Poor Glucose Control

Poor glycemic control , whether too high or too low, is associated with decreased survival in diabetic patients on hemodialysis, Kamyar Kalantar-Zadeh, MD, MPH, PhD, professor of medicine, pediatrics, and epidemiology at the University of California at Los Angeles David Geffen School of Medicine, reported here at Kidney Week 2011: American Society of Nephrology 44th Annual Meeting. Dr. Kalantar-Zadeh reported that in a 6-year study, moderate hyperglycemia raised the risk for all-cause or cardiovascular mortality of hemodialysis patients with diabetes, and levels of glycated hemoglobin (HbA1c) below 6% or blood glucose below 100 mg/dL were associated with an elevated risk for death. According to most studies, he said, if glucose is well controlled, there are improvements in mortality, microvascular complications, and cardiovascular disease. One study showed that for every 1% decrease in HbA1c, deaths related to diabetes decreased 21%, microvascular complications decreased 37%, and myocardial infarctions decreased 14%. "Diabetes mellitus is a potent cardiovascular risk factor in both the general population and dialysis patients, almost half of whom suffer from diabetes in the United States," Dr. Kalantar-Zadeh said during a news conference. "Some guidelines recommend that diabetic dialysis patients follow the same HbA1c target area as the American Diabetic Association." However, he said, although there are some data from studies with varying methodologies, there is no clear guidance on glucose targets for the dialysis patient population. He and his colleagues examined the predictive value of glycemic control on all-cause and cardiovascular mortality, using a large database (n = 54,757) of hemodialysis patients with HbA1c data from 2001 to 2006, and follow-up to 2007. Random (not necessarily fasting) serum glucose measurements correlated moderately well with HbA1c (correlation coefficient, r = 0.56). Examining a range of HbA1c values (from less than 5% to more than 10%), they found the lowest all-cause mortality between 6% and 8%. Above 8%, the higher the HbA1c, the greater the mortality; it is "up to 50% higher for HbA1c above 10%," Dr. Kalantar-Zadeh said. "At the same time,...a very low HbA1c level, below 5%...increased mortality." A similar relation was seen for cardiovascular mortality. A subgroup analysis showed that HbA1c above 7% had a detrimental effect on mortality for all parameters and groups of maintenance hemodialysis diabetic patients examined, including race, sex, age, and serum albumin, hemoglobin, and ferritin levels. The same sort of relation held when random glucose measurements were considered. All-cause mortality rose at glucose levels below 100 mg/dL, and rose dramatically above 200 mg/dL. The lowest death rates were seen at glucose levels between 100 mg/dL and 200 mg/dL. Cardiovascular mortality was lowest in this same range. Subgroup analyses in terms of glucose levels yielded results very similar to those of HbA1c. Potential limitations of the study are that it was observational, Dr. Kalantar-Zadeh noted. Patients were not randomized to receive treatments, treatments for diabetes were not considered, and medication data were lacking. In addition, HbA1c and glucose measurements were taken at random times. Dr. Kalantar-Zadeh concluded that poor glycemic control, with HbA1c above 8% or glucose above 200 mg/dL, "appears to be associated with decreased survival in prevalent diabetic dialysis patients, and moderate hyperglycemia increases the risk for all-cause or cardiovascular mortality of diabetic hemodialysis patients, especially in...Caucasians, men, and individuals with serum albumin less than 3.8 g/dL." Levels of HbA1c below 6% or glucose below 100 mg/dL "are bad, too," he said. He suggested performing controlled trials to target a certain range of HbA1c in diabetic dialysis patients to verify these observational findings. News conference moderator Katherine Tuttle, MD, executive director for research at Providence Sacred Heart Medical Center and professor of medicine at the University of Washington School of Medicine in Spokane, who was not involved in the study, said that clinical guidelines have been updated and will be issued soon. Although she could not elaborate before they are published, she said: "You will see a change in several things, including targets for glycemic control based on published data. I think the data presenting will only add to that." She said previous Kidney Disease Outcomes Quality Initiative guidelines were based on the primary prevention of kidney disease, and an HbA1c below 7% was shown to prevent new-onset kidney disease. But there were no data on the treatment of patients with kidney disease; those data are expected to figure in the new guidelines, with higher HbA1c targets for people with multiple comorbidities and limited life expectancies, which would include the dialysis population.

