Rehab Journal Review

Journal of Neurosurgery, July 2014

‘A nose could grow in your back’, the creepy and till-recently unsubstantiated salvo that was used to deter people from falling prey to unscrupulous ‘stem cell treatments’ has become almost true. This is the first report of such an “occurrence of a spinal cord mass after olfactory mucosal cell transplantation in a patient with a spinal cord injury.” The tumor was excised, and its biopsy revealed “respiratory epithelium with underlying submucosal glands identical to that seen in normal nasal mucosa.” The lesson: please, let’s wait. Until “better understanding of how to control cell proliferation, survival, migration, and differentiation in the pathological environment to foresee or prevent uncontrolled or abnormal cell growth in human patients.” Thanks Prashanth, for sending the links.

Archives of PMR, July 2014

1289 South Indian film industry is turning back time. Once again, there are talented female actors who can sing well as well as they can act and dance. The recent hit Fy-Fy-Fy sung by actor Ramya Nambeesan is an example. Why did I go off-track? Because of this similar rhyming functional independence tool from the US for spinal cord injury, the SCI-Fi short form, which is claimed to have good good internal consistency, and minimal ceiling and floor effects. We could have a look at this, but we’ve just transitioned to SCIM-II.

Spinal Cord, July 2014

511 This review on use of catheters for clean intermittent catheterization raises more questions than providing answers. Should off-label reuse be encouraged? If yes, how frequently should the catheters be changed? How should they be cleaned/sterilized before each use? How should they be stored? Are hydrophilic self-lubricating catheters better than uncoated tubes for off-label use? What is the overall health economic benefit/liability of each option? It is a shame that in spite of the blanket encouragement for off-label re-use in our practice for more than 3 decades, we don’t have have answers to these questions, and continue based only on ‘belief’. Worse,  “off-label reuse is not supported by legal requirements in Europe or the United States, or in Australia or Canada”. Hunting for post-graduate thesis topics? Do consider these very relevant questions that need answers.

547 One more answer that is long pending: is pharmacological prophylaxis for thromboembolism necessary for everyone with acute spinal cord injury? Do benefits outweigh risks and costs? As I’d mentioned in an earlier post, in spite of the existence of this clinical equipoise, a study proposal from my colleagues was (wrongly) shot down by our institutional review board, judging that a placebo arm is unethical. Dr HS Chhabra has apparently had no such troubles in getting approval for this RCT comparing LMWH Vs ‘No treatment’ in acute SCI. There was no difference between the two arms in the incidence of symptomatic DVT or complications, though the control arm had more asymptomatic DVT, which is of uncertain clinical significance. Hmm… one more clinically relevant thesis topic, awaiting a samaritan.

Lancet, 24 July 2014

Online “Elementary” Holmes would have remarked if he’d read this article. The RCT, comparing paracetamol Vs placebo for low back pain, is an example for how a seemingly simple study could get primetime spotlight if 1) there is real clinical relevance (I’m itching to use that ‘equipoise’ word again) 2) the publisher or the author has  good media relations. Should we continue to use paracetamol? Of course, yes, because it is at least “as good as placebo“.

BMJ, July 2014

Is Dabigatran really that good? Surprise (er…should we really be?)! One more instance of a drug company that has suppressed trial data to improve income. Internal documents accessed through a lawsuit found that “Optimally used (=titrated) dabigatran has the potential to provide patients an even better efficacy and safety profile than fixed dose dabigatran and also a better safety and efficacy profile than a matched warfarin group”. But, “Boehringer Ingelheim, the maker of dabigatran, has failed to share with regulators information about the potential benefits of monitoring anticoagulant activity”, in order not to dilute the marketing USP- ‘use without testing INR’. Lesson for our practice: Do use Dabigatran, but with INR checks to titrate dose for better effectiveness and to reduce bleeding risks.

Practice tid-bits

• Pregnant? Don’t think twice about taking calcium supplements. This Cochrane review has found  “calcium supplements help prevent pre-eclampsia and preterm birth, and lower the risk of a woman dying or having serious problems related to high blood pressure in pregnancy.”

• Can doctors reduce harmful medical overuse worldwide? Yes, we can.

• Still not convinced about the excess medicalization pandemic we all are contributing to everyday? Watch these wonderfully done musical parodies championing the cause of simple and sane evidence-informed healthcare practices. This version of the Hitler parody (the last video) is too good. Meditate, read, and do try to implement in practice.

• This one is for a happy, married life. “Regularly coming home late without informing wife amounts to cruelty“, Bombay HC has ruled. Better make a habit of hurrying home, never know what’s around the corner.

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