User login
Oral steroids modestly improve acute radiculopathy
A 15-day course of oral steroids modestly improved function but not pain in patients with acute radiculopathy due to a herniated lumbar disk, according to a report published online May 19 in JAMA.
Compared with epidural steroid injections, oral steroids provide similar anti-inflammatory activity but avoid MRI, can be delivered quickly by primary care physicians, avert the risks of spinal injection, and are much cheaper. “Oral steroids are used by many community physicians, have been included in some clinical guidelines, and are noted as a treatment option by some authors,” yet no adequately powered clinical trials of the therapy have been performed until now, said Dr. Harley Goldberg of the department of physical medicine at the Kaiser Permanente Northern California Spine Care Program, San Jose, and his associates.
Their study involved 269 adults at three primary care practices who had leg pain extending below the knee in a nerve root distribution, confirmation of a herniated disk on MRI, and scores of 30 or higher on the 100-point Oswestry Disability Index (ODI). These participants were randomly assigned to receive either daily prednisone capsules (cumulative dose, 600 mg) or matching placebo in addition to usual care and were followed for 1 year.
The primary outcome measure was self-reported score on the ODI at 3 weeks. After adjustment for potential confounders, the mean score was 6.4 points higher with prednisone than with placebo, a significant but modest difference. This benefit persisted at 1-year follow-up, with a mean difference of 7.4 points between the two study groups. In addition, the active-treatment group was significantly more likely to achieve at least a 30-point or 50% improvement in ODI score at 3 weeks (RR, 1.7) and at 1 year (RR, 1.3), and showed significantly greater improvement in the physical component summary score on the Short Form 36 at 3 weeks and on the mental component summary score at 1 year, the investigators said (JAMA 2015;313:1915-23).
There were no differences between the active treatment and the placebo groups in measures of below-the-waist pain at either 3 weeks or 1 year, however, and no differences in the proportion of patients achieving 2- to 5-point improvements in pain scores on a 10-point numerical rating scale at either follow-up assessment. Most importantly, there was no significant between-group difference in the likelihood of undergoing spine surgery during the year following treatment; rates of spine surgery were 9.9% among patients who received prednisone and 9.1% among those who received placebo.
Patients who received active treatment were significantly more likely to report adverse effects (49.2%) than those who received placebo (23.9%), but these were minor and transient. No serious treatment-related adverse events occurred.
“Whether the observed improvement in function (without concomitant improvement in pain) merits use of oral steroids for patients with an acute radiculopathy is a difficult decision and, ultimately, becomes a personal one that must be weighed by individual patients and their physicians,” Dr. Goldberg and his associates said.
This study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Goldberg reported having no financial disclosures; one of his associates reported ties to the Orthopaedic Research and Education Foundation, AOSpine, Simpirica, and Intrinsic Orthopedics.
A 15-day course of oral steroids modestly improved function but not pain in patients with acute radiculopathy due to a herniated lumbar disk, according to a report published online May 19 in JAMA.
Compared with epidural steroid injections, oral steroids provide similar anti-inflammatory activity but avoid MRI, can be delivered quickly by primary care physicians, avert the risks of spinal injection, and are much cheaper. “Oral steroids are used by many community physicians, have been included in some clinical guidelines, and are noted as a treatment option by some authors,” yet no adequately powered clinical trials of the therapy have been performed until now, said Dr. Harley Goldberg of the department of physical medicine at the Kaiser Permanente Northern California Spine Care Program, San Jose, and his associates.
Their study involved 269 adults at three primary care practices who had leg pain extending below the knee in a nerve root distribution, confirmation of a herniated disk on MRI, and scores of 30 or higher on the 100-point Oswestry Disability Index (ODI). These participants were randomly assigned to receive either daily prednisone capsules (cumulative dose, 600 mg) or matching placebo in addition to usual care and were followed for 1 year.
The primary outcome measure was self-reported score on the ODI at 3 weeks. After adjustment for potential confounders, the mean score was 6.4 points higher with prednisone than with placebo, a significant but modest difference. This benefit persisted at 1-year follow-up, with a mean difference of 7.4 points between the two study groups. In addition, the active-treatment group was significantly more likely to achieve at least a 30-point or 50% improvement in ODI score at 3 weeks (RR, 1.7) and at 1 year (RR, 1.3), and showed significantly greater improvement in the physical component summary score on the Short Form 36 at 3 weeks and on the mental component summary score at 1 year, the investigators said (JAMA 2015;313:1915-23).
