 Antidepressants
and anticonvulsants for diabetic neuropathy and postherpetic neuralgia:
a quantitative systematic review.
Reference: J Pain Symptom Manage 2000 Dec;20(6):449-58
To determine the relative efficacy and adverse effects of antidepressants
and anticonvulsants in
the treatment of diabetic neuroapathy and postherpetic neuralgia, published
reports were
identified from a variety of electronic databases, including Medline, EMBASE,
the Cochrane
Library and the Oxford Pain Relief Database, and from two previously published
reviews.
Additional studies were identified from the reference lists of retrieved
reports. The relative benefit
(RB) and number-needed-to-treat (NNT) for one patient to achieve at least
50 % pain relief was
calculated from available dichotomous data, as was the relative risk (RR)
and
number-needed-to-harm (NH) for minor adverse effects and drug related study
withdrawal. In
diabetic neuropathy, 16 reports compared antidepressants with placebo (491
patient episodes)
and three compared anticonvulsants with placebo (321). The NNT for at least
50 % pain relief
with antidepressants was 3.4 (95 % confidence interval 2.6-4. 7) and with
anticonvulsants 2. 7
(2. 2-3. 8). In postherpetic neuralgia, three reports compared antidepressants
with placebo (145
patient episodes) and one compared anticonvulsants with placebo (225),
giving an NNT with
antidepressants of 2.1 (1. 7-3) and with anticonvulsants 3.2 (2.4-5). There
was little difference in
the incidence of minor adverse effects with either antidepressants or anticonvulsants
compared
with placebo, with 1VH (minor) values of about 3. For drug-related study
withdrawal,
antidepressants had an NNH (major) of 17 (11-43) compared with placebo,
whereas with
anticonvulsants there was no significant difference from placebo. Antidepressants
and
anticonvulsants had the same efficacy and incidence of minor adverse effects
in these tzoo
neuropathic pain conditions. There was no evidence that selective serotonin
reuptake inhibitors
(SSRIs) were better than older antidepressants, and no evidence that gabapentin
was better than
older anticonvulsants. In these trials patients were more likely to stop
taking antidepressants than
anticonvulsants because of adverse effects.
Lower
ankle/brachial index, as calculated by averaging the dorsalis pedis and
posterior tibial arterial pressures, and association with leg functioning
in peripheral arterial disease.
Reference: J Vasc Surg 2000 Dec;32(6):1164-71
OBJECTIVE: We compared three commonly used methods of ankle/brachial index
(ABI)
calculation to determine their relative association with objective measures
of leg functioning in
peripheral arterial disease. METHOD: The study design was cross-sectional;
the setting was an
academic medical center. The participants were 244 men and women, aged
55 years and older,
with and without peripheral arterial disease, from a noninvasive vascular
laboratory and a general
medicine practice. The main outcome measures were walking velocity and
endurance, measured
with the 4-m walk and the 6-minute walk, respectively. Three methods of
ABI calculation were
assessed: using the highest arterial pressure within each leg (method #1),
using the lowest
pressure in each leg (method #2), and averaging the dorsalis pedis and
posterior tibial pressures
within each leg (method #3). For each method, we established the prevalence
of peripheral
arterial disease. We then used regression analyses to identify the ABI
calculation method most
closely associated with leg functioning. The ABI with the greatest statistical
significance and
largest regression coefficient was considered most closely associated with
leg functioning.
RESULTS: Peripheral arterial disease prevalence ranged from 47% when method
#1 was used
to 59% when method #2 was used. When the right and left legs were compared,
the leg with the
lower ABI, as identified through use of method #3, was most associated
with leg functioning.
Within the leg with the lower ABI, method #3 was more closely associated
with 6-minute walk
distance (regression coefficient = 811.5 feet per 1 unit ABI; P <.001)
and 4-m walking velocity
(regression coefficient = 0.353 m/s per 1 unit ABI; P <.001) than method
#1 or method #2.
CONCLUSION: The lower ABI, determined by averaging the dorsalis pedis and
posterior tibial
arterial pressures in each leg, is most predictive of walking endurance
and walking velocity in
peripheral arterial disease.
