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Room for improvement with HPV vaccine coverage
Six in ten teens now have had at least one dose of the human papillomavirus (HPV) vaccine, but many still are not receiving the second dose, according to 2016 data on vaccination coverage among adolescents published in the Morbidity and Mortality Weekly Report.
Researchers analyzed data from 20,475 adolescents aged 13-17 years in the 2016 National Immunization Survey–Teen, which showed that coverage for at least one dose of the HPV vaccine had increased from 56% in 2015 to 60% in 2016. However only 43% of adolescents – 50% of females and 38% of males – were up to date with the full two-dose vaccination series, in accordance with the updated vaccine recommendations (MMWR. 2017 Aug 25;66:874-82).
“Since HPV vaccine was introduced for females in 2006 and for males in 2011, coverage has increased gradually among females and more rapidly among males,” wrote Tanja Y. Walker and her colleagues from the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. “Coverage with 1 or more doses HPV vaccine among males continues to approach that among females, particularly for adolescents aged 13 years, suggesting that HPV vaccination of both female and male adolescents has been integrated into vaccination practices.”
HPV vaccine coverage with at least one dose was highest in central cities (66%) and lowest among adolescents in nonmetropolitan areas (50%). However, HPV coverage also was higher among adolescents living below the federal poverty line, compared with those living at or above the poverty line.
There was also significant geographic variation in HPV vaccine coverage, ranging from coverage with at least one dose among 90% of females and 88% of males in Rhode Island, to just 37% of males in Indiana and Wyoming and 48% of females in Mississippi. New York City showed the greatest average annual increase in coverage of one or more doses of the HPV vaccine from 2015 to 2016 (7.7 percentage point).
The analysis also looked at coverage for the Tdap vaccine, which increased for one or more doses from 86% to 88% from 2015 to 2016, respectively, while coverage with two or more doses of the meningococcal conjugate vaccine among 17-year-olds increased from 33% to 39%, respectively.
The authors pointed out that coverage for HPV immunization was still 22-28 percentage points below coverage for Tdap and the meningococcal conjugate vaccine, suggesting there was substantial opportunity for improvement.
“Potential contributing factors might include differences in parental acceptance of certain vaccines and provider participation in, and adolescents’ eligibility for, the Vaccines for Children program,” Ms. Walker and her colleagues said.
No conflicts of interest were declared.
Six in ten teens now have had at least one dose of the human papillomavirus (HPV) vaccine, but many still are not receiving the second dose, according to 2016 data on vaccination coverage among adolescents published in the Morbidity and Mortality Weekly Report.
Researchers analyzed data from 20,475 adolescents aged 13-17 years in the 2016 National Immunization Survey–Teen, which showed that coverage for at least one dose of the HPV vaccine had increased from 56% in 2015 to 60% in 2016. However only 43% of adolescents – 50% of females and 38% of males – were up to date with the full two-dose vaccination series, in accordance with the updated vaccine recommendations (MMWR. 2017 Aug 25;66:874-82).
“Since HPV vaccine was introduced for females in 2006 and for males in 2011, coverage has increased gradually among females and more rapidly among males,” wrote Tanja Y. Walker and her colleagues from the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. “Coverage with 1 or more doses HPV vaccine among males continues to approach that among females, particularly for adolescents aged 13 years, suggesting that HPV vaccination of both female and male adolescents has been integrated into vaccination practices.”
HPV vaccine coverage with at least one dose was highest in central cities (66%) and lowest among adolescents in nonmetropolitan areas (50%). However, HPV coverage also was higher among adolescents living below the federal poverty line, compared with those living at or above the poverty line.
There was also significant geographic variation in HPV vaccine coverage, ranging from coverage with at least one dose among 90% of females and 88% of males in Rhode Island, to just 37% of males in Indiana and Wyoming and 48% of females in Mississippi. New York City showed the greatest average annual increase in coverage of one or more doses of the HPV vaccine from 2015 to 2016 (7.7 percentage point).
The analysis also looked at coverage for the Tdap vaccine, which increased for one or more doses from 86% to 88% from 2015 to 2016, respectively, while coverage with two or more doses of the meningococcal conjugate vaccine among 17-year-olds increased from 33% to 39%, respectively.
The authors pointed out that coverage for HPV immunization was still 22-28 percentage points below coverage for Tdap and the meningococcal conjugate vaccine, suggesting there was substantial opportunity for improvement.
“Potential contributing factors might include differences in parental acceptance of certain vaccines and provider participation in, and adolescents’ eligibility for, the Vaccines for Children program,” Ms. Walker and her colleagues said.
No conflicts of interest were declared.
Six in ten teens now have had at least one dose of the human papillomavirus (HPV) vaccine, but many still are not receiving the second dose, according to 2016 data on vaccination coverage among adolescents published in the Morbidity and Mortality Weekly Report.
Researchers analyzed data from 20,475 adolescents aged 13-17 years in the 2016 National Immunization Survey–Teen, which showed that coverage for at least one dose of the HPV vaccine had increased from 56% in 2015 to 60% in 2016. However only 43% of adolescents – 50% of females and 38% of males – were up to date with the full two-dose vaccination series, in accordance with the updated vaccine recommendations (MMWR. 2017 Aug 25;66:874-82).
“Since HPV vaccine was introduced for females in 2006 and for males in 2011, coverage has increased gradually among females and more rapidly among males,” wrote Tanja Y. Walker and her colleagues from the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. “Coverage with 1 or more doses HPV vaccine among males continues to approach that among females, particularly for adolescents aged 13 years, suggesting that HPV vaccination of both female and male adolescents has been integrated into vaccination practices.”
HPV vaccine coverage with at least one dose was highest in central cities (66%) and lowest among adolescents in nonmetropolitan areas (50%). However, HPV coverage also was higher among adolescents living below the federal poverty line, compared with those living at or above the poverty line.
There was also significant geographic variation in HPV vaccine coverage, ranging from coverage with at least one dose among 90% of females and 88% of males in Rhode Island, to just 37% of males in Indiana and Wyoming and 48% of females in Mississippi. New York City showed the greatest average annual increase in coverage of one or more doses of the HPV vaccine from 2015 to 2016 (7.7 percentage point).
The analysis also looked at coverage for the Tdap vaccine, which increased for one or more doses from 86% to 88% from 2015 to 2016, respectively, while coverage with two or more doses of the meningococcal conjugate vaccine among 17-year-olds increased from 33% to 39%, respectively.
The authors pointed out that coverage for HPV immunization was still 22-28 percentage points below coverage for Tdap and the meningococcal conjugate vaccine, suggesting there was substantial opportunity for improvement.
“Potential contributing factors might include differences in parental acceptance of certain vaccines and provider participation in, and adolescents’ eligibility for, the Vaccines for Children program,” Ms. Walker and her colleagues said.
No conflicts of interest were declared.
FROM MMWR
Key clinical point: More than half of teens now have had at least one dose of the HPV vaccine, but many still are not receiving the second dose and immunization rates still are well below those of other vaccines.
Major finding:
Data source: Data from 20,475 adolescents aged 13-17 years in the 2016 National Immunization Survey–Teen.
Disclosures: No conflicts of interest were declared.
Fewer complications, lower mortality with minimally invasive hernia repair
Minimally invasive surgical techniques are now used in nearly 80% of operations for paraesophageal hernia repair (PEH) and are associated with many outcome improvements, in comparison with open surgery, according to a retrospective study of data from nearly 100,000 cases.
“Many studies have shown improved perioperative outcomes in paraesophageal hernia repair with MIS [minimally invasive surgery] approaches, but the optimal approach is still debated,” wrote Patrick J. McLaren, MD, and his colleagues from the division of gastrointestinal and general surgery at Oregon Health & Science University, Portland. “In addition, the extent to which MIS has been adopted on the national level for PEH repair is unknown.” Their research letter was published online Aug. 23 in JAMA Surgery.
They found that the proportion of repair conducted using minimally invasive techniques increased from 9.8% in 2002 to 79.6% in 2012. At the same time, in-hospital mortality associated with paraesophageal hernia repair declined from 3.5% to 1.2%, and the rates of complications dropped from 29.8% to 20.6%.
Compared with open-repair procedures, minimally invasive surgery was associated with significantly lower in-hospital mortality (0.6% vs. 3%; P less than .001); wound complications (0.4% vs. 2.9%; P less than .001); septic complications (0.9% vs. 3.9%; P less than .001); and bleeding complications (0.6% vs. 1.8%; P less than .001), as well as urinary, respiratory, and cardiac complications, and intraoperative injury. No significant differences were seen between the two groups in the incidence of thromboembolic complications.
The mean length of hospital stay was 4.2 days in patients who underwent surgery using minimally invasive techniques, compared with 8.5 days in those who had open surgery.
The authors noted that early research on MIS for PEH raised the question of a possible higher risk of recurrence. While the study did not examine the incidence of hernia recurrence, the authors cited data showing that improvements in minimally invasive surgical techniques have been linked to a reduction in hiatal hernia recurrences.
“Studies have found that recurrences requiring reoperation after MIS repairs are low at 2.2%-6%,” the authors wrote. “Regardless, a role remains for open PEH repairs in cases of multiple prior abdominal operations and acute strangulation and in patients with an unstable condition.”
The study was funded by the Oregon Clinical and Translational Research Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. No conflicts of interest were declared.
This article was updated August 23, 2017.
Minimally invasive surgical techniques are now used in nearly 80% of operations for paraesophageal hernia repair (PEH) and are associated with many outcome improvements, in comparison with open surgery, according to a retrospective study of data from nearly 100,000 cases.
“Many studies have shown improved perioperative outcomes in paraesophageal hernia repair with MIS [minimally invasive surgery] approaches, but the optimal approach is still debated,” wrote Patrick J. McLaren, MD, and his colleagues from the division of gastrointestinal and general surgery at Oregon Health & Science University, Portland. “In addition, the extent to which MIS has been adopted on the national level for PEH repair is unknown.” Their research letter was published online Aug. 23 in JAMA Surgery.