There were no differences between the active treatment and the placebo groups in measures of below-the-waist pain at either 3 weeks or 1 year, however, and no differences in the proportion of patients achieving 2- to 5-point improvements in pain scores on a 10-point numerical rating scale at either follow-up assessment. Most importantly, there was no significant between-group difference in the likelihood of undergoing spine surgery during the year following treatment; rates of spine surgery were 9.9% among patients who received prednisone and 9.1% among those who received placebo.
Patients who received active treatment were significantly more likely to report adverse effects (49.2%) than those who received placebo (23.9%), but these were minor and transient. No serious treatment-related adverse events occurred.
“Whether the observed improvement in function (without concomitant improvement in pain) merits use of oral steroids for patients with an acute radiculopathy is a difficult decision and, ultimately, becomes a personal one that must be weighed by individual patients and their physicians,” Dr. Goldberg and his associates said.
This study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Goldberg reported having no financial disclosures; one of his associates reported ties to the Orthopaedic Research and Education Foundation, AOSpine, Simpirica, and Intrinsic Orthopedics.
A 15-day course of oral steroids modestly improved function but not pain in patients with acute radiculopathy due to a herniated lumbar disk, according to a report published online May 19 in JAMA.
Compared with epidural steroid injections, oral steroids provide similar anti-inflammatory activity but avoid MRI, can be delivered quickly by primary care physicians, avert the risks of spinal injection, and are much cheaper. “Oral steroids are used by many community physicians, have been included in some clinical guidelines, and are noted as a treatment option by some authors,” yet no adequately powered clinical trials of the therapy have been performed until now, said Dr. Harley Goldberg of the department of physical medicine at the Kaiser Permanente Northern California Spine Care Program, San Jose, and his associates.
Their study involved 269 adults at three primary care practices who had leg pain extending below the knee in a nerve root distribution, confirmation of a herniated disk on MRI, and scores of 30 or higher on the 100-point Oswestry Disability Index (ODI). These participants were randomly assigned to receive either daily prednisone capsules (cumulative dose, 600 mg) or matching placebo in addition to usual care and were followed for 1 year.
The primary outcome measure was self-reported score on the ODI at 3 weeks. After adjustment for potential confounders, the mean score was 6.4 points higher with prednisone than with placebo, a significant but modest difference. This benefit persisted at 1-year follow-up, with a mean difference of 7.4 points between the two study groups. In addition, the active-treatment group was significantly more likely to achieve at least a 30-point or 50% improvement in ODI score at 3 weeks (RR, 1.7) and at 1 year (RR, 1.3), and showed significantly greater improvement in the physical component summary score on the Short Form 36 at 3 weeks and on the mental component summary score at 1 year, the investigators said (JAMA 2015;313:1915-23).
There were no differences between the active treatment and the placebo groups in measures of below-the-waist pain at either 3 weeks or 1 year, however, and no differences in the proportion of patients achieving 2- to 5-point improvements in pain scores on a 10-point numerical rating scale at either follow-up assessment. Most importantly, there was no significant between-group difference in the likelihood of undergoing spine surgery during the year following treatment; rates of spine surgery were 9.9% among patients who received prednisone and 9.1% among those who received placebo.
Patients who received active treatment were significantly more likely to report adverse effects (49.2%) than those who received placebo (23.9%), but these were minor and transient. No serious treatment-related adverse events occurred.
“Whether the observed improvement in function (without concomitant improvement in pain) merits use of oral steroids for patients with an acute radiculopathy is a difficult decision and, ultimately, becomes a personal one that must be weighed by individual patients and their physicians,” Dr. Goldberg and his associates said.
This study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Goldberg reported having no financial disclosures; one of his associates reported ties to the Orthopaedic Research and Education Foundation, AOSpine, Simpirica, and Intrinsic Orthopedics.
FROM JAMA
Key clinical point: A 15-day course of oral steroids modestly improved function but not pain in acute radiculopathy due to a herniated lumbar disk.
Major finding: The primary outcome measure, mean self-reported score on the ODI at 3 weeks, was 6.4 points higher with prednisone than with placebo, a significant but modest difference.
Data source: A randomized, double-blind, placebo-controlled trial involving 269 adults followed for 1 year.