Leg
ulcers in peripheral arterial disease (arterial leg ulcers): impaired wound
healing above the threshold of chronic critical limb ischemia.
Reference: J Am Acad Dermatol 2000 Dec; 43(6):1001-8
BACKGROUND: Peripheral arterial disease is the only identifiable etiology
in approximately
10% of leg ulcers. Clinical data on the management of these chronic wounds
are scarce.
OBJECTIVE: We attempted to outline the threshold of systolic ankle pressure
and
ankle-brachial-index (ABI) below which arterial leg ulcers can occur and
to outline the indication
for revascularization in arterial leg ulcers. METHODS: Diagnostic and outcome
analysis was
performed for 26 consecutive patients with arterial leg ulcers. We calculated
sensitivities,
specificities, and receiver operating characteristic (ROC) curves for the
identification of arterial
leg ulcers among all 223 consecutive leg ulcer patients within a 3-year
period, as well as the
ROC curve for patients who required revascularization. RESULTS: The systolic
ankle pressure
was 88 (18-130) mm Hg (median; 95% confidence interval) and the ABI was
0.60 (0.15-0.86),
respectively. Eighteen patients (69%) were subjected to revascularization.
By the end of the
study, 24 patients (92%) healed completely, 1 improved (90% wound closure),
and 1 patient
had to undergo below-knee amputation for chronic osteomyelitis. During
this study, the ankle
pressure and ABI were poor in distinguishing those patients who required
revascularization from
those who healed without revascularization. CONCLUSION: Most arterial leg
ulcers do not
meet the criteria of chronic critical limb ischemia, but they do not heal
under conservative
measures, either. A majority of these patients benefit from revascularization
and should, therefore,
be referred for arterial duplex ultrasound investigation or angiography.
In our study, an ankle
pressure below 110 mm Hg identified all patients (100%) who were subjected
to
revascularization procedures. However, controlled clinical studies are
required to find the systolic
ankle pressure and ABI below which revascularization can be recommended
to speed up the
healing time.
Antioxidant
Supplementation in Atherosclerosis Prevention (ASAP) study: a randomized
trial of the effect of vitamins E and C on 3-year progression of carotid
atherosclerosis.
Reference: J Intern Med 2000 Nov;248(5):377-386
OBJECTIVES: To study the efficacy of vitamin E and C supplementation on
the progression of
carotid atherosclerosis, hypothesizing an enhanced preventive effect in
men and in smokers and
synergism between vitamins. DESIGN AND SUBJECTS: Double-masked two-by-two
factorial
trial, randomization in four strata (by gender and smoking status) to receive
twice daily either 91
mg (136 IU) of d-alpha-tocopherol, 250 mg of slow-release vitamin C, a
combination of these or
placebo for three years. A randomized sample of 520 smoking and nonsmoking
men and
postmenopausal women aged 45-69 years with serum cholesterol >/= 5.0 mmol
L-1 were
studied. SETTING: The population of the city of Kuopio in Eastern Finland.
INTERVENTION:
Twice daily either a special formulation of 91 mg of d-alpha-tocopherol,
250 mg of slow-release
vitamin C, a combination of these (CellaVie(R)) or placebo for three years.
MEASUREMENTS:
Atherosclerotic progression, defined as the linear regression slope of
ultrasonographically
assessed common carotid artery mean intima-media thickness (IMT), was calculated
over
semi-annual assessments. RESULTS: The average increase of the mean IMT
was 0.020 mm
year-1 amongst men randomized to placebo and 0.018 mm year-1 in vitamin
E, 0.017 mm
year-1 in vitamin C and 0.011 mm year-1 in the vitamin combination group
(P = 0.008 for E + C
vs. placebo). The respective means in women were 0.016, 0.015, 0.017 and
0.016 mm year-1.
The proportion of men with progression was reduced by 74% (95% CI 36-89%,
P = 0.003) by
supplementation with the formulation containing both vitamins, as compared
with placebo.
CONCLUSIONS: Our study shows that a combined supplementation with reasonable
doses of
both vitamin E and slow-release vitamin C can retard the progression of
common carotid
atherosclerosis in men. This may imply benefits with regard to other atherosclerosis-based
events.
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Volume
4, Number 1: January 2001