They found that the proportion of repair conducted using minimally invasive techniques increased from 9.8% in 2002 to 79.6% in 2012. At the same time, in-hospital mortality associated with paraesophageal hernia repair declined from 3.5% to 1.2%, and the rates of complications dropped from 29.8% to 20.6%.
Compared with open-repair procedures, minimally invasive surgery was associated with significantly lower in-hospital mortality (0.6% vs. 3%; P less than .001); wound complications (0.4% vs. 2.9%; P less than .001); septic complications (0.9% vs. 3.9%; P less than .001); and bleeding complications (0.6% vs. 1.8%; P less than .001), as well as urinary, respiratory, and cardiac complications, and intraoperative injury. No significant differences were seen between the two groups in the incidence of thromboembolic complications.
The mean length of hospital stay was 4.2 days in patients who underwent surgery using minimally invasive techniques, compared with 8.5 days in those who had open surgery.
The authors noted that early research on MIS for PEH raised the question of a possible higher risk of recurrence. While the study did not examine the incidence of hernia recurrence, the authors cited data showing that improvements in minimally invasive surgical techniques have been linked to a reduction in hiatal hernia recurrences.
“Studies have found that recurrences requiring reoperation after MIS repairs are low at 2.2%-6%,” the authors wrote. “Regardless, a role remains for open PEH repairs in cases of multiple prior abdominal operations and acute strangulation and in patients with an unstable condition.”
The study was funded by the Oregon Clinical and Translational Research Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. No conflicts of interest were declared.
This article was updated August 23, 2017.
Minimally invasive surgical techniques are now used in nearly 80% of operations for paraesophageal hernia repair (PEH) and are associated with many outcome improvements, in comparison with open surgery, according to a retrospective study of data from nearly 100,000 cases.
“Many studies have shown improved perioperative outcomes in paraesophageal hernia repair with MIS [minimally invasive surgery] approaches, but the optimal approach is still debated,” wrote Patrick J. McLaren, MD, and his colleagues from the division of gastrointestinal and general surgery at Oregon Health & Science University, Portland. “In addition, the extent to which MIS has been adopted on the national level for PEH repair is unknown.” Their research letter was published online Aug. 23 in JAMA Surgery.
They found that the proportion of repair conducted using minimally invasive techniques increased from 9.8% in 2002 to 79.6% in 2012. At the same time, in-hospital mortality associated with paraesophageal hernia repair declined from 3.5% to 1.2%, and the rates of complications dropped from 29.8% to 20.6%.
Compared with open-repair procedures, minimally invasive surgery was associated with significantly lower in-hospital mortality (0.6% vs. 3%; P less than .001); wound complications (0.4% vs. 2.9%; P less than .001); septic complications (0.9% vs. 3.9%; P less than .001); and bleeding complications (0.6% vs. 1.8%; P less than .001), as well as urinary, respiratory, and cardiac complications, and intraoperative injury. No significant differences were seen between the two groups in the incidence of thromboembolic complications.
The mean length of hospital stay was 4.2 days in patients who underwent surgery using minimally invasive techniques, compared with 8.5 days in those who had open surgery.
The authors noted that early research on MIS for PEH raised the question of a possible higher risk of recurrence. While the study did not examine the incidence of hernia recurrence, the authors cited data showing that improvements in minimally invasive surgical techniques have been linked to a reduction in hiatal hernia recurrences.
“Studies have found that recurrences requiring reoperation after MIS repairs are low at 2.2%-6%,” the authors wrote. “Regardless, a role remains for open PEH repairs in cases of multiple prior abdominal operations and acute strangulation and in patients with an unstable condition.”
The study was funded by the Oregon Clinical and Translational Research Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. No conflicts of interest were declared.
This article was updated August 23, 2017.
FROM JAMA SURGERY
Key clinical point: Minimally invasive surgery for paraesophageal hernia repair is associated with significantly lower in-hospital mortality and complication rates than open repair.
Major finding: Compared with open-repair procedures, minimally invasive paraesophageal hernia repair was associated with significantly lower in-hospital mortality, wound, septic, bleeding, urinary, respiratory, and cardiac complications, and intraoperative injury.
Data source: A retrospective review of 97,393 inpatient admissions for paraesophageal hernia repair between 2002 and 2012.
Disclosures: The study was funded by the Oregon Clinical and Translational Research Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. No conflicts of interest were declared.
AAP releases revised guidelines on screening, treatment of hypertension
which includes revised BP tables based on normal-weight children only.
The document, published Aug. 21 in Pediatrics, is the first update since 2004, and recommends significant changes in both screening and treatment of hypertension (HTN).
The guidelines also include a simplified screening table for initial screening, which lists the 90th percentile BP for age and sex, for children at the fifth percentile of height. These values give the table a negative predictive value of greater than 99%, although the committee stressed that the table should only be used for screening, and not for diagnosis.
“To diagnose elevated BP or HTN, it is important to locate the actual cutoffs in the complete BP tables because the [systolic] BP and [diastolic] BP cutoffs may be as much as 9 mm Hg higher depending on a child’s age and length or height,” wrote Joseph T. Flynn, MD, and his colleagues on the AAP subcommittee on screening and management of high blood pressure in children.
To ensure consistency between these guidelines and the 2017 adult guidelines from the American Heart Association and American College of Cardiology, the committee also decided to replace the term “prehypertension” with “elevated blood pressure.”
Similarly, the committee recommended adopting revised stage 1 and stage 2 HTN criteria, to enable the staging scheme for children aged 13 years and over to “seamlessly interface” with the 2017 AHA and ACC adult guidelines.
“There are still no data to identify a specific level of BP in childhood that leads to adverse [cardiovascular] outcomes in adulthood,” the committee wrote. “Therefore, the subcommittee decided to maintain a statistical definition for childhood HTN.”
In terms of screening children for hypertension, the guidelines review committee made the recommendation that BP be measured annually in children and adolescents aged 3 years or above. However, if the child is at greater risk of hypertension because of obesity, medications known to increase BP – such as stimulants for ADHD – renal disease, a history of aortic arch obstruction or coarctation, or have diabetes, they should have their BP measured at every health care encounter.
They also stressed it was important to take more than one measurement over time before diagnosing HTN, and to use appropriately-sized cuffs to ensure an accurate measurement.
If a child or adolescent has confirmed auscultatory BP readings at or above the 95th percentile on three different visits, this justifies a diagnosis of HTN, they wrote.
The committee strongly recommended the routine performance of ambulatory BP monitoring in patients with high-risk conditions, such as diabetes, secondary hypertension, or renal disease, to look for abnormal circadian BP patterns that might point to an increased risk of target organ damage.
They also issued revised recommendations on when to perform echocardiography in children newly diagnosed with HTN.
“It is recommended that echocardiography be performed to assess for cardiac target organ damage (left ventricular mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN,” they wrote, suggesting repeat echocardiography could be used to monitor target organ damage at 6-12 month intervals.
They offered a revised definition of left ventricular HTN as a left ventricular mass greater than 51 g/m2.7 for children and adolescents older than 8 years (greater than 115 g/body surface area for boys and greater than 95 g/body surface area for girls).
While previous treatment recommendations used a treatment target of a systolic and diastolic BP below the 95th percentile in children without chronic kidney disease, new evidence prompted a revised recommendation of a target either below the 90th percentile or less than 130/80 mm Hg.
“Longitudinal studies on BP from childhood to adulthood that include indirect measures of [cardiovascular] injury indicate that the risk for subsequent [cardiovascular disease] in early adulthood increases as the BP level in adolescence exceeds 120/80 mm Hg,” they wrote. “In addition, there is some evidence that targeting a BP less than 90th percentile results in reductions in [left ventricular mass index] and prevalence of [left ventricular hypertrophy].”
In hypertensive children and adolescents who have failed lifestyle modifications, such as physical activity, weight loss, and stress reduction (particularly those who have left ventricular hypertrophy, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor such as obesity), pharmacologic treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, long-acting calcium channel blocker, or thiazide diuretic is indicated, according to the revised guidelines.
The guidelines were supported by the American Academy of Pediatrics and endorsed by the American Heart Association. No conflicts of interest were declared.
which includes revised BP tables based on normal-weight children only.
The document, published Aug. 21 in Pediatrics, is the first update since 2004, and recommends significant changes in both screening and treatment of hypertension (HTN).
The guidelines also include a simplified screening table for initial screening, which lists the 90th percentile BP for age and sex, for children at the fifth percentile of height. These values give the table a negative predictive value of greater than 99%, although the committee stressed that the table should only be used for screening, and not for diagnosis.
“To diagnose elevated BP or HTN, it is important to locate the actual cutoffs in the complete BP tables because the [systolic] BP and [diastolic] BP cutoffs may be as much as 9 mm Hg higher depending on a child’s age and length or height,” wrote Joseph T. Flynn, MD, and his colleagues on the AAP subcommittee on screening and management of high blood pressure in children.
To ensure consistency between these guidelines and the 2017 adult guidelines from the American Heart Association and American College of Cardiology, the committee also decided to replace the term “prehypertension” with “elevated blood pressure.”
Similarly, the committee recommended adopting revised stage 1 and stage 2 HTN criteria, to enable the staging scheme for children aged 13 years and over to “seamlessly interface” with the 2017 AHA and ACC adult guidelines.
“There are still no data to identify a specific level of BP in childhood that leads to adverse [cardiovascular] outcomes in adulthood,” the committee wrote. “Therefore, the subcommittee decided to maintain a statistical definition for childhood HTN.”
In terms of screening children for hypertension, the guidelines review committee made the recommendation that BP be measured annually in children and adolescents aged 3 years or above. However, if the child is at greater risk of hypertension because of obesity, medications known to increase BP – such as stimulants for ADHD – renal disease, a history of aortic arch obstruction or coarctation, or have diabetes, they should have their BP measured at every health care encounter.
They also stressed it was important to take more than one measurement over time before diagnosing HTN, and to use appropriately-sized cuffs to ensure an accurate measurement.
If a child or adolescent has confirmed auscultatory BP readings at or above the 95th percentile on three different visits, this justifies a diagnosis of HTN, they wrote.