Child abuse

Women who suffer either physical or sexual abuse early in life have a significantly increased risk for subsequent cardiovascular events, including myocardial infarction and stroke, a new study suggests. The study, using data from the Nurses' Health Study II, shows that women who reported they had experienced forced sexual activity during childhood or adolescence had a greater than 50% increased risk for cardiovascular disease. The relationship with physical abuse was significant but less robust, the authors note, and will have to be confirmed in other data sets.

This is the third study to show that forced sex among girls is linked with at least a 50% increase in cardiovascular event risk, lead author Janet Rich-Edwards, ScD, MPH, associate professor in the Department of Medicine at Brigham and Women's Hospital in Boston, Massachusetts, said at a press conference here. The relationship was only partially explained by traditional cardiovascular risk factors. "The consistency of the sexual abuse studies suggests that we continue our abuse prevention efforts in childhood, and that we also develop specific cardiovascular disease prevention strategies tailored to the needs of women who've experienced abuse in childhood," Dr. Rich-Edwards concluded. The results were presented here at the American Heart Association (AHA) 2011 Scientific Sessions. A national survey of 8000 women conducted by the National Institute of Justice and the Centers for Disease Control and Prevention in 1995 to 1996 showed that 52% of women "were willing to report to a stranger on the telephone that they had been physically assaulted during their lives, and 18% reported completed or attempted rape," Dr. Rich-Edwards said. "I have to say that no matter how many times I see this, the data shock me every time." Most attacks took place in childhood, with 54% of those who reported a rape, or 9% of the overall group, reporting that the assault occurred before the age of 18 years, "so this is an exposure of girls and adolescent women." There are 2 other studies in the literature looking at cardiovascular outcomes after physical or sexual abuse, she noted. One, the Adverse Childhood Experience Study of 17,000 men and women, found an increased risk for coronary heart disease of 50% for physical abuse and 40% for sexual abuse. The other, the National Comorbidity Survey of 4251 women, showed divergent findings for physical and sexual abuse, with no increased risk for coronary heart disease for those reporting physical abuse, but a 5-fold increased risk for those with a history of sexual abuse. "Both of these studies are considerably smaller than the study I'm going to show you today, and much less rigorous in terms of defining coronary heart disease and stroke," Dr. Rich-Edwards noted. Her report used data from the Nurses' Health Study II, which includes 116,640 female registered nurses, from 14 US states, who were aged 25 to 42 years at baseline in 1989.b"At the end of follow-up for this particular analysis in 2007, they were age 43 to 60, so take note, these are very early cardiovascular events for women," she said. The study's biennial questionnaire in 2001 asked women about their life experience with violence. "This allows us to look at events prospectively after they reported the violence to us, and retrospectively from the beginning of the study until 2001, when we asked the questions."For both periods, cardiovascular events were validated by medical records. Self-reported unvalidated events were also included; both previous studies used only self-reported events. After excluding those who did not return the violence questionnaire or who had a history of cancer, myocardial infarction, or stroke before baseline, the study group included 67,315 women free of cardiovascular disease or cancer. Child abuse was assessed using the Conflict Tactics Scale, a questionnaire that assesses levels of exposure. Spanking for discipline was not included as abuse. Physical abuse was classified as mild, moderate, or severe, depending on responses, and sexual abuse was classified as unwanted sexual touching or forced sexual activity while the woman was a child or teenager. Physical abuse, classified as mild, moderate, or severe, was reported by 54% of the cohort, and 9% reported severe physical abuse, the researchers report. Sexual abuse was reported by 33% of the women, and 11% reported forced sexual activity before age 18 years. They