COMMENTARY

A Round-Up of Seven New Neurology Studies

Hans-Christoph Diener, MD, PhD

Disclosures

April 24, 2018

Dear colleagues, I am Christoph Diener, a neurologist from the Department of Neurology at the University of Essen in Germany. Today I would like to tell you about important neurology studies published in February and March of 2018.

Parkinson Disease

The EARLYSTIM study[1] was published in the New England Journal of Medicine 2 years ago. This was a randomized trial performed in France and Germany, and it included 251 patients with Parkinson disease (PD) and early motor complications. The patients were randomly assigned to best medical care or best medical care plus bilateral subthalamic deep brain stimulation. In terms of motor outcomes, deep brain stimulation was clearly superior to best medical treatment.

A predefined subgroup or secondary analysis has now looked at behavioral outcomes, including behavior, apathy, and depression, in these two patient groups.[2] The patients who received deep brain stimulation clearly demonstrated improved behavior, particularly hyperdopaminergic behavior. There was a trend for improvement of comorbid depression, but this was not significant.

Migraine

An exciting study of migraine has been published in Brain.[3] The investigators performed magnetic resonance (MR) spectroscopy in patients with chronic migraine, episodic migraine, and in healthy controls. They measured N-acetylaspartate, which is an important biomarker for the integrity of neural systems.

In patients with chronic migraine, the investigators found reduced N-acetylaspartate in the thalamus, the occipital cortex, and the anterior cingulate cortex. These are all brain structures that are involved in pain transmission and the emotional paths of pain perception. This would indicate that chronic migraine biologically is different from episodic migraine.

Alzheimer Disease

A major challenge in Alzheimer disease (AD) research is to identify patients at the beginning of the disease, to include them in the randomized trials for treatment. The gold standard for identifying early AD pathology is amyloid-beta positron-emission tomography (PET). Now, a group in Japan has published a new way to measure amyloid beta biomarkers in serum.[4] This group measured high-performance amyloid beta biomarkers by immunoprecipitation combined with mass spectroscopy.

This was much more sensitive than the usual way to measure this biomarker in serum; they validated this new method with two populations who underwent amyloid PIB-PET (using Pittsburgh compound-B). This will make it much easier in the future to identify patients with early AD for treatment trials.

Treatment of Septic Shock

Two exciting papers about the treatment of septic shock were published in the New England Journal of Medicine.[5,6] The two studies compared glucocorticoids versus placebo.

A study from New Zealand[5] included 3800 patients in septic shock and compared hydrocortisone with placebo. This trial found no difference between hydrocortisone and placebo in terms of 90-day mortality, which was about 40%, but hydrocortisone was found superior for the resolution of shock symptoms at the time of ventilation.

A French study[6] included 1401 patients who were treated with hydrocortisone plus fludrocortisone or placebo. This study found reduced mortality at ICU discharge and at day 180 in the treatment versus the placebo group. Even the accompanying editorial[7] had some difficulty explaining the difference in mortality outcomes between the trials, but the bottom line is that most probably we should use glucocorticoids in patients with septic shock.

Multiple Sclerosis

An interesting study in Neurology reports the impact of smoking on patients with multiple sclerosis (MS).[8] The Danish Multiple Sclerosis Biobank identified 874 patients who were treated with beta-interferon for relapsing-remitting multiple sclerosis. They found that patients who smoked had a 20% higher relapse rate than nonsmokers. This result has clear implications for how we talk to our MS patients.

Combining Triptans and Serotonin Reuptake Inhibitors

The last study is from JAMA Neurology.[9] About 14 years ago, the FDA issued a warning that triptans should not be taken together with serotonin reuptake inhibitors (SSRIs) because of the risk for the so-called serotonin syndrome. For this new study, US investigators looked at prescriptions in the Boston area during a period of 14 years. They identified almost 48,000 patients who received a prescription for a triptan for migraine; 19,000 of these patients also received a prescription for an SSRI at the same time.

They then looked at hospital admissions and identified two cases of confirmed serotonin syndrome, which translated to 0.6 cases per 10,000 patient-years. I believe that this clearly shows no risk of serotonin syndrome when patients who are taking SSRIs receive a triptan.

Ladies and gentlemen, interesting results in Parkinson disease, migraine, Alzheimer disease, MS, and critical care medicine.

I am Christoph Diener, a neurologist at the University of Essen in Germany. Thank you very much for listening.

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