The committee strongly recommended the routine performance of ambulatory BP monitoring in patients with high-risk conditions, such as diabetes, secondary hypertension, or renal disease, to look for abnormal circadian BP patterns that might point to an increased risk of target organ damage.
They also issued revised recommendations on when to perform echocardiography in children newly diagnosed with HTN.
“It is recommended that echocardiography be performed to assess for cardiac target organ damage (left ventricular mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN,” they wrote, suggesting repeat echocardiography could be used to monitor target organ damage at 6-12 month intervals.
They offered a revised definition of left ventricular HTN as a left ventricular mass greater than 51 g/m2.7 for children and adolescents older than 8 years (greater than 115 g/body surface area for boys and greater than 95 g/body surface area for girls).
While previous treatment recommendations used a treatment target of a systolic and diastolic BP below the 95th percentile in children without chronic kidney disease, new evidence prompted a revised recommendation of a target either below the 90th percentile or less than 130/80 mm Hg.
“Longitudinal studies on BP from childhood to adulthood that include indirect measures of [cardiovascular] injury indicate that the risk for subsequent [cardiovascular disease] in early adulthood increases as the BP level in adolescence exceeds 120/80 mm Hg,” they wrote. “In addition, there is some evidence that targeting a BP less than 90th percentile results in reductions in [left ventricular mass index] and prevalence of [left ventricular hypertrophy].”
In hypertensive children and adolescents who have failed lifestyle modifications, such as physical activity, weight loss, and stress reduction (particularly those who have left ventricular hypertrophy, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor such as obesity), pharmacologic treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, long-acting calcium channel blocker, or thiazide diuretic is indicated, according to the revised guidelines.
The guidelines were supported by the American Academy of Pediatrics and endorsed by the American Heart Association. No conflicts of interest were declared.
which includes revised BP tables based on normal-weight children only.
The document, published Aug. 21 in Pediatrics, is the first update since 2004, and recommends significant changes in both screening and treatment of hypertension (HTN).
The guidelines also include a simplified screening table for initial screening, which lists the 90th percentile BP for age and sex, for children at the fifth percentile of height. These values give the table a negative predictive value of greater than 99%, although the committee stressed that the table should only be used for screening, and not for diagnosis.
“To diagnose elevated BP or HTN, it is important to locate the actual cutoffs in the complete BP tables because the [systolic] BP and [diastolic] BP cutoffs may be as much as 9 mm Hg higher depending on a child’s age and length or height,” wrote Joseph T. Flynn, MD, and his colleagues on the AAP subcommittee on screening and management of high blood pressure in children.
To ensure consistency between these guidelines and the 2017 adult guidelines from the American Heart Association and American College of Cardiology, the committee also decided to replace the term “prehypertension” with “elevated blood pressure.”
Similarly, the committee recommended adopting revised stage 1 and stage 2 HTN criteria, to enable the staging scheme for children aged 13 years and over to “seamlessly interface” with the 2017 AHA and ACC adult guidelines.
“There are still no data to identify a specific level of BP in childhood that leads to adverse [cardiovascular] outcomes in adulthood,” the committee wrote. “Therefore, the subcommittee decided to maintain a statistical definition for childhood HTN.”
In terms of screening children for hypertension, the guidelines review committee made the recommendation that BP be measured annually in children and adolescents aged 3 years or above. However, if the child is at greater risk of hypertension because of obesity, medications known to increase BP – such as stimulants for ADHD – renal disease, a history of aortic arch obstruction or coarctation, or have diabetes, they should have their BP measured at every health care encounter.
They also stressed it was important to take more than one measurement over time before diagnosing HTN, and to use appropriately-sized cuffs to ensure an accurate measurement.
If a child or adolescent has confirmed auscultatory BP readings at or above the 95th percentile on three different visits, this justifies a diagnosis of HTN, they wrote.
The committee strongly recommended the routine performance of ambulatory BP monitoring in patients with high-risk conditions, such as diabetes, secondary hypertension, or renal disease, to look for abnormal circadian BP patterns that might point to an increased risk of target organ damage.
They also issued revised recommendations on when to perform echocardiography in children newly diagnosed with HTN.
“It is recommended that echocardiography be performed to assess for cardiac target organ damage (left ventricular mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN,” they wrote, suggesting repeat echocardiography could be used to monitor target organ damage at 6-12 month intervals.
They offered a revised definition of left ventricular HTN as a left ventricular mass greater than 51 g/m2.7 for children and adolescents older than 8 years (greater than 115 g/body surface area for boys and greater than 95 g/body surface area for girls).
While previous treatment recommendations used a treatment target of a systolic and diastolic BP below the 95th percentile in children without chronic kidney disease, new evidence prompted a revised recommendation of a target either below the 90th percentile or less than 130/80 mm Hg.
“Longitudinal studies on BP from childhood to adulthood that include indirect measures of [cardiovascular] injury indicate that the risk for subsequent [cardiovascular disease] in early adulthood increases as the BP level in adolescence exceeds 120/80 mm Hg,” they wrote. “In addition, there is some evidence that targeting a BP less than 90th percentile results in reductions in [left ventricular mass index] and prevalence of [left ventricular hypertrophy].”
In hypertensive children and adolescents who have failed lifestyle modifications, such as physical activity, weight loss, and stress reduction (particularly those who have left ventricular hypertrophy, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor such as obesity), pharmacologic treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, long-acting calcium channel blocker, or thiazide diuretic is indicated, according to the revised guidelines.
The guidelines were supported by the American Academy of Pediatrics and endorsed by the American Heart Association. No conflicts of interest were declared.
FROM PEDIATRICS
Oral contraceptive use linked to lower rheumatoid arthritis risk
The use of oral contraceptives may be associated with a reduced risk of rheumatoid arthritis based on findings from a large, population-based, case-control study in Sweden.
The lowered risk for rheumatoid arthritis in the study conducted by Cecilia Orellana, PhD, of the Institute of Environmental Medicine at the Karolinska Institute, Stockholm, and her coauthors applied only to patients who tested positive for anticitrullinated protein antibodies (ACPA) and to those who used oral contraceptives for 7 or more years. The investigators also found a significant reduction in RA risk for women who breastfed their children.
“All of these findings together support the notion of RA as two different disease entities with different risk factors patterns,” the authors wrote.
The researchers looked at 2,578 women with RA and 4,129 female controls from the Swedish Epidemiological Investigation of RA study and found that women who had ever used OCs had 13% lower odds of developing RA than did women who had never used OCs, even after adjusting for age, residential area, smoking, and alcohol consumption. However, this association was significant only for ACPA-positive RA – where the risk was 16% lower – and not for ACPA-negative disease (Ann Rheum Dis. 2017 Aug 17. doi: 10.1136/annrheumdis-2017-211620).
Duration of oral contraceptive use was also positively associated with a decreased risk of RA; women who had taken OCs for 7 or more years had a 19% lower risk of RA, compared with never users.
However, the authors noted that they only collected information on the use of OCs as a whole and not on particular preparations or doses.
Women who had never used OCs and who had also smoked had more than twofold higher odds of developing RA than did women who had used OCs and who had never smoked. Women who had used OCs but who also smoked were 71% more likely to develop RA.
“Since both smoking and the use of OC have been linked to an increased predisposition to venous thrombotic events (VTE), women with a history of VTEs (especially if they smoke) might be recommended not to use OC by their physician. We can therefore not exclude the possibility that our findings on an interaction between non-OC use and smoking merely reflects that smoking women, who have an increased RA risk, do not receive OC prescription as often. The physiopathology of RA is complex and not fully understood, but our findings may contribute to the knowledge regarding mechanisms of importance for the development of RA,” the authors wrote.
The investigators also saw an influence of breastfeeding on the likelihood of developing RA, with a significant 23% lower odds for the disease among women who breastfed their children for 13 months or more and 7% lower odds in women who had breastfed their children for 7-12 months, compared with those who had breastfed for 0-6 months. Once again, this effect was only significant for ACPA-positive RA.
The study was supported by the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, King Gustav V’s 80-Year Foundation, Vinnova, the Swedish Foundation for Strategic Research, the Swedish Rheumatic Foundation, the Stockholm County Council, the Insurance Company AFA, the Innovative Medicines Initiative, and the National Institutes of Health. The authors said that they had no competing interests.
The use of oral contraceptives may be associated with a reduced risk of rheumatoid arthritis based on findings from a large, population-based, case-control study in Sweden.
The lowered risk for rheumatoid arthritis in the study conducted by Cecilia Orellana, PhD, of the Institute of Environmental Medicine at the Karolinska Institute, Stockholm, and her coauthors applied only to patients who tested positive for anticitrullinated protein antibodies (ACPA) and to those who used oral contraceptives for 7 or more years. The investigators also found a significant reduction in RA risk for women who breastfed their children.
“All of these findings together support the notion of RA as two different disease entities with different risk factors patterns,” the authors wrote.
The researchers looked at 2,578 women with RA and 4,129 female controls from the Swedish Epidemiological Investigation of RA study and found that women who had ever used OCs had 13% lower odds of developing RA than did women who had never used OCs, even after adjusting for age, residential area, smoking, and alcohol consumption. However, this association was significant only for ACPA-positive RA – where the risk was 16% lower – and not for ACPA-negative disease (Ann Rheum Dis. 2017 Aug 17. doi: 10.1136/annrheumdis-2017-211620).
Duration of oral contraceptive use was also positively associated with a decreased risk of RA; women who had taken OCs for 7 or more years had a 19% lower risk of RA, compared with never users.
However, the authors noted that they only collected information on the use of OCs as a whole and not on particular preparations or doses.
Women who had never used OCs and who had also smoked had more than twofold higher odds of developing RA than did women who had used OCs and who had never smoked. Women who had used OCs but who also smoked were 71% more likely to develop RA.
“Since both smoking and the use of OC have been linked to an increased predisposition to venous thrombotic events (VTE), women with a history of VTEs (especially if they smoke) might be recommended not to use OC by their physician. We can therefore not exclude the possibility that our findings on an interaction between non-OC use and smoking merely reflects that smoking women, who have an increased RA risk, do not receive OC prescription as often. The physiopathology of RA is complex and not fully understood, but our findings may contribute to the knowledge regarding mechanisms of importance for the development of RA,” the authors wrote.