found that mild or moderate physical abuse in childhood and adolescence was not associated with cardiovascular disease, but a 46% increase in risk was seen in those with a history of severe physical abuse after adjustment for age, race, parental cardiovascular history, body type of the girl at age 5 years, and parental education, Dr. Rich-Edwards noted. After further adjustment for risk factors in adulthood that are likely themselves to be linked to a history of abuse, including smoking, alcohol use, body mass index, diabetes, and hypertension, the association between physical abuse and cardiovascular events was "dampened," she noted. "In fact, 47% (95% confidence interval, 24% - 71%) of the association between severe physical abuse and adult cardiovascular disease is explained by these established cardiovascular risk factors." The relationship with sexual abuse was stronger. Women with a history of forced sexual activity had a 56% increase in risk for cardiovascular events; there was no increased risk seen with sexual touching only. When the researchers adjusted for cardiovascular risk factors in adulthood, the relationship was again mitigated, but not as much as with physical abuse; these risk factors accounted for about 38% of the excess risk (95% confidence interval, 25% - 53%). "So just shy of 40% of the association between forced sex in childhood and cardiovascular disease in adulthood is explained by established risk factors, which is a lot left unexplained," Dr. Rich-Edwards noted. Additional analyses showed that the associations were stronger for women without adult abuse, and for stroke than for myocardial infarction. Simultaneous adjustment for both sexual and physical abuse again dampened both associations "modestly," the researchers note. There was also a relationship between case confirmation and risk for cardiovascular events, with the lowest risk seen in the "definite" confirmed cases of physical and sexual abuse, although the association with forced sex was still statistically significant. When they included definite, probable, and unconfirmed cases of physical and sexual abuse, hazard ratios increased to 1.77 for physical abuse and 2.06 for forced sex (P < .05 for both). "I think what this points to is, first and foremost, the need for prevention; not only the prevention of child abuse, but in pediatrics offices and other agencies that spot child abuse, understanding that it's not just a short-term problem, but there's really a long tail of chronic disease that ensues from this," Dr. Rich-Edwards concluded. About 40% of the increased risk appears to stem from lifestyle risk factors, so those events might be prevented, "just by applying what we know." In the adult primary care setting, where these women will most probably first be seen, it is important that physicians talk about the issue, and let women know that, "though they may have had their bodies disrespected as children, there's a lot they can do as adults to take good care of themselves," she said. Tailored approaches for these women taking into account their experiences might also be developed. "Finally, the fact that we can explain only about half of it through our known pathways means we have a lot more work to do in terms of understanding the other ways in which this early psychosocial stress is literally embodied," she concluded. Factors like stress reactivity, for example, which appears heightened in women with a history of abuse, are just beginning to be investigated now. Asked for comment on these findings, Donna K. Arnett, PhD, professor and chair of epidemiology at the University of Alabama, Birmingham, and president-elect of the American Heart Association, called these results "disturbing on a number of levels." "First, the prevalence of abuse is much higher than many of us realize, and that it's associated with these other cardiovascular risk factors and other cardiovascular disease in later life provides a compelling case that we need to address this early in childhood said" Dr. Arnett. "We need to screen for it, we need to understand it, and we need to intervene at the cause, which is this physical or sexual abuse in children, so that we prevent downstream cardiovascular disease." Interestingly, known cardiovascular disease risk factors did not entirely account for the increased risk, particularly for the sexual abuse, she noted, "and that's one that gets underreported, because it's often unseen."

