Spinal Cord, August 2014

629  Clinical researchers in general share a belief of being the torchbearers of the spirit of scientific enquiry. At times, this leads to a tendency to get so consumed with Mission Science that we miss the woods for the trees. And end up being just a pain in the a**e (literally, in this instance). That’ s the feeling I got reading this paper on Melatonin supplementation for sleep disturbance following cervical spinal cord injury. The following parameters were being studied during polysomnography (PSG) using contraptions attached to the patients as they tried to sleep in spite of the researchers’ best efforts- “central electroencephalography, bilateral electro-oculography, electromyography (chin, diaphragmatic), electrocardiography, blood oxygen saturation, nasal pressure, leg movements, body position and respiratory movements (chest and abdomen)”. And then the big OMG parameter “A rectal thermoresistor-measured core body temperature during the PSG.” I had visions of Guantanamo Bay. That’s where it snaps. I understand the logic, best objective outcomes and all that. But, I do not agree to the design where sleep quality is studied by torturing people with wires head to toes, in addition to shoving a piece of instrument up their bottoms. Not all that is technically possible is necessary, or humanly desirable. I know my opinions don’t count, but doesn’t it make better sense to first make it conducive for people to sleep by taking off all the wires, and then use just a self-reported sleep quality outcome tool? What matters more than subjective judgments for sleep quality? Ironically, all the objective recordings notwithstanding, the authors conclude “Melatonin improved subjective sleep with participants reporting faster sleep initiation, having longer sleep duration and improved psychological well-being”. Does melatonin work better in subcontinental conditions in a better designed study? Potential PG thesis topic.

646 For those who hold a generalized prejudice about women in Islamic countries, time to wake up. This month, Maryam Mirzakhani, a Persian mathematician working in the US, became the first ever female winner of the prestigious Field’s medal, the highest prize in Mathematics. And then, this study on Sexual dysfunction in women with SCI- a study from Iran. The results of this descriptive study are similar to those from other parts of the world, that women with SCI do have significant dysfunction in multiple aspects of their sexual functioning. What might be surprising to many, though, was the statement “Of 118 eligible patients with SCI, 13 (11%) declined to participate because of discomfort over answering questions about sexual functioning”. I see only the positive side that almost 90% of women interviewed were willing answer, which seems an at/above par score for any country. The authors have tried to explain the 11% non-response as follows  “(this)  reflects the highly personal and private nature of sexual activity in Iran.”  Dear authors, your choice of words is funny, and strongly suggestive of a prejudiced view about sexual practices in the rest of the world. Please be assured that except perhaps at carnivals such as Mardi Gras and in certain types of private parties, sexual activity is still personal and private in many parts of the world, not just in Iran.

S24 I’m surprised Spinal Cord chose to publish a single case report of USG guided phenol block of obturator nerve for adductor spasticity. Did we miss out on reporting the scores of guided blocks that have become part of our routine practice?

S27 For the past many years, we have been using a Ferticare vibrator in the management of anejaculation following SCI. Placement of the diaphragm is usually over the frenulum or the dorsum. This case series promotes a new type of penile vibrator, whose name would not look out of place in the marvel universe. The fork shape of the Viberect-X3 appears to provide added zing by simultaneously stimulating the frenulum and the dorsum . I’m not sure if the claimed advantage of sandwiching is really significant, since the reported success rates of 77% do not seem to add much to what is already possible. Moreover, unlike the Ferticare product, amplitude and frequency in this new product seem to be non-adjustible.

Archives of PMR, August 2014

1585 Plantar fasciitis is one of those conditions which could be as troublesome to the treating team as to the patients. In some, everything could fail to achieve symptom relief- medications, footwear modifications, injections, surgery. This systematic review on utility of extracorporeal shockwave therapy in plantar fasciitis has reported its surprisingly positive findings in Cochrane-like tables and illustrations. “…efficacy of low-intensity ESWT is worthy of recognition. The short-term pain relief and functional outcomes of this treatment are satisfactory”- a tall claim. If true, we should start using ECSW. But, apart from the odd title of the article that makes no grammatical sense to me in spite of repeated reading, there are other glaring errors, either in the published illustrations or in my understanding. Competition alert! Those who point out either or both correctly would receive a personalized gift.

JAMA, August 2014

799 One of the most significant impacts of technology on us over the past couple of decades has been the decentralization and simplification of key processes on a mass scale. Carry a phone anywhere, print a document at home, get cash anytime from ATMs without going to banks during workhours, book Indian train ticket from anywhere, share with friends personal status updates  in a few seconds from anywhere including space. None of this was commonplace 20 years ago.  ‘Power to the patients’ is a logical extension of such technological advancements. This UK study on “Effect of Self-monitoring and Medication Self-titration on Systolic Blood Pressure in Hypertensive Patients” spectacularly concludes “self-monitoring with self-titration of antihypertensive medication compared with usual care resulted in lower systolic blood pressure at 12 months”. Self titration resulted in a systolic BP that was lesser by almost 10mmHg. I am among those who believe routine blood pressure monitoring at the population level should be delinked from clinics and hospitals, provided we have the right type of evidence. In addition to monitoring, delinking titration of medication too is one step ahead. This changes nothing as yet, with just the surrogate outcome measurement of BP recording at 1 year reported in this study. Long term followup to evaluate benefits/harms in terms of change (or the lack of it) in morbidity and mortality trends, could give us the correct picture.

In spite of examples such as a placebo controlled trial in management of cardiac arrest,  I realized from a few reactions that clinical equipoise and the ethics of placebo controls have not been understood and/or accepted by a few of you. I would keep repeating until somebody shoots me. When there exists a true uncertainty about benefits or harms from an intervention, it IS ethical to study it irrespective of whether it is the standard of care or not. Any intervention that does not have conclusive, cumulative scientific evidence in its favor can be contested by a placebo in a properly designed trial. Dr.Trisha Greenhalgh, best-selling author and academician, has a way of explaining things. I’ve expanded on it.  “If you have a cardiac arrest, you may get a ‘totally useless placebo’ – or ‘a totally useless (and potentially harmful) adrenaline shot’. We do not know for sure the benefits or harms of either intervention. If the situation arises, would you help us find the truth by participating in this study? The results of the study could lead to millions of people worldwide avoiding ineffective intervention in future”.

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I’d be attending the Cochrane Colloquium 20-27 September 2014. A week full of discussions on different aspects of pragmatic evidence informed healthcare; could be toxic.

source: Buzzfeed