The investigators also saw an influence of breastfeeding on the likelihood of developing RA, with a significant 23% lower odds for the disease among women who breastfed their children for 13 months or more and 7% lower odds in women who had breastfed their children for 7-12 months, compared with those who had breastfed for 0-6 months. Once again, this effect was only significant for ACPA-positive RA.
The study was supported by the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, King Gustav V’s 80-Year Foundation, Vinnova, the Swedish Foundation for Strategic Research, the Swedish Rheumatic Foundation, the Stockholm County Council, the Insurance Company AFA, the Innovative Medicines Initiative, and the National Institutes of Health. The authors said that they had no competing interests.
The use of oral contraceptives may be associated with a reduced risk of rheumatoid arthritis based on findings from a large, population-based, case-control study in Sweden.
The lowered risk for rheumatoid arthritis in the study conducted by Cecilia Orellana, PhD, of the Institute of Environmental Medicine at the Karolinska Institute, Stockholm, and her coauthors applied only to patients who tested positive for anticitrullinated protein antibodies (ACPA) and to those who used oral contraceptives for 7 or more years. The investigators also found a significant reduction in RA risk for women who breastfed their children.
“All of these findings together support the notion of RA as two different disease entities with different risk factors patterns,” the authors wrote.
The researchers looked at 2,578 women with RA and 4,129 female controls from the Swedish Epidemiological Investigation of RA study and found that women who had ever used OCs had 13% lower odds of developing RA than did women who had never used OCs, even after adjusting for age, residential area, smoking, and alcohol consumption. However, this association was significant only for ACPA-positive RA – where the risk was 16% lower – and not for ACPA-negative disease (Ann Rheum Dis. 2017 Aug 17. doi: 10.1136/annrheumdis-2017-211620).
Duration of oral contraceptive use was also positively associated with a decreased risk of RA; women who had taken OCs for 7 or more years had a 19% lower risk of RA, compared with never users.
However, the authors noted that they only collected information on the use of OCs as a whole and not on particular preparations or doses.
Women who had never used OCs and who had also smoked had more than twofold higher odds of developing RA than did women who had used OCs and who had never smoked. Women who had used OCs but who also smoked were 71% more likely to develop RA.
“Since both smoking and the use of OC have been linked to an increased predisposition to venous thrombotic events (VTE), women with a history of VTEs (especially if they smoke) might be recommended not to use OC by their physician. We can therefore not exclude the possibility that our findings on an interaction between non-OC use and smoking merely reflects that smoking women, who have an increased RA risk, do not receive OC prescription as often. The physiopathology of RA is complex and not fully understood, but our findings may contribute to the knowledge regarding mechanisms of importance for the development of RA,” the authors wrote.
The investigators also saw an influence of breastfeeding on the likelihood of developing RA, with a significant 23% lower odds for the disease among women who breastfed their children for 13 months or more and 7% lower odds in women who had breastfed their children for 7-12 months, compared with those who had breastfed for 0-6 months. Once again, this effect was only significant for ACPA-positive RA.
The study was supported by the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, King Gustav V’s 80-Year Foundation, Vinnova, the Swedish Foundation for Strategic Research, the Swedish Rheumatic Foundation, the Stockholm County Council, the Insurance Company AFA, the Innovative Medicines Initiative, and the National Institutes of Health. The authors said that they had no competing interests.
FROM ANNALS OF THE RHEUMATIC DISEASES
Key clinical point:
Major finding: The odds of ACPA-positive rheumatoid arthritis were 16% lower in women who had ever used oral contraceptives.
Data source: A population-based, case-control study in 2,578 women with rheumatoid arthritis and 4,129 female controls.
Disclosures: The study was supported by the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, King Gustav V’s 80-Year Foundation, Vinnova, the Swedish Foundation for Strategic Research, the Swedish Rheumatic Foundation, the Stockholm County Council, the Insurance Company AFA, the Innovative Medicines Initiative, and the National Institutes of Health. The authors said that they had no competing interests.
U.S. opioid, heroin overdose deaths may be one-fifth higher than reported
Christopher J. Ruhm, PhD, of the University of Virginia, Charlottesville, conducted an analysis using improved estimates of state-level opioid and heroin overdose fatalities during 2014 and of changes over time during 2008-2014. The analysis suggests that, in 2014, national opioid mortality rates were actually 24% greater than reported and that heroin overdose fatality rates were 22% higher than reported (Am J Prev Med. 2017 Aug 7. doi: 10.1016/j.amepre.2017.06.009).
To correct for this, Dr. Ruhm extrapolated the drug category in these unspecified cases by using information from death certificate reports where at least one specific drug category was identified as the cause of death. The variables considered included sex, ethnicity, marital status, education, day of the week indicators, location of death (such as hospital inpatient or ED) or arriving at the hospital already deceased, and interactions among these variables.
“The corrected rates provide the best currently available information on geographic variation in opioid and heroin involved fatality rates,” Dr. Ruhm noted.
The differences between corrected and reported rates of fatal opioid and heroin overdose varied significantly between states; in some cases, the correct rates were more than double the reported rates.
In Pennsylvania, for example, the corrected rates of opioid and heroin overdose fatalities were 108% and 107% greater than the reported rates, respectively; in Mississippi, the corrected rates were 107% and 139% higher than reported. Alabama, Indiana, and Louisiana also showed large disparities between corrected and reported rates.
Dr. Ruhm also noted significant variability between the states in whether a specific drug was mentioned on the death certificate or not. In Rhode Island, Connecticut, and New Hampshire, a drug category was mentioned for more than 99% of drug poisoning deaths; but in Pennsylvania, Indiana, Mississippi, Louisiana, and Alabama, this was reported in only about half of these incidents.
There was a general trend toward underreporting in the South, while rates of nonreporting were lower in parts of the Northeast and the West.
Dr. Ruhm suggested that additional training and standardization could be helpful in states with low specification rates, “particularly because this is a bigger problem when death certificates are completed by coroners rather than medical examiners and in states without centralized oversight.”
Overall, the growth in opioid-involved drug deaths from 2008 to 2014 was similar between the reported and corrected rates. However, in the case of heroin-related mortality, the increase was underestimated by the reported data by about 18%. Again, this difference varied between states, with substantial underestimates seen in Pennsylvania, Indiana, New Jersey, Louisiana, and Alabama.
“Understanding the inaccuracies resulting from the lack of specificity of drug involvement on death certificates is also important because federal policies often target states believed to have especially severe opioid or heroin problems,” Dr. Ruhm explained. “More fundamentally, geographic disparities in drug poisoning deaths are substantial, and a correct assessment of them is almost certainly a prerequisite for designing policies to address the fatal drug epidemic.”
Dr. Ruhm declared no conflicts of interest.
Christopher J. Ruhm, PhD, of the University of Virginia, Charlottesville, conducted an analysis using improved estimates of state-level opioid and heroin overdose fatalities during 2014 and of changes over time during 2008-2014. The analysis suggests that, in 2014, national opioid mortality rates were actually 24% greater than reported and that heroin overdose fatality rates were 22% higher than reported (Am J Prev Med. 2017 Aug 7. doi: 10.1016/j.amepre.2017.06.009).
To correct for this, Dr. Ruhm extrapolated the drug category in these unspecified cases by using information from death certificate reports where at least one specific drug category was identified as the cause of death. The variables considered included sex, ethnicity, marital status, education, day of the week indicators, location of death (such as hospital inpatient or ED) or arriving at the hospital already deceased, and interactions among these variables.
“The corrected rates provide the best currently available information on geographic variation in opioid and heroin involved fatality rates,” Dr. Ruhm noted.
The differences between corrected and reported rates of fatal opioid and heroin overdose varied significantly between states; in some cases, the correct rates were more than double the reported rates.
In Pennsylvania, for example, the corrected rates of opioid and heroin overdose fatalities were 108% and 107% greater than the reported rates, respectively; in Mississippi, the corrected rates were 107% and 139% higher than reported. Alabama, Indiana, and Louisiana also showed large disparities between corrected and reported rates.
Dr. Ruhm also noted significant variability between the states in whether a specific drug was mentioned on the death certificate or not. In Rhode Island, Connecticut, and New Hampshire, a drug category was mentioned for more than 99% of drug poisoning deaths; but in Pennsylvania, Indiana, Mississippi, Louisiana, and Alabama, this was reported in only about half of these incidents.
There was a general trend toward underreporting in the South, while rates of nonreporting were lower in parts of the Northeast and the West.
Dr. Ruhm suggested that additional training and standardization could be helpful in states with low specification rates, “particularly because this is a bigger problem when death certificates are completed by coroners rather than medical examiners and in states without centralized oversight.”
Overall, the growth in opioid-involved drug deaths from 2008 to 2014 was similar between the reported and corrected rates. However, in the case of heroin-related mortality, the increase was underestimated by the reported data by about 18%. Again, this difference varied between states, with substantial underestimates seen in Pennsylvania, Indiana, New Jersey, Louisiana, and Alabama.
“Understanding the inaccuracies resulting from the lack of specificity of drug involvement on death certificates is also important because federal policies often target states believed to have especially severe opioid or heroin problems,” Dr. Ruhm explained. “More fundamentally, geographic disparities in drug poisoning deaths are substantial, and a correct assessment of them is almost certainly a prerequisite for designing policies to address the fatal drug epidemic.”
Dr. Ruhm declared no conflicts of interest.
Christopher J. Ruhm, PhD, of the University of Virginia, Charlottesville, conducted an analysis using improved estimates of state-level opioid and heroin overdose fatalities during 2014 and of changes over time during 2008-2014. The analysis suggests that, in 2014, national opioid mortality rates were actually 24% greater than reported and that heroin overdose fatality rates were 22% higher than reported (Am J Prev Med. 2017 Aug 7. doi: 10.1016/j.amepre.2017.06.009).
To correct for this, Dr. Ruhm extrapolated the drug category in these unspecified cases by using information from death certificate reports where at least one specific drug category was identified as the cause of death. The variables considered included sex, ethnicity, marital status, education, day of the week indicators, location of death (such as hospital inpatient or ED) or arriving at the hospital already deceased, and interactions among these variables.
