Section Editor
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WriteClick Editor’s Choice
Robert C. Griggs, MD
Editors’ Note: In response to the article “The quest to prevent stroke in atrial fibrillation: Fighting the fluttering heart in Singapore,” Dr. Sethi comments on the challenges faced by neurologists in countries where traditional and Western medicines are used in parallel. Authors Goh et al. outline efforts made in Singapore to integrate the 2 spheres. Dr. Svenningsson et al. question several aspects of the article “MS disease activity in RESTORE: A randomized 24-week natalizumab treatment interruption study” on ethical grounds, specifically the risk vs value balance of a study with a predictable result and the generalizability of the conclusions. Author Fox addresses these concerns. —Megan Alcauskas, MD, and Robert C. Griggs, MD
THE QUEST TO PREVENT STROKE IN ATRIAL FIBRILLATION: FIGHTING THE FLUTTERING HEART IN SINGAPORE
Nitin K. Sethi, New York: Goh et al.1 made some interesting observations in their article. The rates of anticoagulation are particularly low in Southeast Asian countries. In these countries, neurologists are challenged with patient distrust of allopathic/Western medicine. Patients do not exclusively follow one medicine system: traditional (Ayurveda, homeopathy, Unani, or Chinese) vs allopathic. Patients seek consultation from practitioners of both systems, so they may be taking warfarin as well as “natural” blood thinners, only to discontinue the Western medicine in favor of the natural alternative. The current dismal rate of anticoagulation can only be improved if public health campaigns are targeted not just at patients but also at practitioners of Eastern Medicine in these countries. Eastern and Western medicine should not simply coexist; they should be truly integrated. Author Response: Orlanda Q.M. Goh, Gillianne Lai, Tian Ming Tu, Kim En Lee, Singapore: We thank Dr. Sethi for his comments. Integration of complementary-alternative (traditional) medicine with Western medicine is not new and has been attempted in many parts of the world, including Singapore.2 Since 2000, public health measures have aimed to integrate both domains. These measures include establishing
professional accreditation boards for traditional medicine, passing legislation in parliament, and accrediting education courses for complementary-alternative medicine practitioners. In addition, complementaryalternative medicine practitioners were legally permitted to practice within Western health care sites2 to offer synergistic health care.2 Despite establishing public health measures for the last decade, the use of anticoagulation in our stroke patients with atrial fibrillation is low.1 The success of the integration of complementary-alternative medicine with Western medicine has not yet been measured. The underutilization of anticoagulation cannot be corrected by public health measures alone. We agree with Dr. Sethi that Eastern and Western medicine cannot just coexist and we must strive to integrate both domains. Ignoring complementary-alternative medicine is no longer an option. © 2014 American Academy of Neurology 1.
2.
Goh O, Lai G, Tu TM, Lee KE. The quest to prevent stroke in atrial fibrillation: fighting the fluttering heart in Singapore. Neurology 2014;82:2034–2036. Lee TL. Complementary and alternative medicine, and traditional Chinese medicine: time for critical engagement. Ann Acad Med Singapore 2006;35:749–752.
MS DISEASE ACTIVITY IN RESTORE: A RANDOMIZED 24-WEEK NATALIZUMAB TREATMENT INTERRUPTION STUDY
Anders Svenningsson, Peter Sundstrom, Jonatan Salzer, Mattias Vagberg, Umea, Sweden: We question the ethical soundness of the RESTORE study.1 RESTORE investigated the consequences of discontinuing natalizumab treatment in multiple sclerosis (MS). Natalizumab temporarily (1–3 months) blocks the migration of lymphocytes into the brain.2,3 Earlier observational studies (n 5 11 cited in RESTORE) showed recurrence of disease activity a few months after discontinuing treatment. The RESTORE study, sponsored by Biogen Idec, stated that the study provided Class II evidence of MS inflammatory activity returning after natalizumab interruption. The typical study patients (40 years old, less than 10 years since MS onset) started natalizumab treatment 2 years before, presumably Neurology 83
November 25, 2014
2099
The quest to prevent stroke in atrial fibrillation: Fighting the fluttering heart in Singapore Nitin K. Sethi, Orlanda Q.M. Goh, Gillianne Lai, et al. Neurology 2014;83;2099 DOI 10.1212/WNL.0000000000001062 This information is current as of November 24, 2014 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/83/22/2099.1.full.html
References
This article cites 2 articles, 1 of which you can access for free at: http://www.neurology.org/content/83/22/2099.1.full.html##ref-list-1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
