associated with low levels of folates, the administration of PDE5 inhibitors may fail if not preceded by the correction of the alterated levels of Hcy and folates.
Lombardo F, et al. Treatment of erectile dysfunction due to C677T mutation
of the MTHFR gene with vitamin B6 and folic acid in patients non responders to PDE5i. J Sex Med. 2010 Jan;7(1 Pt 1):216-23.
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10. Melatonin Might Improve Diet-Induced Insulin Resistance
Abstract: Obesity and insulin resistance represent a problem of utmost clinical significance worldwide. Insulin-resistant states are characterized by the inability of insulin to induce proper signal transduction leading to defective glucose uptake in skeletal muscle tissue and impaired insulin-induced vasodilation.
In various pathophysiological models, melatonin interacts with crucial molecules of the insulin signaling pathway, but its effects on glucose homeostasis are not known. In a diet-induced mouse model of insulin resistance and normal chow-fed control mice, we sought to assess the effects of an eight week oral treatment with melatonin on insulin and glucose tolerance and to understand underlying mechanisms.
In high-fat diet-fed mice, but not in normal chow-fed control mice, melatonin significantly improved insulin sensitivity and glucose tolerance, as evidenced by a higher rate of glucose infusion to maintain euglycemia during hyperinsulinemic clamp studies and an attenuated hyperglycemic response to an ip glucose challenge. Regarding underlying mechanisms, we found that melatonin restored insulin induced vasodilation to skeletal muscle, a major site of glucose utilization.
This was due, at least in part, to the improvement of insulin signal transduction in the vasculature, as evidenced by increased insulin-induced phosphorylation of Akt and endoethelial nitric oxide synthase in aortas harvested from melatonin-treated high-fat diet-fed mice.
In contrast, melatonin had no effect on the ability of insulin to promote glucose uptake in skeletal muscle tissue in vitro. These data demonstrate for the first time that in a diet-induced rodent model of insulin resistance, melatonin improves glucose homeostasis by restoring the vascular action of insulin.
Sartori C, et al. Melatonin Improves Glucose Homeostasis and Endothelial Vascular Function in High-Fat Diet-Fed Insulin-Resistant Mice. Endocrinology. 2009 Dec;150(12):5311-7.
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11.Direct Acid Erosion May Not Be Cause of Reflux Esophagitis
Background and Aims: Reflux esophagitis is believed to be caused by the caustic effects of refluxed gastric acid on esophageal epithelial cells. However, caustic chemical injuries develop rapidly, whereas esophagitis might not appear until weeks after the induction of reflux in animal models. We studied early histologic events in the development of reflux esophagitis in a rat model and performed in vitro experiments to determine whether exposure to acidified bile salts causes esophageal epithelial cells to secrete chemokines that might contribute to inflammation.
Methods: At various time points after esophagoduodenostomy, the rat esophagus was removed and inflammatory changes were analyzed by histologic analyses. Human esophageal squamous cell lines were exposed to acidified bile salts to evaluate their effects on cytokine production and immune-cell migration.
Results: Reflux esophagitis started at postoperative day 3 with lymphocytic infiltration of the submucosa that progressed to the epithelial surface-these findings contradicted those expected from a caustic chemical injury. Basal cell and papillary hyperplasia preceded the development of surface erosions. Exposure of squamous cells to acidified bile salts significantly increased the secretion of interleukin-8 and interleukin-1beta; conditioned media from these cells caused significant increases in the migration rates of T cells and neutrophils.
Conclusions: These findings support, but do not prove, an alternative concept for the development of reflux esophagitis in which refluxed gastric juice does not directly damage the esophagus, but rather stimulates esophageal epithelial cells to secrete chemokines that mediate damage of esophageal tissue.
Souza R, et al. Gastroesophageal Reflux Might Cause Esophagitis Through a Cytokine-Mediated Mechanism Rather Than Caustic Acid Injury. Gastroenterology. 2009 Nov;137(5):1776-84.
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12. Asthmatic Children on Corticosteroids May Benefit from Magnesium Supplementation
Abstract: Hypomagnesaemia is suggested to be associated with increased incidence of wheeze, airway hyperreactivity and impairment of lung functions. We aimed to assess the serum magnesium level in asthmatic children and evaluate the effect of corticosteroid treatment on it.
The study included 89 chronic asthmatic children aged 5 to 15 years receiving inhaled fluticasone propionate and short courses of oral methyl prednisolone during exacerbation. About 12 of them stopped steroid treatment three months before inclusion in the study. About 27 healthy children served as controls. Serum magnesium was significantly lower in asthmatics receiving steroid compared to controls and to those not receiving steroid.
No significant difference was found between asthmatics not receiving steroid and controls. A significant negative correlation was found between serum magnesium and frequency of oral corticosteroid. Thus, use of corticosteroid in asthmatics reduces magnesium level with recovery to normal after steroid cessation. Magnesium supplementation is recommended to those receiving steroid.
Fatouh A, et al. Magnesium level in chronic asthmatic children --effect of corticosteroid treatment. International Journal of Food Safety, Nutrition and Public Health 2009;2(2):101-110.
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13.Current Evidence Shows That Antivirals are No Benefit to Bell’s Palsy Recovery
Background: Antiviral agents against herpes simplex virus are widely used in the treatment
of idiopathic facial paralysis (Bell’s palsy), but their effectiveness is uncertain. Significant morbidity can be associated with severe cases.
Objectives: This review addresses the effect of antiviral therapy on Bell’s palsy.
Search Strategy: We updated the search of the Cochrane Neuromuscular Disease Group Trials Register (December 2008), MEDLINE (from January 1966 to December 8 2008), EMBASE (from January 1980 to December 8 2008) and LILACS (from January 1982 to December 2008).
Selection Criteria: Randomized trials of antivirals with and without corticosteroids versus control therapies for the treatment of Bell’s palsy.
Data Collection and Analysis: Twenty-three papers were selected for consideration.
Main Results: Seven trials including 1987 participants met the inclusion criteria, adding five studies to the two in the previous review.Incomplete recovery at one year. There was no significant benefit in the rate of incomplete recovery from antivirals compared with placebo (n = 1886, RR 0.88, 95% CI 0.65 to 1.18). In meta-analyses with some unexplained heterogeneity, the outcome with antivirals was significantly worse than with corticosteroids (n = 768, RR 2.82, 95% CI 1.09 to 7.32) and the outcome with antivirals plus corticosteroids was significantly better than with placebo (n = 658, RR 0.56, 95% CI 0.41 to 0.76).
Motor synkinesis or crocodile tears at one year. In single trials, there was no significant difference in long term sequelae comparing antivirals and corticosteroids with corticosteroids alone (n = 99, RR 0.39, 95% CI 0.14 to 1.07) or antivirals with corticosteroids (n = 101, RR 1.03, 95% CI 0.51 to 2.07).Adverse events. There was no significant difference in rates of adverse events between antivirals and placebo (n = 1544, RR 1.06, 95% CI 0.81 to 1.38), between antivirals and corticosteroids (n = 667, RR 0.96, 95% CI 0.65 to 1.41) or between the antiviral-corticosteroid combination and placebo (n = 658, RR 1.15, 95% CI 0.79 to 1.66).
Authors’ Conclusions: High quality evidence showed no significant benefit from anti-herpes simplex antivirals compared with placebo in producing complete recovery from Bell’s palsy. Moderate quality evidence showed that antivirals were significantly less likely than corticosteroids to produce complete recovery.
Lockhart P, et al. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD001869.
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