“The corrected rates provide the best currently available information on geographic variation in opioid and heroin involved fatality rates,” Dr. Ruhm noted.
The differences between corrected and reported rates of fatal opioid and heroin overdose varied significantly between states; in some cases, the correct rates were more than double the reported rates.
In Pennsylvania, for example, the corrected rates of opioid and heroin overdose fatalities were 108% and 107% greater than the reported rates, respectively; in Mississippi, the corrected rates were 107% and 139% higher than reported. Alabama, Indiana, and Louisiana also showed large disparities between corrected and reported rates.
Dr. Ruhm also noted significant variability between the states in whether a specific drug was mentioned on the death certificate or not. In Rhode Island, Connecticut, and New Hampshire, a drug category was mentioned for more than 99% of drug poisoning deaths; but in Pennsylvania, Indiana, Mississippi, Louisiana, and Alabama, this was reported in only about half of these incidents.
There was a general trend toward underreporting in the South, while rates of nonreporting were lower in parts of the Northeast and the West.
Dr. Ruhm suggested that additional training and standardization could be helpful in states with low specification rates, “particularly because this is a bigger problem when death certificates are completed by coroners rather than medical examiners and in states without centralized oversight.”
Overall, the growth in opioid-involved drug deaths from 2008 to 2014 was similar between the reported and corrected rates. However, in the case of heroin-related mortality, the increase was underestimated by the reported data by about 18%. Again, this difference varied between states, with substantial underestimates seen in Pennsylvania, Indiana, New Jersey, Louisiana, and Alabama.
“Understanding the inaccuracies resulting from the lack of specificity of drug involvement on death certificates is also important because federal policies often target states believed to have especially severe opioid or heroin problems,” Dr. Ruhm explained. “More fundamentally, geographic disparities in drug poisoning deaths are substantial, and a correct assessment of them is almost certainly a prerequisite for designing policies to address the fatal drug epidemic.”
Dr. Ruhm declared no conflicts of interest.
FROM THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE
Key clinical point: Death certificates for drug overdose that fail to specify the drug ivolved may be responsible for a significant underestimation of opioid and heroin fatality rates in the United States.
Major finding: In 2014, national opioid mortality rates were actually 24% greater than reported, and heroin overdose fatality rates were 22% higher than reported.
Data source: Analysis using improved estimates of state-level opioid and heroin overdose fatalities during 2014 and of changes over time during 2008-2014.
Disclosures: No conflicts of interest were declared.
Pediatric version of SOFA effective
An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.
Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.
“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.
Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).
“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.
In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO2:FiO2 ratio as an alternative surrogate of lung injury.
The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.
Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.
The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.
Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.
Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.
The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.
“In addition, the respiratory subscore criteria – based on the ratio of PaO2 to the fraction of inspired oxygen (FiO2) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.
“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.
They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.
No conflicts of interest were reported.
An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.
Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.
“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.
Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).
“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.
In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO2:FiO2 ratio as an alternative surrogate of lung injury.
The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.
Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.
The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.
Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.
Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.
The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.
“In addition, the respiratory subscore criteria – based on the ratio of PaO2 to the fraction of inspired oxygen (FiO2) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.
“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.
They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.
No conflicts of interest were reported.
An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.
Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.
“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.
Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).
“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.
In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO2:FiO2 ratio as an alternative surrogate of lung injury.
The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.
Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.
The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.
Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.
Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.
The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.
“In addition, the respiratory subscore criteria – based on the ratio of PaO2 to the fraction of inspired oxygen (FiO2) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.
“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.
They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.
No conflicts of interest were reported.
FROM JAMA PEDIATRICS
Key clinical point: A pediatric version of the Sequential Organ Failure Assessment score for sepsis can discriminate in-hospital mortality in critically ill children.
Major finding: An age-adjusted version of the SOFA score for sepsis has found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.
Data source: A retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger.
Disclosures: No conflicts of interest were declared.
Manage headache separately from idiopathic intracranial hypertension
Headache in idiopathic intracranial hypertension appears to be clinically independent of raised intracranial pressure and may require a different treatment approach than simply lowering intracranial pressure, say the authors of a study published online July 28 in Headache.
The researchers looked at data from 165 patients with untreated idiopathic intracranial hypertension (IIH) and mild vision loss, who were randomized to weight loss plus acetazolamide or placebo as part of the Idiopathic Intracranial Hypertension Treatment Trial.
In the 139 patients who had headaches at baseline, the researchers saw no significant correlation between lumbar puncture opening pressure – which was measured at baseline and 6 months – and Headache Impact Test-6 scores, or with the presence or absence of headache (Headache. 2017 Jul 28. doi: 10.1111/head.13153).
The study also failed to show any significant difference in headache outcomes between the acetazolamide and placebo groups at 6 months, although headaches in both groups improved overall during the course of the study.
“A substantial proportion of participants had severe headaches at 6 months, stressing the importance of incorporating other headache treatments,” the authors wrote. “These data support the view that additional treatments beyond those used to lower intracranial pressure are needed to treat the headaches associated with IIH.”
At baseline, participants with headache reported taking a range of symptomatic headache treatments including acetaminophen, ibuprofen, naproxen, and combination medications. Some also reported taking hydrocodone, tramadol, or combination formulations containing codeine.
More than one-third (37%) of the participants were assessed as overusing symptomatic pain medications, and 15 of these met the criteria for overuse of opioids or combination medications. Researchers noted that the mean Headache Impact Test-6 scores were significantly higher in those who were overusing medications, compared with those who weren’t.
The most common headache phenotype was migraine (52%), followed by tension-type headache (22%), probable migraine (16%), and probable tension-type headache (4%), with 7% unclassified.
Patients with headache also experienced associated symptoms such as photophobia, phonophobia, nausea, vomiting, visual loss or obscurations, diplopia, and dizziness.
The study was funded by the National Eye Institute. No conflicts of interest were declared.
Headache in idiopathic intracranial hypertension appears to be clinically independent of raised intracranial pressure and may require a different treatment approach than simply lowering intracranial pressure, say the authors of a study published online July 28 in Headache.
The researchers looked at data from 165 patients with untreated idiopathic intracranial hypertension (IIH) and mild vision loss, who were randomized to weight loss plus acetazolamide or placebo as part of the Idiopathic Intracranial Hypertension Treatment Trial.
In the 139 patients who had headaches at baseline, the researchers saw no significant correlation between lumbar puncture opening pressure – which was measured at baseline and 6 months – and Headache Impact Test-6 scores, or with the presence or absence of headache (Headache. 2017 Jul 28. doi: 10.1111/head.13153).
The study also failed to show any significant difference in headache outcomes between the acetazolamide and placebo groups at 6 months, although headaches in both groups improved overall during the course of the study.
“A substantial proportion of participants had severe headaches at 6 months, stressing the importance of incorporating other headache treatments,” the authors wrote. “These data support the view that additional treatments beyond those used to lower intracranial pressure are needed to treat the headaches associated with IIH.”
At baseline, participants with headache reported taking a range of symptomatic headache treatments including acetaminophen, ibuprofen, naproxen, and combination medications. Some also reported taking hydrocodone, tramadol, or combination formulations containing codeine.
More than one-third (37%) of the participants were assessed as overusing symptomatic pain medications, and 15 of these met the criteria for overuse of opioids or combination medications. Researchers noted that the mean Headache Impact Test-6 scores were significantly higher in those who were overusing medications, compared with those who weren’t.
The most common headache phenotype was migraine (52%), followed by tension-type headache (22%), probable migraine (16%), and probable tension-type headache (4%), with 7% unclassified.
Patients with headache also experienced associated symptoms such as photophobia, phonophobia, nausea, vomiting, visual loss or obscurations, diplopia, and dizziness.
The study was funded by the National Eye Institute. No conflicts of interest were declared.
Headache in idiopathic intracranial hypertension appears to be clinically independent of raised intracranial pressure and may require a different treatment approach than simply lowering intracranial pressure, say the authors of a study published online July 28 in Headache.
The researchers looked at data from 165 patients with untreated idiopathic intracranial hypertension (IIH) and mild vision loss, who were randomized to weight loss plus acetazolamide or placebo as part of the Idiopathic Intracranial Hypertension Treatment Trial.
In the 139 patients who had headaches at baseline, the researchers saw no significant correlation between lumbar puncture opening pressure – which was measured at baseline and 6 months – and Headache Impact Test-6 scores, or with the presence or absence of headache (Headache. 2017 Jul 28. doi: 10.1111/head.13153).
The study also failed to show any significant difference in headache outcomes between the acetazolamide and placebo groups at 6 months, although headaches in both groups improved overall during the course of the study.
“A substantial proportion of participants had severe headaches at 6 months, stressing the importance of incorporating other headache treatments,” the authors wrote. “These data support the view that additional treatments beyond those used to lower intracranial pressure are needed to treat the headaches associated with IIH.”
At baseline, participants with headache reported taking a range of symptomatic headache treatments including acetaminophen, ibuprofen, naproxen, and combination medications. Some also reported taking hydrocodone, tramadol, or combination formulations containing codeine.
More than one-third (37%) of the participants were assessed as overusing symptomatic pain medications, and 15 of these met the criteria for overuse of opioids or combination medications. Researchers noted that the mean Headache Impact Test-6 scores were significantly higher in those who were overusing medications, compared with those who weren’t.
The most common headache phenotype was migraine (52%), followed by tension-type headache (22%), probable migraine (16%), and probable tension-type headache (4%), with 7% unclassified.
Patients with headache also experienced associated symptoms such as photophobia, phonophobia, nausea, vomiting, visual loss or obscurations, diplopia, and dizziness.
The study was funded by the National Eye Institute. No conflicts of interest were declared.
FROM HEADACHE
Key clinical point: and may require a different treatment approach.
Major finding: There were no significant differences in lumbar puncture opening pressure between patients with and without headache.
Data source: A subanalysis of 139 patients with headaches at baseline in addition to idiopathic intracranial hypertension and mild vision loss in the Idiopathic Intracranial Hypertension Treatment Trial.