Disclosures: This study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Goldberg reported having no financial disclosures; one of his associates reported ties to the Orthopaedic Research and Education Foundation, AOSpine, Simpirica, and Intrinsic Orthopedics.
Ischemia a bigger concern than PE recurrence?
Among patients taking anticoagulants after venous thromboembolism, mortality due to ischemic events is twice that due to recurrent pulmonary embolism, according to a report published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders. “In clinical practice in patients with VTE, most of the physician’s attention is often focused on the resolution of VTE signs and symptoms, whereas less attention is paid to the prevention of ischemic events,” said Dr. Olga Madridano of Hospital Universitario Infanta Sofia, Madrid, and her associates.
These study findings show that when prescribing anticoagulation for these patients, it is crucial to identify those who may also require concomitant antiplatelet therapy to prevent ischemic events, the investigators noted.
Dr. Madridano and her colleagues analyzed data from an international registry of VTE cases to determine how often major ischemic events – stroke, MI, limb amputation, or mesenteric ischemia – occur during anticoagulant therapy. They assessed the case reports of 23,370 consecutive patients in 10 European countries, Canada, and Ecuador who were enrolled in the registry during a 5-year period.
During a mean of 9.2 months of anticoagulation treatment, 597 patients developed recurrent VTE: 267 had pulmonary embolism and 330 had deep vein thrombosis. A total of 162 developed major ischemic events: 86 had stroke, 53 had MI, 13 required limb amputation, and 11 had mesenteric ischemia. There were 21 deaths from PE recurrences and 53 from ischemic events.
Thus, the number of PE recurrences was greater than that of ischemic events, but the mortality from PE recurrences was only half that from ischemic events. “We hypothesize that some patients who subsequently died of MI or stroke might have benefited from concomitant therapy with antiplatelets,” Dr. Madridano and her associates said (J. Vasc. Surg.: Venous Lymph. Dis. 2015;3:135-41). However, it is important to note that mortality due to bleeding complications (83 deaths) was even higher than mortality due to PE recurrence and ischemic events put together (74 deaths). Earlier discontinuation of anticoagulant therapy might have reduced the rate of major bleeding, they added.
The VTE registry is supported by an unrestricted grant from Sanofi Spain and by Bayer Pharma AG. Dr. Madridano and her associates reported having no financial disclosures.
Among patients taking anticoagulants after venous thromboembolism, mortality due to ischemic events is twice that due to recurrent pulmonary embolism, according to a report published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders. “In clinical practice in patients with VTE, most of the physician’s attention is often focused on the resolution of VTE signs and symptoms, whereas less attention is paid to the prevention of ischemic events,” said Dr. Olga Madridano of Hospital Universitario Infanta Sofia, Madrid, and her associates.
These study findings show that when prescribing anticoagulation for these patients, it is crucial to identify those who may also require concomitant antiplatelet therapy to prevent ischemic events, the investigators noted.
Dr. Madridano and her colleagues analyzed data from an international registry of VTE cases to determine how often major ischemic events – stroke, MI, limb amputation, or mesenteric ischemia – occur during anticoagulant therapy. They assessed the case reports of 23,370 consecutive patients in 10 European countries, Canada, and Ecuador who were enrolled in the registry during a 5-year period.
During a mean of 9.2 months of anticoagulation treatment, 597 patients developed recurrent VTE: 267 had pulmonary embolism and 330 had deep vein thrombosis. A total of 162 developed major ischemic events: 86 had stroke, 53 had MI, 13 required limb amputation, and 11 had mesenteric ischemia. There were 21 deaths from PE recurrences and 53 from ischemic events.
Thus, the number of PE recurrences was greater than that of ischemic events, but the mortality from PE recurrences was only half that from ischemic events. “We hypothesize that some patients who subsequently died of MI or stroke might have benefited from concomitant therapy with antiplatelets,” Dr. Madridano and her associates said (J. Vasc. Surg.: Venous Lymph. Dis. 2015;3:135-41). However, it is important to note that mortality due to bleeding complications (83 deaths) was even higher than mortality due to PE recurrence and ischemic events put together (74 deaths). Earlier discontinuation of anticoagulant therapy might have reduced the rate of major bleeding, they added.