Autism

Autism may be an advantage in some settings and should not be viewed as a defect that needs suppressing, according to a provocative article published online November 2 in Nature.


Recent data and my own personal experience suggest it's time to start thinking of autism as an advantage in some spheres, not a cross to bear," said author Laurent Mottron, MD, PhD, from the University of Montreal's Centre for Excellence in Pervasive Development Disorders. According to the article, the definition of autism itself is biased, being characterized by "a suite of negative characteristics," focusing on deficits that include problems with language and social interactions. However, in certain settings, such as scientific research, people with autism exhibit cognitive strength."We think that the kind of strengths and cognitive profile that we find in autistics are much more specific than scientists usually acknowledge," said Dr. Mottron."Unfortunately, there is no gold standard for the diagnosis of autism. Clinical diagnoses are reliable among scientists, but it is just a consensus...everybody may fail."He noted that as a result of a diagnosis, many individuals with autism end up working at repetitive, menial jobs despite their potential to make more significant contributions to society."After 18 years of age they're not kids anymore, and they're forgotten," he said. "People have a cliché, that if he's autistic you can do nothing with him. That's not true. The fact that you have some terrible autistic life is not representative of autism in general. Dr. Mottron has 8 individuals with autism people in his research group including 4 assistants, 3 students, and 1 researcher, Michelle Dawson, whom he met almost 10 years ago during a television documentary about autism. Following the show, Ms. Dawson experienced problems in her job as a postal worker and was asked by Dr. Mottron to edit some of his papers. "She gave exceptional feedback, and it was clear that she had read the entire bibliography," Dr. Mottron noted. Her single-minded autistic abilities to discern patterns out of mountains of data and instant recall of correct information made her perfectly suited to a career in science, he said. Though lacking a formal doctorate, Ms Dawson has since coauthored 13 papers and several book chapters. Dr. Mottron said Ms. Dawson and other individuals with autism have convinced him that more than anything, people with autism "need opportunities, frequently support, but rarely treatment." As a result, he believes that "autism should be described and investigated as an accepted variant within human species, not as a defect to be suppressed." Dr. Mottron noted that autistic brains do function differently, relying less on verbal centers and demonstrating stimulation in regions that process both visual information and language. Advantages may include spotting a pattern in a distracting environment, auditory tasks such as discriminating sound pitches, detecting visual structures, and mentally manipulating complex 3-dimensional shapes. Individuals with autism also perform Raven's Matrices at an average of 40% faster than nonautistics, using their analytical skills to complete an ongoing visual pattern. Other benefits of autism include the ability to simultaneously process large amounts of perceptual information as data sets and the presence of instantaneous and correct recall. Because data and facts are of paramount importance to people with autism, they also tend not to get bogged down in career politics or seek popularity via promotional publishing; online essays such as those posted by Ms. Dawson in her blog may instead receive unintentional acclaim. "I no longer believe intellectual disability is intrinsic to autism," Dr. Mottron said, noting that intelligence in people with autism should be measured with nonverbal tests. In his article, Dr. Mottron cites recent data, including an epidemiological study that showed the disorder is 3.5 times more prevalent than common statistics suggest. He noted that the study showed that many of those with autism have "no adaptive problems at all," and can function relatively normally. However, he added, a focus on "normocentrism" prevails in some countries. France, for example, has proposed mandatory interventions aimed at forcing children with autism to adopt "typical" learning and social behaviors, rather than allowing them to make the most of their differently wired brains. Dr. Mottron finds such a concept concerning. "There is no current treatment for autism, just educational strategies that do not put the emphasis on learning abilities for nonsocial information...We need to take their learning style for what it is and feed it," he said.


"What we know is that if we reach these individuals at a young age, when their brains are malleable, we can cognitively redirect the transmission of information via the corpus callosum to the speech areas in the left hemisphere of the brain, and oftentimes speech and language will kick in." She continued: "The audio processing of music in the brain combined with the forward, backward, and side-to-side movements stimulate and activate the dormant areas of the brain that, in autism, do not generally receive transmission of neurons. "Movement and music, when combined with gross motor and visual processing, oftentimes helps the areas of the brain of the individual with autism to work together to allow for a whole-brain processing approach," she added.


"I think it's critically important to acknowledge the potential strengths associated with autism, but it's equally important, if not more important, to reiterate the notion of the right to effective treatment, said " Jonathan Tarbox, PhD, BCBA-D, director of research and development at the Center for Autism and Related Disorders, Tarzana, California. "If an individual with autism is having a difficult time in their life because they don't know how to do something that they want to do, and there is a proven effective method to teach that skill, then we as fellow humans have a moral and ethical responsibility to provide the treatment that addresses it," he said. Behavioral intervention programs, he said, should be used in a supportive environment to treat skill deficits in individuals with autism wanting to learn, similar to those used for literacy and mathematics. He added that autism is no different: People who have skill deficits and want to learn have a right to effective treatment. Dr. Tarbox took exception to Dr. Mottron's contention that individuals with autism need opportunity more than treatment. Environmental support, he said, does create opportunity. In addition, he noted that research shows that early intensive behavioral intervention increases the ability to communicate and function independently. "How can a newly found ability to communicate not be considered an opportunity?" he said. One of Dr. Mottron's main points is that the performance of individuals with autism on visual intelligence tests is often overlooked, showing that the true intelligence of people with autism is higher overall than verbal intelligence tests would indicate. "This is, of course, true, but true intelligence is of little relevance to a person's everyday quality of life. What really matters is one's ability to do what one wants to do in life independently; that is, without having to rely on support from others," said Dr. Tarbox. "There are many people, autistic and nonautistic, who have superior intelligence but still have much difficulty in life and suffer for it. Unfortunately, vocal language is the medium with which most humans interact, so deficits in one's ability to vocally communicate are going to create barriers for people." Dr. Mottron also states that no education programs are tailored to the unique ways that people with autism learn. However, Dr. Tarbox noted that there are "many tens of thousands of special education teachers, speech and language pathologists, and applied behavior analysts working to change what they do to help individuals with autism learn." The aim of behavioral interventions, he added, is not to try to teach individuals with autism to adopt typical learning and behavior but, rather, to teach skills that help increase independence. Such programs, he said, "teach skills that open doors for individuals with autism, but they do not dictate which door to take."
"I think what Dr. Mottron was getting to is the idea that autism is a different way of being, not necessary a disordered way of being, and the difference can give us strengths and abilities that other people may not have," said Stephen M. Shore, EdD, assistant professor at Adelphi University in Long Island, New York."At the same time, there are many challenges that come with being on the autistic spectrum, such as sensory issues, communication, interacting with others. These things are challenges, and we do have to address them," Dr. Shore noted.