Disclosures: The study was funded by the National Eye Institute. No conflicts of interest were declared.
First trimester antibiotics may increase birth defect risk
Exposure to clindamycin and doxycycline during the first trimester may be associated with an increased risk of organ-specific malformations such as ventricular/atrial septal defect, new research suggests.
In a population-based cohort study in 139,938 liveborn singletons, there was an 81% increased risk of ventricular/septal defect (adjusted odds ratio, 1.81) associated with clindamycin exposure during the first trimester, compared with no exposure. Similarly, there was a 67% greater risk of musculoskeletal system malformations (aOR, 1.67) associated with clindamycin exposure (Br J Clin Pharmacol. 2017 Jul 19. doi: 10.1111/bcp.13364).
Doxycycline exposure was associated with a greater than threefold increased risk of ventricular/atrial septal defect (aOR, 3.19), and greater than twofold increase in the risk of circulatory system malformation (aOR, 2.38) and cardiac malformations (aOR, 2.46).
The study also found a 46% higher risk of digestive system malformations associated with macrolide exposure (aOR, 1.46), while quinolone exposure was associated with an 89% higher risk of urinary system malformations (aOR, 1.89).
“There is currently a debate on a possible association between macrolide use and infantile pyloric stenosis,” the researchers wrote. “Though evidence suggested that late pregnancy and early infancy were the time windows of interest for this malformation, little attention has been paid to the first trimester of pregnancy.”
Phenoxymethylpenicillin exposure was associated with a 85% increased risk of nervous system malformations (aOR, 1.85), and erythromycin exposure doubled the risk of urinary system malformations (aOR, 2.12). Moxifloxacin exposure was associated with a fivefold increased risk of respiratory system malformations (aOR, 5.48), but the authors noted that there were just two exposed cases.
However, there was no increased risk for major congenital malformation seen with amoxicillin, cephalosporins, and nitrofurantoin.
Overall, 11% of pregnancies in the study recorded exposure to antibiotics during the first trimester, and 9.9% of the study population were diagnosed with a major congenital malformation in the first year of life.
“Though the absolute risks for specific birth defects was small, physicians should consider prescribing safer antibiotics for the treatment of maternal infections when possible until more data are available,” the researchers wrote.
The study was supported by the Réseau Québécois. One author reported being a consultant on litigation involving antidepressants and birth defects. No other conflicts of interest were declared.
Exposure to clindamycin and doxycycline during the first trimester may be associated with an increased risk of organ-specific malformations such as ventricular/atrial septal defect, new research suggests.
In a population-based cohort study in 139,938 liveborn singletons, there was an 81% increased risk of ventricular/septal defect (adjusted odds ratio, 1.81) associated with clindamycin exposure during the first trimester, compared with no exposure. Similarly, there was a 67% greater risk of musculoskeletal system malformations (aOR, 1.67) associated with clindamycin exposure (Br J Clin Pharmacol. 2017 Jul 19. doi: 10.1111/bcp.13364).
Doxycycline exposure was associated with a greater than threefold increased risk of ventricular/atrial septal defect (aOR, 3.19), and greater than twofold increase in the risk of circulatory system malformation (aOR, 2.38) and cardiac malformations (aOR, 2.46).
The study also found a 46% higher risk of digestive system malformations associated with macrolide exposure (aOR, 1.46), while quinolone exposure was associated with an 89% higher risk of urinary system malformations (aOR, 1.89).
“There is currently a debate on a possible association between macrolide use and infantile pyloric stenosis,” the researchers wrote. “Though evidence suggested that late pregnancy and early infancy were the time windows of interest for this malformation, little attention has been paid to the first trimester of pregnancy.”
Phenoxymethylpenicillin exposure was associated with a 85% increased risk of nervous system malformations (aOR, 1.85), and erythromycin exposure doubled the risk of urinary system malformations (aOR, 2.12). Moxifloxacin exposure was associated with a fivefold increased risk of respiratory system malformations (aOR, 5.48), but the authors noted that there were just two exposed cases.
However, there was no increased risk for major congenital malformation seen with amoxicillin, cephalosporins, and nitrofurantoin.
Overall, 11% of pregnancies in the study recorded exposure to antibiotics during the first trimester, and 9.9% of the study population were diagnosed with a major congenital malformation in the first year of life.
“Though the absolute risks for specific birth defects was small, physicians should consider prescribing safer antibiotics for the treatment of maternal infections when possible until more data are available,” the researchers wrote.
The study was supported by the Réseau Québécois. One author reported being a consultant on litigation involving antidepressants and birth defects. No other conflicts of interest were declared.
Exposure to clindamycin and doxycycline during the first trimester may be associated with an increased risk of organ-specific malformations such as ventricular/atrial septal defect, new research suggests.
In a population-based cohort study in 139,938 liveborn singletons, there was an 81% increased risk of ventricular/septal defect (adjusted odds ratio, 1.81) associated with clindamycin exposure during the first trimester, compared with no exposure. Similarly, there was a 67% greater risk of musculoskeletal system malformations (aOR, 1.67) associated with clindamycin exposure (Br J Clin Pharmacol. 2017 Jul 19. doi: 10.1111/bcp.13364).
Doxycycline exposure was associated with a greater than threefold increased risk of ventricular/atrial septal defect (aOR, 3.19), and greater than twofold increase in the risk of circulatory system malformation (aOR, 2.38) and cardiac malformations (aOR, 2.46).
The study also found a 46% higher risk of digestive system malformations associated with macrolide exposure (aOR, 1.46), while quinolone exposure was associated with an 89% higher risk of urinary system malformations (aOR, 1.89).
“There is currently a debate on a possible association between macrolide use and infantile pyloric stenosis,” the researchers wrote. “Though evidence suggested that late pregnancy and early infancy were the time windows of interest for this malformation, little attention has been paid to the first trimester of pregnancy.”
Phenoxymethylpenicillin exposure was associated with a 85% increased risk of nervous system malformations (aOR, 1.85), and erythromycin exposure doubled the risk of urinary system malformations (aOR, 2.12). Moxifloxacin exposure was associated with a fivefold increased risk of respiratory system malformations (aOR, 5.48), but the authors noted that there were just two exposed cases.
However, there was no increased risk for major congenital malformation seen with amoxicillin, cephalosporins, and nitrofurantoin.
Overall, 11% of pregnancies in the study recorded exposure to antibiotics during the first trimester, and 9.9% of the study population were diagnosed with a major congenital malformation in the first year of life.
“Though the absolute risks for specific birth defects was small, physicians should consider prescribing safer antibiotics for the treatment of maternal infections when possible until more data are available,” the researchers wrote.
The study was supported by the Réseau Québécois. One author reported being a consultant on litigation involving antidepressants and birth defects. No other conflicts of interest were declared.
FROM THE BRITISH JOURNAL OF CLINICAL PHARMACOLOGY
Key clinical point:
Major finding: Clindamycin exposure during the first trimester is associated with an 81% increased risk of ventricular/septal defect and 67% greater risk of musculoskeletal system malformations.
Data source: Population-based cohort study in 139,938 liveborn singletons.
Disclosures: The study was supported by the Réseau Québécois. One author reported being a consultant on litigation involving antidepressants and birth defects. No other conflicts of interest were declared.
Better bariatric surgery outcomes with lower preoperative BMI
Delaying bariatric surgery until body mass index is highly elevated may reduce the likelihood of achieving a BMI of less than 30 within a year, according toa paper published online July 26 in JAMA Surgery.
A retrospective study using prospectively gathered clinical data of 27,320 adults who underwent bariatric surgery in Michigan showed around one in three (36%) achieved a BMI below 30 within a year after surgery (JAMA Surgery 2017, July 26. doi: 10.1001/jamasurg.2017.2348). But obese patients with a body mass index of less than 40 kg/m2 before undergoing bariatric surgery are significantly more likely to achieve a postoperative BMI of under 30.
Individuals who had a preoperative BMI of less than 40 had a 12-fold higher chance of getting their BMI below 30, compared to those whose preoperative BMI was 40 or above (95% confidence interval 1.71-14.16, P less than .001). Only 8.5% of individuals with a BMI at or above 50 achieved a postoperative BMI below 30.
The likelihood of getting below 30 within a year was eightfold higher in patients who had a sleeve gastrectomy, 21 times greater in those who underwent Roux-en-Y bypass, and 82 times higher in those who had a duodenal switch, compared with patients who had adjustable gastric banding (P less than .001).
The researchers also compared other outcomes in individuals whose BMI dropped below 30 and in those who did not achieve this degree of weight loss. The analysis showed that those with a BMI below 30 after 1 year had at least a twofold greater chance of discontinuing cholesterol-lowering medications, insulin, diabetes medications, antihypertensives, and CPAP for sleep apnea, compared with those whose BMI remained at 30 or above. They were also more than three times more likely to report being ‘very satisfied’ with the outcomes of surgery.
The authors noted that the cohort’s mean BMI was 48, which was above the established threshold for bariatric surgery, namely a BMI of 40, or 35 with weight-related comorbidities.
“Our results suggest that patients with morbid obesity should be targeted for surgery when their BMI is still less than 40, as these patients are more likely to achieve a target BMI that results in substantial reduction in weight-related comorbidities,” the authors wrote.
However, they stressed that their findings should not be taken as a reason to exclude patients with a BMI above 40 from surgery, pointing out that even for patients with higher preoperative BMIs, bariatric surgery offered substantial health and quality of life benefits.
They also acknowledged that 1-year weight data was available for around 50% of patients in the registry, which may have led to selection bias.
“Policies and practice patterns that delay or incentivize patients to pursue bariatric surgery only once the BMI is highly elevated can result in inferior outcomes,” the investigators concluded.
Blue Cross Blue Shield of Michigan/Blue Care Network funded the study. Three authors had received salary support from Blue Cross Blue Shield. No other conflicts of interest were declared.
Patients with obesity need a multidisciplinary approach to achieve a healthy weight, and AGA believes that gastroenterologists are in a unique position to lead the care team.
