Varenicline and evaluated outcomes in smoking cessation programmes

The morbidity and mortality rates attributed to smoking are substantial and cigarette smoke remains the first preventable cause of premature death worldwide. Despite the knowledge of the adverse consequences of smoking, many smokers struggle to quit. Cigarette smoking is the primary cause of chronic obstructive pulmonary disease, and smoking cessation represents the most effective way of stopping its progression. Varenicline is one of the first-line smoking cessation aids recommended in many Clinical Practice Guidelines and its efficacy and safety have been demonstrated in several clinical trials. Varenicline has a unique mechanism of action and clinical trials support its use as an effective and generally well-tolerated therapy. This article reviews the clinical pharmacological trials on smoking cessation published in recent years on varenicline, with particular attention to the outcomes used in the studies. MedLine, the Cochrane database and Embase were evaluated. Almost all the trials have, as a primary endpoint, the abstinence from cigarettes at 9-12 weeks of treatment. Only one study considers lung function spirometric changes as a secondary endpoint. No study has evaluated lung function. This marker could be very important as a way of evaluating, objectively, an improvement in lung function, which correlates also with subjective parameters, as dyspnea and fatigue.

The adverse event profile of perampanel: meta-analysis of randomized controlled trials

BACKGROUND AND PURPOSE

To identify adverse events (AEs) significantly associated with perampanel treatment in double-blind clinical studies (RCTs). Serious AEs, study withdrawals due to AEs and dose-effect responses of individual AEs were also investigated.

METHODS

All placebo controlled, double-blind RCTs investigating therapeutic effects of oral perampanel were searched. AEs were assessed for their association with perampanel after exclusion of synonyms, rare AEs and non-assessable AEs. Risk difference (RD) was used to evaluate the association of any AE (99% confidence intervals) and withdrawals or serious AEs (95% confidence intervals) with perampanel.

RESULTS

Nine RCTs (five in pharmacoresistant epilepsy and four in Parkinson's disease) were included in our study. Almost 4000 patients had been recruited, 2627 of whom were randomized to perampanel and treated with drug doses of 0.5 mg/day (n = 68), 1 mg/day (n = 65), 2 mg/day (n = 753), 4 mg/day (n = 1017), 8 mg/day (n = 431) or 12 mg/day (n = 293). Serious AEs were not significantly associated with perampanel treatment. The experimental drug was significantly associated with an increased risk of AE-related study withdrawals at 4 mg/day [RD (95% confidence interval) 0.03 (0.00, 0.06)] and 12 mg/day [RD (95% confidence interval) 0.13 (0.07, 0.18)]. Of 15 identified AEs, five (dizziness, ataxia, somnolence, irritability and weight increase) were found to be significantly associated with perampanel and one (seizure worsening) was significantly associated with placebo.

CONCLUSIONS

Vestibulocerebellar AEs (dizziness, ataxia), sedative effects (somnolence), irritability and weight increase were significantly associated with perampanel treatment.

An integrated fMRI, SEPs and MEPs approach for assessing functional organization in the malformed sensorimotor cortex

PURPOSE

Malformations of cortical development are often accompanied by an abnormal cortical pattern. Due to its propensity to involve discrete cortical areas, polymicrogyria represents an interesting model for assessing the reorganization of cortical function in relation to the disrupted anatomy. Functional MRI, TMS and SEPs can provide a highly complementary, multimodal approach to map noninvasively the functional rearrangement of sensorimotor functions in the polymicrogyric cortex, and to obtain a coherent modelling. We report here an illustrative case which is included in a patients series under study using a block design 3T fMRI, short-latency SEPs as identified on the basis of their latency, polarity, and scalp distribution and an assessment of the area and volume of the motor maps and the relative position of the center of gravity and hot spot.