Diagnosed himself with autism at age 2 and a half years, and nonverbal until age 4 years, Dr. Shore was originally recommended for institutionalization. With the help of family and others, he completed a doctoral dissertation at Boston University in Massachusetts that was focused on matching best practice to the needs of people on the autism spectrum. He now spends his time researching, teaching, writing books, and conducting autism workshops around the world. According to Dr. Shore, the best way to address those issues is to find a way to use a person's strengths to overcome their challenges. "There is a point in time when you have to get off the remediation and start moving on to finding a way the person can be successful in communication," he said. Methods may include use of a computer keyboard, rather than a pen, to write, or pointing at pictures to communicate, he said. Adjusting the environment also plays a vital role and often benefits people without autism. "Many autistics have sensory issues and perceive fluorescent lights as most people strobe lights, which will really affect productivity at work and school," Dr. Shore said. "Research shows that everybody's productivity is affected by fluorescent lamps, so everyone benefits by using alternate lighting." With respect to the plethora of methodologies used to address autism in children, Dr. Shore notes that the wide variety of diversity within the autism spectrum disorders necessitates a tailored approach. Parents and educators are encouraged to pick one or more approaches that best suits the child's needs and abilities. This may include use of Applied Behavioral Analysis, Treatment and Education of Autistic and Related Communication-Handicapped Children, Daily Life Therapy, the Miller Method, the Developmental/Individual Difference/Relationship-based method, relationship development intervention, and social communication/emotional regulation. "You can have a right or wrong approach on an individual basis, but not on a generic basis," he said.

Fat Melter

Deep in the jungles of West Africa, there are places where obesity is completely unknown.
The natives just don’t get fat.
A professor doing population studies discovered this curious fact. After watching this group and comparing them to others, he found something unique about their diet:
The locals use a paste derived from the seed of a “bush mango” to thicken their soups.
This professor, an expert in nutritional biochemistry at the University in nearby Cameroon, created an extract of this seed and ran his own tests.
After 10 weeks, the people taking this extract dropped an average of 28 pounds and dropped 6 inches around their waist.
The results were published in a national, peer-reviewed medical journal.
FOX News picked up the story from Reuters when the study hit the media last year.
Along with a healthy diet and regular exercise, you can use this very same natural extract to help drop unwanted fat.

