Coventina's Column

A neurological team led by Professor Keith Muir at Glasgow's Southern General Hospital has started the first ever trial of stem cells in stroke. The PISCES trial will investigate the injection of expanded neural stem cells into the affected region of the brain in ischaemic stroke patients at a range of cell doses. Professor Muir revealed in late November 2010, that the first patient to have undergone the intervention had been discharged with no adverse effects. Follow-up will continue for a number of years. Coventina is delighted that such trials are occurring in patients debilitated by the Western world's most common cause of disability and third most prevalent cause of death, and shudders at the thought that had a certain Alaskan Republican found her way into power in the USA, such trials might have been halted there and besmirched by ill-informed hysteria here.

A recent study (Lancet, Vol. 376, Issue 9755, 27 November 2010–3 December 2010, pp. 1838–1845) has shown that use of weekly text messages via mobile phones, significantly increased adherence to antiretroviral treatment in patients with HIV in Kenya commencing such therapy. Weekly short messaging service (SMS) messages, with instructions to reply within 48 hours, were found to lead to better compliance with drugs and improved rates of viral suppression. Coventina wonders if such interventions might also be of benefit in the UK, in subgroups of patients known to have poor compliance with their treatment, such as young people with diabetes rebelling against their labelling with the chronic illness tag, and whose treatment provides long-term benefits rather than immediately visible short-term ones. Coventina admires a salient feature of this trial: the patients’ requirement to reply, a feature which elevated the advice from what might be seen as nagging carping to interactive dialogue, to which patients respond far more positively.

It's well known that obesity is linked to increased morbidity and mortality and that body mass index (BMI), despite its imperfection as a tool due to its inability to discern between fat and muscle, serves as a useful measure of obesity. A recent meta-analysis of 19 prospective studies involving 1.46 million white adults aged 19-84 (N Engl J Med 2010;363:2211–9, December 2, 2010) has provided more detailed information about the relationship between BMI and mortality. A BMI of 22.5-24.9 was taken as the reference range, and hazard ratios among women were as follows: 1.47 for a BMI of 15.0–18.4; 1.14 for a BMI of 18.5–19.9; 1.00 for a BMI of 20.0–22.4; 1.13 for a BMI of 25.0–29.9; 1.44 for a BMI of 30.0–34.9; 1.88 for a BMI of 35.0–39.9; and 2.51 for a BMI of 40.0–49.9. The results for males were similar. While there are no major surprises in the results, Coventina thinks definitive figures from pooled studies involving vast numbers of patients are always useful to enshrine health advice as factual. It's also sobering to see again a finding that has been demonstrated before, namely that mortality among the very underweight is higher than among the moderately overweight, as evidenced by the hazard ratio of 1.47 in the BMI 15–18.4 group, compared with that of 1.44 in the 30–34.9 group, although coexisting disease such as cancer in the very underweight might have confounded the figures. Still, despite all the pressures on women in the West to become and stay skinny, the number of individuals affected by obesity are far higher, and these figures provide easily digested evidence that may help propel the obese into taking action: it sounds far more stark to warn a patient with a BMI of 41 that they are two and a half more times likely to die early than their normal weight counterpart than it does to use more woolly and nebulous admonishments.

Chronic low back pain is one of the most common causes of prolonged sick leave from work in the UK, and causes considerable distress and difficulty for sufferers. A group of researchers in The Netherlands has compared the cost-benefit of an integrated system of care with that of traditional care in 134 adult patients (BMJ 2010;341:c6414, Nov. 30 2010). Integrated care consisted of intervention in the workplace based on participatory ergonomics with involvement by a supervisor as well as a regimen of graded activities based on cognitive behavioural techniques. Traditional care was standard treatment provided by general practitioners and occupational physicians based on Dutch guidelines. The primary outcome was how long it took before the patient could return to work, and this was significantly lower in the integrated care group. The integrated care group also showed significant improvements in quality of life and function with a simultaneous reduction in costs. As George Osborne struggles to reduce the UK's phenomenal incapacity benefit bill, interventions like this may, despite the initial time and resources required to set them up, prove beneficial to both patient and purse.

Spontaneous osteonecrosis of the knee (sponk) is a rare and painful condition which, if unresponsive to analgesics and other non-surgical treatments, is sometimes only controlled by arthroplasty. Coventina was interested to see that a small study of patients showed that joint-preserving treatment had recently been shown to be highly effective in these patients refractory to nonsurgical treatment (Arch Orthop Trauma Surg 2010; 130:11–6). Fifteen patients with sponk that was still debilitating despite non-operative treatment were treated with joint-preserving operations consisting of a combination of arthroscopy and core decompression using a small diameter drill or osteochondral autograph transfers. Thirteen of the 15, or 87%, showed knee joint survival. While this is a very small study and, in addition, the techniques used may only defer rather than permanently deflect the need for arthroplasty, given the limited lifespan of replaced joints any technique that can delay the need for more invasive intervention is worth further investigation.