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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
Early benefit of aspirin after TIA or ischemic stroke (July 2016)
The risk of recurrent ischemic stroke is highest in the first days and weeks after a transient ischemic attack (TIA) or ischemic stroke, but the benefit of aspirin in this time period has not been well studied. In a recent pooled analysis of data from over 15,000 subjects in 12 trials evaluating aspirin for secondary prevention, the benefit of aspirin was strongest in the early weeks after TIA or ischemic stroke . Compared with control (mostly placebo), aspirin reduced the relative risk of recurrent ischemic stroke within the first six weeks by 58 percent (1 versus 2.4 percent, absolute risk reduction 1.4 percent). The benefit of aspirin in this time frame was greatest for the subgroup of patients with TIA or minor stroke. These findings emphasize that aspirin should be started as early as possible after the diagnosis of TIA or ischemic stroke is confirmed. (See "Antiplatelet therapy for secondary prevention of stroke", section on 'Aspirin'.)
Risk of stroke after transient ischemic attack or minor stroke (May 2016)
In a report from the TIAregistry.org project, a prospective multinational registry of over 4700 patients with transient ischemic attack (TIA) or minor stroke who were seen at sites providing urgent evaluation by stroke specialists, the estimated risks of stroke at days 2, 30, 90, and 365 after the index event were 1.5, 2.8, 3.7, and 5.1 percent, respectively . These rates are lower than those previously reported (estimated as 10 to 17 percent over the first 90 days), possibly due to the more rapid implementation of newer and more effective strategies for the secondary prevention of ischemic stroke. (See "Initial evaluation and management of transient ischemic attack and minor ischemic stroke", section on 'Risk of recurrent stroke'.)
Postmenopausal estrogen and cognitive function (August 2016)
While limited observational and clinical trial data have suggested that early, but not late, postmenopausal exposure to estrogen provides protection against later cognitive impairment, a new randomized trial found no benefit of estrogen regardless of when it was started. In the Early versus Late Intervention Trial with Estradiol (ELITE), 643 postmenopausal women, stratified according to time since menopause (<6 years [early] versus >10 years [late]), received oral estradiol (with progesterone for women with a uterus) or placebo for a median of five years . When compared with placebo, estradiol, whether it was started early or late, had no effect on verbal memory, executive function, or global cognition. (See "Estrogen and cognitive function", section on 'Younger menopausal women'.)
Declining use of feeding tubes in advanced dementia (August 2016)
Patients with advanced dementia commonly have eating problems in the final stages of illness, and caregivers are faced with decisions about whether to continue oral feeding by hand or place a long-term feeding tube. The available evidence fails to demonstrate any health benefits of tube feeding over ongoing hand feeding, and an increasing number of consensus-based guidelines advocate against feeding tube placement in this setting. In keeping with these recommendations, a recent study in the United States found that the proportion of nursing home residents with advanced dementia who received a feeding tube within one year of the onset of feeding problems decreased by approximately 50 percent between the years 2000 and 2014 . Advance care planning is critical in the management of patients with dementia and should include preparatory discussions about eating problems and other common complications encountered in the advanced stages of the disease. (See "Palliative care of patients with advanced dementia", section on 'Oral versus tube feeding'.)
Thrombotic microangiopathy from interferon (October 2016)
Drug-induced thrombotic microangiopathy (DITMA) has been described with a number of chemotherapeutic, immunosuppressive, and other drugs. Unlike thrombotic thrombocytopenic purpura (TTP), DITMA is not associated with severely reduced ADAMTS13 activity, and the principal treatment is drug discontinuation rather than plasma exchange. A new report has provided strong evidence for interferon as a cause of TMA . Patients receiving interferon who develop signs of a TMA should have the drug discontinued promptly before organ failure develops. (See "Drug-induced thrombotic microangiopathy", section on 'Immunosuppressive agents'.)
Daclizumab approved in the US for treating relapsing-remitting multiple sclerosis (June 2016)
Daclizumab, a humanized monoclonal antibody, was recently approved by the US Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis . The approval was based upon evidence from two randomized controlled trials that daclizumab is effective for reducing relapse rates, and evidence from one trial that it may be effective for reducing disability progression. However, the clinical utility of daclizumab is likely to be limited by the risk of serious adverse events, including hepatotoxicity and infection, making it a second- or third-line agent for patients who have had an inadequate response to two or more disease-modifying agents for relapsing-remitting multiple sclerosis. Daclizumab will be available in the United States only through a restricted distribution program. (See "Disease-modifying treatment of relapsing-remitting multiple sclerosis in adults", section on 'Daclizumab'.)
