DynaMed Weekly Update

June 9, 2009

Volume 4 Issue 23

DynaMed Systematic Literature Surveillance

For the week ending June 5, 2009

This week, 1246 articles were considered for inclusion in DynaMed and 451 met criteria for inclusion.

Based on the criteria of selecting “articles most likely to change clinical practice,” one article of significant interest is included in this weekly update.

Updated AHA/ASA Recommendation Expands Time Window for rt-PA Treatment to < 4.5 Hours after Stroke Onset for Some Patients

In 2007 the American Heart Association/American Stroke Association (AHA/ASA) recommended recombinant tissue plasminogen activator (rt-PA, Alteplase) for selected adults with ischemic stroke with symptom onset within 3 hours (Stroke 2007 May;38(5):1655). The AHA/ASA has now expanded the timeframe for rt-PA treatment to 4.5 hours after stroke onset with some exceptions. Additional patient exclusions (rt-PA not indicated) during the 3-4.5 hour timeframe are age > 80 years, NIH stroke scale score > 25, history of previous stroke or diabetes, or if taking oral anticoagulants (regardless of INR). The updated recommendations can be found in Stroke 2009 Aug;40(8):2945 PDF.

The new recommendation is based primarily on the third European Cooperative Acute Stroke Study (ECASS III) trial which found that rt-PA given 3-4.5 hours after onset of non-severe stroke reduced disability at 90 days (level 1 [likely reliable] evidence) (N Engl J Med 2008 Sep 25;359(13):1317). However, other randomized trials and observational studies have presented conflicting evidence. In the Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) randomized trial, rt-PA given 3-5 hours after the onset of stroke increased rates of symptomatic and fatal intracranial hemorrhage with no apparent benefit in functional outcomes (level 1 [likely reliable] evidence) (JAMA 1999 Dec 1;282(21):2019). The Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) observational study of 12,529 patients given rt-PA for ischemic stroke reported trends toward higher mortality and intracerebral hemorrhage rates associated with rt-PA treatment after 3 hours from stroke onset (level 2 [mid-level] evidence) (Lancet 2008 Oct 11;372(9646):1303).

For more information, see the Thrombolytics for acute stroke topic in DynaMed.

DynaMed Topic Activity

New summaries added to DynaMed this week:

· Gout - prevention of recurrent attacks

· Gout - treatment of acute attack

· Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS)

· Protein C deficiency

· Sweet's syndrome

· VACTERL

DynaMed Peer Review

We are currently seeking reviewers for:

· Gout - prevention of recurrent attacks

· Gout - treatment of acute attack

· Protein C deficiency

For more information, see Editorial Policies for Authors & Reviewers and DynaMed Peer Review.

Medical Calculators Added to DynaMed

DynaMed now includes more than 500 clinical calculators, decision rules and statistics calculators to give clinicians even more decision making tools to use at the point of care.

After logging in, click on Calculators in the upper right corner of the screen to access this new feature.

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DynaMed Weekly Update is a compilation of 1 to 5 articles that are of significant interest to clinicians. Articles are selected from DynaMed's Systematic Literature Surveillance as articles most likely to change clinical practice. Updates are prepared by the DynaMed Editorial Team which includes 28 clinicians from multiple disciplines. Send comments to DynaMedEditor@epnet.com. To learn more about DynaMed, go to www.dynamicmedical.com.

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Copyright © 2009 EBSCO Publishing. All rights reserved.
DynaMed® is a registered trademark of and published by DynaMed LLC. Original date of on-line publication December 15, 1995 with continuous daily updating. ISSN: 1554-1177. Subscriptions and queries can be addressed to DynaMed LLC, EBSCO Publishing, 10 Estes St., Ipswich, Massachusetts, USA 01938-0602, telephone (978) 356-6500, facsimile (978) 356-6565, e-mail Editor@DynamicMedical.com. The opinions expressed herein are solely those of the authors and editors and may or may not represent the official position of cooperating or endorsing Medical Societies. Development of DynaMed was supported in part by the National Science Foundation through a Small Business Innovative Research grant. (All other support comes from subscriptions. No advertisements are accepted.)