Clot lysis treatment

A clot lytic treatment strategy with low-dose recombinant tissue-type plasminogen activator (rtPA) speeds clot removal in patients with intracerebral hemorrhage (ICH) that is complicated by intraventricular hemorrhage (IVH), results of a phase 2 trial confirm. Moreover, it does so with an "acceptable safety profile compared to placebo and historical controls," the authors, led by Neal Naff, MD, from Johns Hopkins University, Baltimore, Maryland, write. One caveat with the novel treatment, however, is that it appears to be associated with more bleeding,said senior author Daniel F. Hanley, MD, also from Johns Hopkins. Still, the aim in treating this condition, which can be almost 100% fatal, is to reduce the patient's exposure to blood, thereby reducing injury to the brain. "This drug has to be used carefully because of the increased risk of bleeding, but it will dissolve the blood clot that has formed in the intraventricular space," Dr. Hanley said. "Most of the blood clot is like an iceberg that sits under the water, doing nothing. Getting that blood clot out eliminates one big part of that iceberg that can damage the brain." Results of this phase 2 trial were published in the November issue of Stroke. The current study was done to assess the safety of low-dose rtPA administered via extraventricular drainage catheter for the treatment of ICH with massive IVH with regard to mortality, ventricular infection, and bleeding events. The study also tested whether administration of 3 mg of rtPA via external ventricular device (EVD) every 12 hours increased the rate of intraventricular clot lysis compared with placebo (normal saline)-irrigated catheters. The study included 48 patients aged between 18 and 75 years with a small supratentorial ICH of 30 mL or less and massive IVH. All had an EVD already placed for the treatment of obstructive hydrocephalus. A computed tomography scan was done to ensure that the EVD had been properly placed and that the clot was stable. The patients were then randomly assigned to receive either 3 mg/3 mL of rtPA (n = 26 patients) or 3 mL of normal saline (n = 22 patients) injected into the ventricular spaces via the EVD. This continued every 12 hours until computed tomography showed that clot resolution was sufficient for safe removal of the catheter or until the occurrence of symptomatic bleeding, infection, or death. The median duration of dosing was 7.5 days for rtPA and 12 days for placebo. The researchers report that the frequency of death and ventriculitis was substantially lower than expected. The predicted 30-day mortality was 75% for both treatment groups. The actual mortality was 19% in the rtPA-treated group and 23% in the placebo group. Ventriculitis occurred in 8% of the rtPA-treated group and 9% of the placebo group. Symptomatic bleeding was higher with rtPA, affecting 23% of patients compared with 5% of patients receiving placebo (P = .1). The study showed that the greatest amount of lysing activity in patients receiving rtPA occurred during the first 3 days. There was a significant beneficial effect of rtPA on the rate of clot resolution. The authors report that the estimated resolution for rtPA-treated patients during the first 3 days was 22.3% per day (95% confidence interval, 16.7% - 28.0%), and for patients receiving placebo, it was 9.9% per day (95% confidence interval, 3.5% - 16.2%). As a result of these findings, the researchers concluded that low-dose rtPA for the treatment of ICH with IVH has an acceptable safety profile and call for more data from a "well-designed phase 3 clinical trial, such as [Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR)] III," to fully evaluate the treatment. "We concluded that because there was no difference in infection, no difference in death rate, and the difference in bleeding rate was not statistically significant," Dr. Hanley explained. He added that the dose of rtPA should probably be lower, "or at least lower doses should be tested," because of the increased bleeding that was seen in this study. This treatment strategy for ICH with IVH has been explored in other studies by the same group. In 2008, at the 17th European Stroke Conference, Dr. Hanley presented results of the CLEAR-IVH trial, which showed that administration of 1 mg of tissue plasminogen activator every 8 hours for up to 4 days reduced expected mortality by 70% and also resulted in a dramatic improvement in functional outcomes in patients with IVH. The next year, at the American Stroke Association International Stroke Conference 2009, Dr. Hanley announced that the National Institutes of Health was set to fund a multicentre, 500-patient study to expand on the findings of the CLEAR-IVH trial. Finally, in July 2010, the American Heart Association/American Stroke Association released a new guideline on the management of spontaneous ICH, emphasizing that ICH is a very treatable disorder. The new guideline makes mention of the CLEAR-IVH trial, noting that the efficacy and safety of intraventricular rtPA in IVH are still "uncertain and considered investigational." In an accompanying editorial, Heinrich P. Mattle, MD, and Andreas Raabe, MD, from the University of Bern in Switzerland, point out that the results raise the issue of whether rtPA is the best thrombolytic for this application. Most of the animal and early patient work with this approach was done with urokinase, and there is some evidence to suggest rtPA may be toxic or enhance formation of edema, they write. In fact, they note, "the principal investigators of this trial were forced to terminate an earlier study because commercial withdrawal of urokinase in the United States precluded additional enrollment of patients. Was the choice of rtPA in this study a regulatory issue, or is there a good scientific reason for the selection of rtPA?" Nevertheless, they conclude that Dr. Naff, Dr. Hanley, and their team "have made a great achievement and they have to be congratulated for this successful phase II trial." The editorialists concur with the researchers that the treatment must be studied in further phase 3 trials and point out that CLEAR III is already underway, as is the Dutch Intraventricular Thrombolysis after Cerebral Hemorrhage study (DITCH), a smaller trial being conducted in the Netherlands. They also voice concern about the bleeding that was seen in the rtPA-treated patients. The current study "shows the slippery slope of using thrombolytics in cerebral hemorrhage," they note. "It is nothing else but logical to accelerate clot removal with rtPA," but the trend toward more bleeding "could be a signal that the expected benefit of rtPA might easily turn into harm.