RESULTS

A 15 years old girl, with drug-resistant epilepsy and left perisylvian polymicrogyria that was part of a large epileptogenic network including also the mesial aspect of the left frontal lobe, exhibited a normal distribution of somatomotor responses in the expected anatomic sites, with a dissociation between motor functions, which were slightly impaired in the malformed hemisphere, and bilaterally normal sensory responses. In this patient, a large resection of epileptogenic zone, sparing eloquent areas as previously identified, should be planned in order to improve seizure outcome.

CONCLUSIONS

An integrated fMRI, TMS and SEP mapping approach helps defining the relationship between epileptogenic zones and somatomotor areas. Studies of greater number of patients will be necessary in order to identify the general rules that determine the functional representation in the malformed cortex.

Mild cognitive impairment: loss of linguistic task-induced changes in motor cortex excitability

BACKGROUND

In amnestic mild cognitive impairment (aMCI), functional neuronal connectivity may be altered, as suggested by quantitative EEG and neuroimaging data. In young healthy humans, the execution of linguistic tasks modifies the excitability of the hand area of the dominant primary motor cortex (M1(hand)), as tested by transcranial magnetic stimulation (TMS). We used TMS to investigate functional connectivity between language-related cortical areas and M1(hand) in aMCI.

METHODS

Ten elderly women with aMCI and 10 age-matched women were recruited. All participants were right handed and underwent a neuropsychological evaluation. In the first TMS experiment, participants performed three different tasks: reading aloud, viewing of non-letter strings (baseline), and nonverbal oral movements. The second experiment included the baseline condition and three visual searching/matching tasks using letters, geometric shapes, or digits as target stimuli.

RESULTS

In controls, motor evoked potentials (MEP) elicited by suprathreshold TMS of the left M1(hand) were significantly larger during reading aloud (170% baseline) than during nonverbal oral movements, whereas no difference was seen for right M1(hand) stimulation. Similarly, MEP elicited by left M1(hand) stimulation during letter and shape searching/matching tasks were significantly larger compared to digit task. In contrast, linguistic task performance did not produce any significant MEP modulation in patients with aMCI, although neuropsychological evaluation showed normal language abilities.

CONCLUSIONS

Findings suggest that functional connectivity between the language-related brain regions and the dominant M1(hand) may be altered in amnestic mild cognitive impairment. Follow-up studies will reveal whether transcranial magnetic stimulation application during linguistic tasks may contribute to characterize the risk of conversion to Alzheimer disease.

Management of hypertension and stroke prevention: results of the Italian cardiologist survey

OBJECTIVE

To provide an overview of current habits, priorities, perceptions and knowledge of cardiologists with regard to hypertension and stroke prevention in outpatient practice.

METHODS

A sample of 203 cardiologists operating in outpatient clinics and randomly selected amongst members of the largest Italian Outpatient Cardiologist Association were interviewed by e-mail, in April-May 2007.

RESULTS

The interviewed cardiologists reported that hypertensive outpatients represent a large percentage of their practice population, in which the clinical priority was blood pressure (BP) reduction. Stroke was identified as the most important event to prevent and it was also perceived as the most preventable hypertension-related cardiovascular event. A remarkably high rate of achieved BP control was reported, to a degree that it is inconsistent with current epidemiological reports and with the relatively low percentage use of combination therapies declared by cardiologists. Additional risk factors, organ damage, diabetes mellitus and atrial fibrillation were consistently reported in hypertensive patients. Among antihypertensive drug classes, a preference for angiotensin-converting enzyme inhibitors has been expressed by the majority of physicians; this choice was generally justified by evidence derived from international trials or by the antihypertensive efficacy of this drug class.

CONCLUSIONS

The results confirm the presence of weaknesses in the current services for patients with hypertension, even when being managed by cardiologists. Discrepancies between perceptions and reality, or clinical practice and guideline recommendations are also highlighted. An analysis of these aspects may help to identify current areas of potential improvement for stroke prevention in the clinical management of hypertension in cardiology practice.