Everolimus for refractory epilepsy associated with tuberous sclerosis (September 2016)
Tuberous sclerosis complex (TSC) is characterized by the development of benign tumors in multiple organs, including the brain, and medically intractable epilepsy is a major cause of morbidity. The mammalian target of rapamycin (mTOR) pathway is over-activated in TSC, and mTOR inhibitors such as everolimus are known to have antitumor efficacy. Data on antiseizure effects have been limited, however. In the recent 18-week EXIST-3 trial, which enrolled over 360 subjects with TSC and treatment-resistant epilepsy, the proportion of subjects achieving a ≥50 percent reduction in seizure frequency was significantly greater for the low- and high-exposure everolimus groups compared with placebo (28, 40, and 15 percent, respectively) . The most common adverse events associated with everolimus were stomatitis, diarrhea, and pyrexia. While longer-term data are needed, these results suggest that everolimus is an effective and safe treatment option for patients with TSC and treatment-resistant epilepsy. (See "Tuberous sclerosis complex: Management", section on 'Refractory epilepsy'.)
Long QT syndrome mutations and sudden unexpected death in epilepsy (May 2016)
Sudden unexpected death in epilepsy (SUDEP) accounts for up to one-third of premature deaths in patients with epilepsy, and the pathophysiologic mechanisms are not well defined. A new study suggests that some patients may be predisposed to SUDEP due to congenital long QT syndrome (LQTS). In a study of 61 SUDEP cases for which whole blood was available at autopsy, exome sequencing identified pathogenic LQTS mutations in four patients . An additional nine patients had candidate pathogenic variants in dominant cardiac arrhythmia genes. Prospective studies are needed to determine whether electrocardiogram monitoring or other strategies can identify patients at risk for SUDEP and lead to interventions to reduce risk in patients with epilepsy. (See "Sudden unexpected death in epilepsy", section on 'Genetic factors'.)
Complications of dopaminergic therapy for restless legs syndrome (August 2016)
The main complication of long-term dopaminergic therapy for restless legs syndrome/Willis-Ekbom disease (RLS/WED) is “augmentation,” or an increase in symptom severity with increasing doses of medication. This may present as earlier onset of symptoms during the day, increased intensity of symptoms, or spread to previously uninvolved body parts (eg, arms, trunk). New consensus-based guidelines on the identification and management of augmentation recommend avoiding dopaminergic drugs as first-line therapy for RLS/WED when possible, screening patients on dopaminergic therapy for augmentation as part of routine clinical follow-up (table 1), and using the lowest doses possible to control symptoms . Treatment options for augmentation reviewed in the guideline include altering the dopaminergic dosing schedule, switching to an extended release preparation, and transitioning to an alpha-2-delta calcium channel ligand (eg, gabapentin enacarbil, pregabalin). In addition, alternative causes of worsening symptoms should be sought, such as low iron stores, sleep deprivation, and certain drugs such as serotonergic antidepressants. (See "Treatment of restless legs syndrome/Willis-Ekbom disease and periodic limb movement disorder in adults", section on 'Augmentation'.)
Thymectomy for myasthenia gravis (August 2016)
Lacking evidence from randomized trials, thymectomy for patients with nonthymomatous myasthenia gravis (MG) had been controversial. Now, the benefit of thymectomy is supported by the results of the multicenter, assessor-blinded MGTX trial, which enrolled 126 subjects with generalized acetylcholine receptor (AChR) antibody-associated MG and randomly assigned them to thymectomy plus alternate-day prednisone or alternate-day prednisone alone . Over a three-year period, thymectomy improved multiple clinical outcomes, including quantitative strength testing, average alternating-day prednisone requirements (44 versus 60 mg), need for azathioprine immunosuppression (17 versus 48 percent), and hospitalization for acute exacerbations (9 versus 37 percent). Based on these results and prior observational data, we recommend thymectomy for patients age <60 years with nonthymomatous, generalized acetylcholine receptor (AChR) antibody-associated MG. Thymectomy is also indicated in all patients with thymoma if resection is feasible. (See "Thymectomy for myasthenia gravis", section on 'Efficacy'.)