To provide gastroenterologists with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management, including a model for how to operationalize business issues, AGA has created an Obesity Practice Guide. The program includes an obesity program to help gastroenterologists manage their patients with obesity, as well as a framework focused on the business operational issues related to the management of obese patients. Learn more at www.gastro.org/obesity.
The authors’ conclusion that bariatric surgery should be more liberally applied to patients with less severe obesity is consistent with multiple reports of improved control of type 2 diabetes, if not remission, among lower-BMI patient populations following MBS [metabolic and bariatric surgery]. However, these reports generally do not refute the importance of weight loss in achieving important clinical benefit among patients with obesity-related comorbid disease.
One strength of the present study is that it is a clinical database. However, 50% attrition of the follow-up weight loss data at 1 year is potentially problematic.
Bruce M. Wolfe, MD, FACS, and Elizaveta Walker, MPH, are in the division of bariatric surgery, department of surgery, at Oregon Health & Science University, Portland. These comments are taken from an accompanying editorial (JAMA Surgery 2017 Jul 26. doi: 10.1001/jamasurg.2017.2349). No conflicts of interest were declared.
The authors’ conclusion that bariatric surgery should be more liberally applied to patients with less severe obesity is consistent with multiple reports of improved control of type 2 diabetes, if not remission, among lower-BMI patient populations following MBS [metabolic and bariatric surgery]. However, these reports generally do not refute the importance of weight loss in achieving important clinical benefit among patients with obesity-related comorbid disease.
One strength of the present study is that it is a clinical database. However, 50% attrition of the follow-up weight loss data at 1 year is potentially problematic.
Bruce M. Wolfe, MD, FACS, and Elizaveta Walker, MPH, are in the division of bariatric surgery, department of surgery, at Oregon Health & Science University, Portland. These comments are taken from an accompanying editorial (JAMA Surgery 2017 Jul 26. doi: 10.1001/jamasurg.2017.2349). No conflicts of interest were declared.
The authors’ conclusion that bariatric surgery should be more liberally applied to patients with less severe obesity is consistent with multiple reports of improved control of type 2 diabetes, if not remission, among lower-BMI patient populations following MBS [metabolic and bariatric surgery]. However, these reports generally do not refute the importance of weight loss in achieving important clinical benefit among patients with obesity-related comorbid disease.
One strength of the present study is that it is a clinical database. However, 50% attrition of the follow-up weight loss data at 1 year is potentially problematic.
Bruce M. Wolfe, MD, FACS, and Elizaveta Walker, MPH, are in the division of bariatric surgery, department of surgery, at Oregon Health & Science University, Portland. These comments are taken from an accompanying editorial (JAMA Surgery 2017 Jul 26. doi: 10.1001/jamasurg.2017.2349). No conflicts of interest were declared.
Delaying bariatric surgery until body mass index is highly elevated may reduce the likelihood of achieving a BMI of less than 30 within a year, according toa paper published online July 26 in JAMA Surgery.
A retrospective study using prospectively gathered clinical data of 27,320 adults who underwent bariatric surgery in Michigan showed around one in three (36%) achieved a BMI below 30 within a year after surgery (JAMA Surgery 2017, July 26. doi: 10.1001/jamasurg.2017.2348). But obese patients with a body mass index of less than 40 kg/m2 before undergoing bariatric surgery are significantly more likely to achieve a postoperative BMI of under 30.
Individuals who had a preoperative BMI of less than 40 had a 12-fold higher chance of getting their BMI below 30, compared to those whose preoperative BMI was 40 or above (95% confidence interval 1.71-14.16, P less than .001). Only 8.5% of individuals with a BMI at or above 50 achieved a postoperative BMI below 30.
The likelihood of getting below 30 within a year was eightfold higher in patients who had a sleeve gastrectomy, 21 times greater in those who underwent Roux-en-Y bypass, and 82 times higher in those who had a duodenal switch, compared with patients who had adjustable gastric banding (P less than .001).
The researchers also compared other outcomes in individuals whose BMI dropped below 30 and in those who did not achieve this degree of weight loss. The analysis showed that those with a BMI below 30 after 1 year had at least a twofold greater chance of discontinuing cholesterol-lowering medications, insulin, diabetes medications, antihypertensives, and CPAP for sleep apnea, compared with those whose BMI remained at 30 or above. They were also more than three times more likely to report being ‘very satisfied’ with the outcomes of surgery.
The authors noted that the cohort’s mean BMI was 48, which was above the established threshold for bariatric surgery, namely a BMI of 40, or 35 with weight-related comorbidities.
“Our results suggest that patients with morbid obesity should be targeted for surgery when their BMI is still less than 40, as these patients are more likely to achieve a target BMI that results in substantial reduction in weight-related comorbidities,” the authors wrote.
However, they stressed that their findings should not be taken as a reason to exclude patients with a BMI above 40 from surgery, pointing out that even for patients with higher preoperative BMIs, bariatric surgery offered substantial health and quality of life benefits.
They also acknowledged that 1-year weight data was available for around 50% of patients in the registry, which may have led to selection bias.
“Policies and practice patterns that delay or incentivize patients to pursue bariatric surgery only once the BMI is highly elevated can result in inferior outcomes,” the investigators concluded.
Blue Cross Blue Shield of Michigan/Blue Care Network funded the study. Three authors had received salary support from Blue Cross Blue Shield. No other conflicts of interest were declared.
Patients with obesity need a multidisciplinary approach to achieve a healthy weight, and AGA believes that gastroenterologists are in a unique position to lead the care team.
To provide gastroenterologists with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management, including a model for how to operationalize business issues, AGA has created an Obesity Practice Guide. The program includes an obesity program to help gastroenterologists manage their patients with obesity, as well as a framework focused on the business operational issues related to the management of obese patients. Learn more at www.gastro.org/obesity.
Delaying bariatric surgery until body mass index is highly elevated may reduce the likelihood of achieving a BMI of less than 30 within a year, according toa paper published online July 26 in JAMA Surgery.
A retrospective study using prospectively gathered clinical data of 27,320 adults who underwent bariatric surgery in Michigan showed around one in three (36%) achieved a BMI below 30 within a year after surgery (JAMA Surgery 2017, July 26. doi: 10.1001/jamasurg.2017.2348). But obese patients with a body mass index of less than 40 kg/m2 before undergoing bariatric surgery are significantly more likely to achieve a postoperative BMI of under 30.
Individuals who had a preoperative BMI of less than 40 had a 12-fold higher chance of getting their BMI below 30, compared to those whose preoperative BMI was 40 or above (95% confidence interval 1.71-14.16, P less than .001). Only 8.5% of individuals with a BMI at or above 50 achieved a postoperative BMI below 30.
The likelihood of getting below 30 within a year was eightfold higher in patients who had a sleeve gastrectomy, 21 times greater in those who underwent Roux-en-Y bypass, and 82 times higher in those who had a duodenal switch, compared with patients who had adjustable gastric banding (P less than .001).
The researchers also compared other outcomes in individuals whose BMI dropped below 30 and in those who did not achieve this degree of weight loss. The analysis showed that those with a BMI below 30 after 1 year had at least a twofold greater chance of discontinuing cholesterol-lowering medications, insulin, diabetes medications, antihypertensives, and CPAP for sleep apnea, compared with those whose BMI remained at 30 or above. They were also more than three times more likely to report being ‘very satisfied’ with the outcomes of surgery.
The authors noted that the cohort’s mean BMI was 48, which was above the established threshold for bariatric surgery, namely a BMI of 40, or 35 with weight-related comorbidities.
“Our results suggest that patients with morbid obesity should be targeted for surgery when their BMI is still less than 40, as these patients are more likely to achieve a target BMI that results in substantial reduction in weight-related comorbidities,” the authors wrote.
However, they stressed that their findings should not be taken as a reason to exclude patients with a BMI above 40 from surgery, pointing out that even for patients with higher preoperative BMIs, bariatric surgery offered substantial health and quality of life benefits.
They also acknowledged that 1-year weight data was available for around 50% of patients in the registry, which may have led to selection bias.
“Policies and practice patterns that delay or incentivize patients to pursue bariatric surgery only once the BMI is highly elevated can result in inferior outcomes,” the investigators concluded.
Blue Cross Blue Shield of Michigan/Blue Care Network funded the study. Three authors had received salary support from Blue Cross Blue Shield. No other conflicts of interest were declared.
Patients with obesity need a multidisciplinary approach to achieve a healthy weight, and AGA believes that gastroenterologists are in a unique position to lead the care team.
To provide gastroenterologists with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management, including a model for how to operationalize business issues, AGA has created an Obesity Practice Guide. The program includes an obesity program to help gastroenterologists manage their patients with obesity, as well as a framework focused on the business operational issues related to the management of obese patients. Learn more at www.gastro.org/obesity.
FROM JAMA SURGERY
Key clinical point: A BMI below 40 prior to undergoing bariatric surgery gives patients a significantly better chance of achieving a 1-year postoperative BMI under 30.
Major finding: Obese patients with a BMI less than 40 before undergoing bariatric surgery are more than 12 times more likely to achieve a postoperative BMI of under 30.
Data source: A retrospective study using prospectively gathered clinical data of 27, 320 adults who underwent bariatric surgery.
Disclosures: Blue Cross Blue Shield of Michigan/Blue Care Network funded the study. Three authors had received salary support from Blue Cross Blue Shield. No other conflicts of interest were declared.
Better bariatric surgery outcomes with lower preoperative BMI
Delaying bariatric surgery until body mass index is highly elevated may reduce the likelihood of achieving a BMI of less than 30 within a year, according to a paper published online July 26 in JAMA Surgery.
A retrospective study using prospectively gathered clinical data of 27,320 adults who underwent bariatric surgery in Michigan showed around one in three (36%) achieved a BMI below 30 within a year after surgery (JAMA Surgery 2017, July 26. doi: 10.1001/jamasurg.2017.2348). But obese patients with a body mass index of less than 40 kg/m2 before undergoing bariatric surgery are significantly more likely to achieve a postoperative BMI of under 30.