The VTE registry is supported by an unrestricted grant from Sanofi Spain and by Bayer Pharma AG. Dr. Madridano and her associates reported having no financial disclosures.
Among patients taking anticoagulants after venous thromboembolism, mortality due to ischemic events is twice that due to recurrent pulmonary embolism, according to a report published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders. “In clinical practice in patients with VTE, most of the physician’s attention is often focused on the resolution of VTE signs and symptoms, whereas less attention is paid to the prevention of ischemic events,” said Dr. Olga Madridano of Hospital Universitario Infanta Sofia, Madrid, and her associates.
These study findings show that when prescribing anticoagulation for these patients, it is crucial to identify those who may also require concomitant antiplatelet therapy to prevent ischemic events, the investigators noted.
Dr. Madridano and her colleagues analyzed data from an international registry of VTE cases to determine how often major ischemic events – stroke, MI, limb amputation, or mesenteric ischemia – occur during anticoagulant therapy. They assessed the case reports of 23,370 consecutive patients in 10 European countries, Canada, and Ecuador who were enrolled in the registry during a 5-year period.
During a mean of 9.2 months of anticoagulation treatment, 597 patients developed recurrent VTE: 267 had pulmonary embolism and 330 had deep vein thrombosis. A total of 162 developed major ischemic events: 86 had stroke, 53 had MI, 13 required limb amputation, and 11 had mesenteric ischemia. There were 21 deaths from PE recurrences and 53 from ischemic events.
Thus, the number of PE recurrences was greater than that of ischemic events, but the mortality from PE recurrences was only half that from ischemic events. “We hypothesize that some patients who subsequently died of MI or stroke might have benefited from concomitant therapy with antiplatelets,” Dr. Madridano and her associates said (J. Vasc. Surg.: Venous Lymph. Dis. 2015;3:135-41). However, it is important to note that mortality due to bleeding complications (83 deaths) was even higher than mortality due to PE recurrence and ischemic events put together (74 deaths). Earlier discontinuation of anticoagulant therapy might have reduced the rate of major bleeding, they added.
The VTE registry is supported by an unrestricted grant from Sanofi Spain and by Bayer Pharma AG. Dr. Madridano and her associates reported having no financial disclosures.
Key clinical point: Among patients receiving anticoagulation after VTE, mortality from ischemic events is twice that from recurrent pulmonary embolism.
Major finding: During a mean of 9.2 months of anticoagulation treatment, there were 21 deaths from PE recurrences and 53 from ischemic events.
Data source: An observational cohort study involving 23,370 consecutive patients entered into an international registry of acute VTE cases during a 5-year period.
Disclosures: The VTE registry is supported by an unrestricted grant from Sanofi Spain and by Bayer Pharma AG. Dr. Madridano and her associates reported having no financial disclosures.
Statins, fibrates lower stroke risk in elderly
Both statin and fibrate therapies taken to improve lipid profiles decreased the risk of stroke by 30% in a community-dwelling population of elderly people, according to prospective European study published online May 19 in the British Medical Journal.
Participants in almost all the randomized clinical trials assessing cardiovascular drugs are younger than age 70, so the benefits of these agents in older patients – particularly their effectiveness as primary prevention in people who have no known cardiovascular illness – is uncertain. Nevertheless, “in real life, statins are commonly prescribed to older people without clinical evidence of atherosclerosis,” said Dr. Annick Alperovitch of the University of Bordeaux (France) and her associates.
To assess the effects of statin and fibrate therapies on incident cardiovascular events in an elderly population, the investigators analyzed data from an ongoing cohort study of vascular disease among elderly residents of Bordeaux, Dijon, and Montpellier. Dr. Alperovitch and her associates examined the medical records of a subset of 7,484 men and women (mean age 74 years) who were followed every 2 years for a mean of 9 years. A total of 27% reported using lipid-lowering medications at baseline; roughly half used statins and half used fibrates. There were 292 strokes during follow-up.
The risk of stroke was cut by roughly 30% among statin and fibrate users, compared with nonusers (hazard ratio, 0.66). This decrease was similar between the two medications. All-cause mortality was slightly lower in people who took statins or fibrates, compared with nonusers (HR 0.87), the investigators said (Br. Med. J. 2015 May 19 [doi:10.1136/bmj.h2335]).
This is the first observational study to show a significant association between lipid-lowering drugs and decreased stroke risk, they noted.