®
WriteClick Editor’s Choice
Robert C. Griggs, MD
Editors’ Note: In response to the article “The quest to prevent stroke in atrial fibrillation: Fighting the fluttering heart in Singapore,” Dr. Sethi comments on the challenges faced by neurologists in countries where traditional and Western medicines are used in parallel. Authors Goh et al. outline efforts made in Singapore to integrate the 2 spheres. Dr. Svenningsson et al. question several aspects of the article “MS disease activity in RESTORE: A randomized 24-week natalizumab treatment interruption study” on ethical grounds, specifically the risk vs value balance of a study with a predictable result and the generalizability of the conclusions. Author Fox addresses these concerns. —Megan Alcauskas, MD, and Robert C. Griggs, MD
THE QUEST TO PREVENT STROKE IN ATRIAL FIBRILLATION: FIGHTING THE FLUTTERING HEART IN SINGAPORE
Nitin K. Sethi, New York: Goh et al.1 made some interesting observations in their article. The rates of anticoagulation are particularly low in Southeast Asian countries. In these countries, neurologists are challenged with patient distrust of allopathic/Western medicine. Patients do not exclusively follow one medicine system: traditional (Ayurveda, homeopathy, Unani, or Chinese) vs allopathic. Patients seek consultation from practitioners of both systems, so they may be taking warfarin as well as “natural” blood thinners, only to discontinue the Western medicine in favor of the natural alternative. The current dismal rate of anticoagulation can only be improved if public health campaigns are targeted not just at patients but also at practitioners of Eastern Medicine in these countries. Eastern and Western medicine should not simply coexist; they should be truly integrated. Author Response: Orlanda Q.M. Goh, Gillianne Lai, Tian Ming Tu, Kim En Lee, Singapore: We thank Dr. Sethi for his comments. Integration of complementary-alternative (traditional) medicine with Western medicine is not new and has been attempted in many parts of the world, including Singapore.2 Since 2000, public health measures have aimed to integrate both domains. These measures include establishing
professional accreditation boards for traditional medicine, passing legislation in parliament, and accrediting education courses for complementary-alternative medicine practitioners. In addition, complementaryalternative medicine practitioners were legally permitted to practice within Western health care sites2 to offer synergistic health care.2 Despite establishing public health measures for the last decade, the use of anticoagulation in our stroke patients with atrial fibrillation is low.1 The success of the integration of complementary-alternative medicine with Western medicine has not yet been measured. The underutilization of anticoagulation cannot be corrected by public health measures alone. We agree with Dr. Sethi that Eastern and Western medicine cannot just coexist and we must strive to integrate both domains. Ignoring complementary-alternative medicine is no longer an option. © 2014 American Academy of Neurology 1.
2.
Goh O, Lai G, Tu TM, Lee KE. The quest to prevent stroke in atrial fibrillation: fighting the fluttering heart in Singapore. Neurology 2014;82:2034–2036. Lee TL. Complementary and alternative medicine, and traditional Chinese medicine: time for critical engagement. Ann Acad Med Singapore 2006;35:749–752.
MS DISEASE ACTIVITY IN RESTORE: A RANDOMIZED 24-WEEK NATALIZUMAB TREATMENT INTERRUPTION STUDY
Anders Svenningsson, Peter Sundstrom, Jonatan Salzer, Mattias Vagberg, Umea, Sweden: We question the ethical soundness of the RESTORE study.1 RESTORE investigated the consequences of discontinuing natalizumab treatment in multiple sclerosis (MS). Natalizumab temporarily (1–3 months) blocks the migration of lymphocytes into the brain.2,3 Earlier observational studies (n 5 11 cited in RESTORE) showed recurrence of disease activity a few months after discontinuing treatment. The RESTORE study, sponsored by Biogen Idec, stated that the study provided Class II evidence of MS inflammatory activity returning after natalizumab interruption. The typical study patients (40 years old, less than 10 years since MS onset) started natalizumab treatment 2 years before, presumably Neurology 83
November 25, 2014
2099
The quest to prevent stroke in atrial fibrillation: Fighting the fluttering heart in Singapore Nitin K. Sethi, Orlanda Q.M. Goh, Gillianne Lai, et al. Neurology 2014;83;2099 DOI 10.1212/WNL.0000000000001062 This information is current as of November 24, 2014 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/83/22/2099.1.full.html
References
This article cites 2 articles, 1 of which you can access for free at: http://www.neurology.org/content/83/22/2099.1.full.html##ref-list-1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