Whole brain radiation therapy and cognitive function in patients with limited number of brain metastases (August 2016)
Deferral of adjunctive whole brain radiation therapy (WBRT) in patients with a limited number of brain metastases who are eligible for surgery or stereotactic radiosurgery (SRS) has become more common over the last several years. This practice is supported by accumulating data from randomized trials showing that, although WBRT improves intracranial disease control, it does not appear to improve overall survival, and it is associated with early and delayed side effects that may worsen quality of life. A randomized trial of SRS plus WBRT versus SRS alone in 213 patients with brain metastases found that cognitive deterioration at three months was more common in patients who received WBRT (92 versus 64 percent), while overall survival was similar . Cognitive testing at 6 and 12 months and quality of life measures also favored SRS alone. Based on these results and other relevant studies, we suggest deferring adjunctive WBRT in most patients with a limited number of brain metastases. Such patients require serial neuroimaging after SRS alone to monitor for the development of new or progressive tumors. (See "Overview of the treatment of brain metastases", section on 'Role of adjunctive WBRT'.)
Radiation plus temozolomide in patients with 1p19q non-co-deleted anaplastic gliomas (July 2016)
Two previous randomized trials in patients with anaplastic oligodendroglial tumors found that postoperative treatment with radiation plus PCV (procarbazine, lomustine, and vincristine) improved survival compared with radiation alone. However, the benefit of PCV was primarily seen in patients whose tumors contained co-deletion of chromosomes 1p and 19q. The CATNON trial enrolled 748 patients with newly diagnosed anaplastic gliomas without 1p19q co-deletion and randomly assigned them to one of four treatment arms: radiation alone, radiation with concurrent temozolomide (TMZ), radiation with concurrent and 12 cycles of adjuvant TMZ, and radiation with 12 cycles of adjuvant TMZ . In an interim analysis with a median follow-up of over two years, patients who were randomized to receive 12 cycles of adjuvant TMZ had improved overall survival compared with those who received radiation without adjuvant TMZ (hazard ratio 0.65). Based on these results, we now recommend radiation plus chemotherapy in all patients with newly diagnosed anaplastic gliomas, rather than just those with 1p19q co-deleted tumors. The choice between PCV and TMZ should be individualized based on molecular characteristics of the tumor and patient preferences. (See "Management of anaplastic oligodendroglial tumors", section on 'CATNON'.)
Radiation plus temozolomide in older adults with glioblastoma (June 2016)
Shorter courses of radiation are increasingly used to treat older adults with glioblastoma, but the safety and efficacy of temozolomide in combination with such regimens have not been well studied. In a multinational phase III trial, 562 adults ≥65 years of age with a good performance status were randomly assigned to receive hypofractionated radiation (40 Gy in 15 fractions) plus concurrent and adjuvant temozolomide or radiation alone . Overall survival was significantly prolonged in patients assigned to combination therapy (9.3 versus 7.6 months), and quality of life outcomes were similar aside from an increase in nausea and constipation related to chemotherapy. The addition of temozolomide was especially beneficial in the subset of patients with O-6-methylguanine-DNA methyltransferase (MGMT) methylated tumors (13.5 versus 7.7 months). (See "Management of glioblastoma in older adults", section on 'Efficacy'.)
Botulinum toxin type A for children with spastic cerebral palsy (April 2016)
Botulinum toxin type A (BTX A) is a common treatment for spasticity in children with cerebral palsy (CP); however, studies to date have been small and have not focused on functional outcomes. In a recent randomized placebo-controlled trial of 235 children with spastic CP with dynamic equinus foot deformity, BTX A treatment improved muscle tone and resulted in a modest overall improvement in clinical status . The growing evidence of successful use of BTX A in children with spastic CP supports the use of this agent in patients who have increased muscle tone that interferes with function or is likely to lead to joint contracture with growth. (See "Management and prognosis of cerebral palsy", section on 'Botulinum toxin'.)
Chronic sleep-wake disturbances after traumatic brain injury (July 2016)
Sleep-wake disturbances are very common in the weeks to months following traumatic brain injury (TBI), and a new study suggests that many of these symptoms persist long term. In a prospective case-control study in which 31 patients with TBI of any severity were evaluated at 18 months after injury, 67 percent of patients had evidence of excessive daytime sleepiness on objective testing, compared with only 19 percent of healthy controls . Patients also had persistent pleiosomnia (increased need for sleep), requiring an average of one more hour of sleep per 24 hours than controls. As in earlier studies, patients tended to underestimate their symptoms, emphasizing the importance of both subjective and objective sleep testing in patients with sleep-wake complaints after TBI. (See "Sleep-wake disorders in patients with traumatic brain injury", section on 'Natural history'.)
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