The overall incidence of stroke in this study was low (0.47 per 100 person-years), so even a 30% decrease produced “a limited number of avoided cases.” That may be attributable in part to the generally healthy lifestyle, high educational achievement, and high economic status of this urban French study population. But if the findings are confirmed in future studies, they could have an important impact on public health in other populations, Dr. Alperovitch and her associates said.
The findings of a single observational study will not change guidelines regarding cholesterol therapy, but they are sufficiently compelling to warrant further research on primary prevention of stroke in elderly people.
This is the first observational study to describe a significant association between lipid-lowering medications and decreased stroke risk. Previous studies have shown only a weak association in early middle age, and no association in the elderly.
Graeme J. Hankey, M.D., is professor of neurology at the University of Western Australia’s Harry Perkins Institute of Medical Research, Perth, and honorary senior research fellow at Western Australian Neuroscience Research Institute, also in Perth. He reported ties to Sanofi Aventis, Bayer Pharmaceuticals, and Medscape. Dr. Hankey made these remarks in an editorial accompanying Dr. Alperovitch’s report (Br. Med. J. 2015 May 19 [doi:10.1136/bmj.h2568]).
The findings of a single observational study will not change guidelines regarding cholesterol therapy, but they are sufficiently compelling to warrant further research on primary prevention of stroke in elderly people.
This is the first observational study to describe a significant association between lipid-lowering medications and decreased stroke risk. Previous studies have shown only a weak association in early middle age, and no association in the elderly.
Graeme J. Hankey, M.D., is professor of neurology at the University of Western Australia’s Harry Perkins Institute of Medical Research, Perth, and honorary senior research fellow at Western Australian Neuroscience Research Institute, also in Perth. He reported ties to Sanofi Aventis, Bayer Pharmaceuticals, and Medscape. Dr. Hankey made these remarks in an editorial accompanying Dr. Alperovitch’s report (Br. Med. J. 2015 May 19 [doi:10.1136/bmj.h2568]).
The findings of a single observational study will not change guidelines regarding cholesterol therapy, but they are sufficiently compelling to warrant further research on primary prevention of stroke in elderly people.
This is the first observational study to describe a significant association between lipid-lowering medications and decreased stroke risk. Previous studies have shown only a weak association in early middle age, and no association in the elderly.
Graeme J. Hankey, M.D., is professor of neurology at the University of Western Australia’s Harry Perkins Institute of Medical Research, Perth, and honorary senior research fellow at Western Australian Neuroscience Research Institute, also in Perth. He reported ties to Sanofi Aventis, Bayer Pharmaceuticals, and Medscape. Dr. Hankey made these remarks in an editorial accompanying Dr. Alperovitch’s report (Br. Med. J. 2015 May 19 [doi:10.1136/bmj.h2568]).
Both statin and fibrate therapies taken to improve lipid profiles decreased the risk of stroke by 30% in a community-dwelling population of elderly people, according to prospective European study published online May 19 in the British Medical Journal.
Participants in almost all the randomized clinical trials assessing cardiovascular drugs are younger than age 70, so the benefits of these agents in older patients – particularly their effectiveness as primary prevention in people who have no known cardiovascular illness – is uncertain. Nevertheless, “in real life, statins are commonly prescribed to older people without clinical evidence of atherosclerosis,” said Dr. Annick Alperovitch of the University of Bordeaux (France) and her associates.
To assess the effects of statin and fibrate therapies on incident cardiovascular events in an elderly population, the investigators analyzed data from an ongoing cohort study of vascular disease among elderly residents of Bordeaux, Dijon, and Montpellier. Dr. Alperovitch and her associates examined the medical records of a subset of 7,484 men and women (mean age 74 years) who were followed every 2 years for a mean of 9 years. A total of 27% reported using lipid-lowering medications at baseline; roughly half used statins and half used fibrates. There were 292 strokes during follow-up.
The risk of stroke was cut by roughly 30% among statin and fibrate users, compared with nonusers (hazard ratio, 0.66). This decrease was similar between the two medications. All-cause mortality was slightly lower in people who took statins or fibrates, compared with nonusers (HR 0.87), the investigators said (Br. Med. J. 2015 May 19 [doi:10.1136/bmj.h2335]).
This is the first observational study to show a significant association between lipid-lowering drugs and decreased stroke risk, they noted.