Individuals who had a preoperative BMI of less than 40 had a 12-fold higher chance of getting their BMI below 30, compared to those whose preoperative BMI was 40 or above (95% confidence interval 1.71-14.16, P less than .001). Only 8.5% of individuals with a BMI at or above 50 achieved a postoperative BMI below 30.
The likelihood of getting below 30 within a year was eightfold higher in patients who had a sleeve gastrectomy, 21 times greater in those who underwent Roux-en-Y bypass, and 82 times higher in those who had a duodenal switch, compared with patients who had adjustable gastric banding (P less than .001).
The researchers also compared other outcomes in individuals whose BMI dropped below 30 and in those who did not achieve this degree of weight loss. The analysis showed that those with a BMI below 30 after 1 year had at least a twofold greater chance of discontinuing cholesterol-lowering medications, insulin, diabetes medications, antihypertensives, and CPAP for sleep apnea, compared with those whose BMI remained at 30 or above. They were also more than three times more likely to report being ‘very satisfied’ with the outcomes of surgery.
The authors noted that the cohort’s mean BMI was 48, which was above the established threshold for bariatric surgery, namely a BMI of 40, or 35 with weight-related comorbidities.
“Our results suggest that patients with morbid obesity should be targeted for surgery when their BMI is still less than 40, as these patients are more likely to achieve a target BMI that results in substantial reduction in weight-related comorbidities,” the authors wrote.
However, they stressed that their findings should not be taken as a reason to exclude patients with a BMI above 40 from surgery, pointing out that even for patients with higher preoperative BMIs, bariatric surgery offered substantial health and quality of life benefits.
They also acknowledged that 1-year weight data was available for around 50% of patients in the registry, which may have led to selection bias.
“Policies and practice patterns that delay or incentivize patients to pursue bariatric surgery only once the BMI is highly elevated can result in inferior outcomes,” the investigators concluded.
Blue Cross Blue Shield of Michigan/Blue Care Network funded the study. Three authors had received salary support from Blue Cross Blue Shield. No other conflicts of interest were declared.
The authors’ conclusion that bariatric surgery should be more liberally applied to patients with less severe obesity is consistent with multiple reports of improved control of type 2 diabetes, if not remission, among lower-BMI patient populations following MBS [metabolic and bariatric surgery]. However, these reports generally do not refute the importance of weight loss in achieving important clinical benefit among patients with obesity-related comorbid disease.
One strength of the present study is that it is a clinical database. However, 50% attrition of the follow-up weight loss data at 1 year is potentially problematic.
Bruce M. Wolfe, MD, FACS, and Elizaveta Walker, MPH, are in the division of bariatric surgery, department of surgery, at Oregon Health & Science University, Portland. These comments are taken from an accompanying editorial (JAMA Surgery 2017 Jul 26. doi: 10.1001/jamasurg.2017.2349). No conflicts of interest were declared.
The authors’ conclusion that bariatric surgery should be more liberally applied to patients with less severe obesity is consistent with multiple reports of improved control of type 2 diabetes, if not remission, among lower-BMI patient populations following MBS [metabolic and bariatric surgery]. However, these reports generally do not refute the importance of weight loss in achieving important clinical benefit among patients with obesity-related comorbid disease.
One strength of the present study is that it is a clinical database. However, 50% attrition of the follow-up weight loss data at 1 year is potentially problematic.
Bruce M. Wolfe, MD, FACS, and Elizaveta Walker, MPH, are in the division of bariatric surgery, department of surgery, at Oregon Health & Science University, Portland. These comments are taken from an accompanying editorial (JAMA Surgery 2017 Jul 26. doi: 10.1001/jamasurg.2017.2349). No conflicts of interest were declared.
The authors’ conclusion that bariatric surgery should be more liberally applied to patients with less severe obesity is consistent with multiple reports of improved control of type 2 diabetes, if not remission, among lower-BMI patient populations following MBS [metabolic and bariatric surgery]. However, these reports generally do not refute the importance of weight loss in achieving important clinical benefit among patients with obesity-related comorbid disease.
One strength of the present study is that it is a clinical database. However, 50% attrition of the follow-up weight loss data at 1 year is potentially problematic.
Bruce M. Wolfe, MD, FACS, and Elizaveta Walker, MPH, are in the division of bariatric surgery, department of surgery, at Oregon Health & Science University, Portland. These comments are taken from an accompanying editorial (JAMA Surgery 2017 Jul 26. doi: 10.1001/jamasurg.2017.2349). No conflicts of interest were declared.
Delaying bariatric surgery until body mass index is highly elevated may reduce the likelihood of achieving a BMI of less than 30 within a year, according to a paper published online July 26 in JAMA Surgery.
A retrospective study using prospectively gathered clinical data of 27,320 adults who underwent bariatric surgery in Michigan showed around one in three (36%) achieved a BMI below 30 within a year after surgery (JAMA Surgery 2017, July 26. doi: 10.1001/jamasurg.2017.2348). But obese patients with a body mass index of less than 40 kg/m2 before undergoing bariatric surgery are significantly more likely to achieve a postoperative BMI of under 30.
Individuals who had a preoperative BMI of less than 40 had a 12-fold higher chance of getting their BMI below 30, compared to those whose preoperative BMI was 40 or above (95% confidence interval 1.71-14.16, P less than .001). Only 8.5% of individuals with a BMI at or above 50 achieved a postoperative BMI below 30.
The likelihood of getting below 30 within a year was eightfold higher in patients who had a sleeve gastrectomy, 21 times greater in those who underwent Roux-en-Y bypass, and 82 times higher in those who had a duodenal switch, compared with patients who had adjustable gastric banding (P less than .001).
The researchers also compared other outcomes in individuals whose BMI dropped below 30 and in those who did not achieve this degree of weight loss. The analysis showed that those with a BMI below 30 after 1 year had at least a twofold greater chance of discontinuing cholesterol-lowering medications, insulin, diabetes medications, antihypertensives, and CPAP for sleep apnea, compared with those whose BMI remained at 30 or above. They were also more than three times more likely to report being ‘very satisfied’ with the outcomes of surgery.
The authors noted that the cohort’s mean BMI was 48, which was above the established threshold for bariatric surgery, namely a BMI of 40, or 35 with weight-related comorbidities.
“Our results suggest that patients with morbid obesity should be targeted for surgery when their BMI is still less than 40, as these patients are more likely to achieve a target BMI that results in substantial reduction in weight-related comorbidities,” the authors wrote.
However, they stressed that their findings should not be taken as a reason to exclude patients with a BMI above 40 from surgery, pointing out that even for patients with higher preoperative BMIs, bariatric surgery offered substantial health and quality of life benefits.
They also acknowledged that 1-year weight data was available for around 50% of patients in the registry, which may have led to selection bias.
“Policies and practice patterns that delay or incentivize patients to pursue bariatric surgery only once the BMI is highly elevated can result in inferior outcomes,” the investigators concluded.
Blue Cross Blue Shield of Michigan/Blue Care Network funded the study. Three authors had received salary support from Blue Cross Blue Shield. No other conflicts of interest were declared.
Delaying bariatric surgery until body mass index is highly elevated may reduce the likelihood of achieving a BMI of less than 30 within a year, according to a paper published online July 26 in JAMA Surgery.
A retrospective study using prospectively gathered clinical data of 27,320 adults who underwent bariatric surgery in Michigan showed around one in three (36%) achieved a BMI below 30 within a year after surgery (JAMA Surgery 2017, July 26. doi: 10.1001/jamasurg.2017.2348). But obese patients with a body mass index of less than 40 kg/m2 before undergoing bariatric surgery are significantly more likely to achieve a postoperative BMI of under 30.
Individuals who had a preoperative BMI of less than 40 had a 12-fold higher chance of getting their BMI below 30, compared to those whose preoperative BMI was 40 or above (95% confidence interval 1.71-14.16, P less than .001). Only 8.5% of individuals with a BMI at or above 50 achieved a postoperative BMI below 30.
The likelihood of getting below 30 within a year was eightfold higher in patients who had a sleeve gastrectomy, 21 times greater in those who underwent Roux-en-Y bypass, and 82 times higher in those who had a duodenal switch, compared with patients who had adjustable gastric banding (P less than .001).
The researchers also compared other outcomes in individuals whose BMI dropped below 30 and in those who did not achieve this degree of weight loss. The analysis showed that those with a BMI below 30 after 1 year had at least a twofold greater chance of discontinuing cholesterol-lowering medications, insulin, diabetes medications, antihypertensives, and CPAP for sleep apnea, compared with those whose BMI remained at 30 or above. They were also more than three times more likely to report being ‘very satisfied’ with the outcomes of surgery.
The authors noted that the cohort’s mean BMI was 48, which was above the established threshold for bariatric surgery, namely a BMI of 40, or 35 with weight-related comorbidities.
“Our results suggest that patients with morbid obesity should be targeted for surgery when their BMI is still less than 40, as these patients are more likely to achieve a target BMI that results in substantial reduction in weight-related comorbidities,” the authors wrote.
However, they stressed that their findings should not be taken as a reason to exclude patients with a BMI above 40 from surgery, pointing out that even for patients with higher preoperative BMIs, bariatric surgery offered substantial health and quality of life benefits.
They also acknowledged that 1-year weight data was available for around 50% of patients in the registry, which may have led to selection bias.
“Policies and practice patterns that delay or incentivize patients to pursue bariatric surgery only once the BMI is highly elevated can result in inferior outcomes,” the investigators concluded.
Blue Cross Blue Shield of Michigan/Blue Care Network funded the study. Three authors had received salary support from Blue Cross Blue Shield. No other conflicts of interest were declared.
FROM JAMA SURGERY
Key clinical point: A BMI below 40 prior to undergoing bariatric surgery gives patients a significantly better chance of achieving a 1-year postoperative BMI under 30.
Major finding: Obese patients with a BMI less than 40 before undergoing bariatric surgery are more than 12 times more likely to achieve a postoperative BMI of under 30.
Data source: A retrospective study using prospectively gathered clinical data of 27, 320 adults who underwent bariatric surgery.
Disclosures: Blue Cross Blue Shield of Michigan/Blue Care Network funded the study. Three authors had received salary support from Blue Cross Blue Shield. No other conflicts of interest were declared.