The overall incidence of stroke in this study was low (0.47 per 100 person-years), so even a 30% decrease produced “a limited number of avoided cases.” That may be attributable in part to the generally healthy lifestyle, high educational achievement, and high economic status of this urban French study population. But if the findings are confirmed in future studies, they could have an important impact on public health in other populations, Dr. Alperovitch and her associates said.
Both statin and fibrate therapies taken to improve lipid profiles decreased the risk of stroke by 30% in a community-dwelling population of elderly people, according to prospective European study published online May 19 in the British Medical Journal.
Participants in almost all the randomized clinical trials assessing cardiovascular drugs are younger than age 70, so the benefits of these agents in older patients – particularly their effectiveness as primary prevention in people who have no known cardiovascular illness – is uncertain. Nevertheless, “in real life, statins are commonly prescribed to older people without clinical evidence of atherosclerosis,” said Dr. Annick Alperovitch of the University of Bordeaux (France) and her associates.
To assess the effects of statin and fibrate therapies on incident cardiovascular events in an elderly population, the investigators analyzed data from an ongoing cohort study of vascular disease among elderly residents of Bordeaux, Dijon, and Montpellier. Dr. Alperovitch and her associates examined the medical records of a subset of 7,484 men and women (mean age 74 years) who were followed every 2 years for a mean of 9 years. A total of 27% reported using lipid-lowering medications at baseline; roughly half used statins and half used fibrates. There were 292 strokes during follow-up.
The risk of stroke was cut by roughly 30% among statin and fibrate users, compared with nonusers (hazard ratio, 0.66). This decrease was similar between the two medications. All-cause mortality was slightly lower in people who took statins or fibrates, compared with nonusers (HR 0.87), the investigators said (Br. Med. J. 2015 May 19 [doi:10.1136/bmj.h2335]).
This is the first observational study to show a significant association between lipid-lowering drugs and decreased stroke risk, they noted.
The overall incidence of stroke in this study was low (0.47 per 100 person-years), so even a 30% decrease produced “a limited number of avoided cases.” That may be attributable in part to the generally healthy lifestyle, high educational achievement, and high economic status of this urban French study population. But if the findings are confirmed in future studies, they could have an important impact on public health in other populations, Dr. Alperovitch and her associates said.
Key clinical point: Statin and fibrate therapies significantly decreased stroke risk in a large cohort of elderly people.
Major finding: The risk of stroke was cut by 30% among statin and fibrate users, compared with nonusers (HR, 0.66).
Data source: A prospective, population-based cohort study of 7,484 elderly community-dwelling people followed for 9 years.
Disclosures: This study was supported by Institut National de la Sante et de la Recherche Medicale, Victor Segalen-Bordeaux II University, and Sanofi-Aventis. Dr. Alperovitch reported receiving honoraria from the French National Medicines Agency, the Fondation Plan Alzheimer, and Fondation Bettencourt-Schueller.
Prevalence of amyloid pathology differs across dementia type and age
The prevalence of amyloid pathology on PET imaging varies according to what type of dementia the patient has, patient age, and apolipoprotein E epsilon-4 (APOE e4) allele status, according to a report published online May 19 in JAMA.
“To correctly interpret the clinical significance of amyloid PET results, clinicians need to understand the prevalence of amyloid positivity across different types of dementia and how this is associated with demographic, genetic, and cognitive factors. Most amyloid PET studies to date come from single centers with modest sample sizes. Therefore, we conducted an individual participant meta-analysis to estimate the prevalence of amyloid positivity in a large sample encompassing a variety of dementia syndromes,” said Rik Ossenkoppele, Ph.D., of the department of neurology and the Alzheimer Center at V.U. University Medical Center, Amsterdam, and his associates (JAMA 2015;313:1939-49).
The investigators pooled data from 29 cohorts involving 1,897 participants with clinical diagnoses of Alzheimer’s disease (1,359 patients), frontotemporal dementia (288), dementia with Lewy bodies (51), vascular dementia (138), and corticobasal syndrome (61), as well as 1,849 healthy control subjects. They found that the prevalence of amyloid pathology on PET decreased with advancing age in Alzheimer’s disease, from 93% at age 50 to 79% at age 90. However, the prevalence of amyloid pathology increased with advancing age in the other dementias.
This suggests that amyloid PET “might have the potential to be most helpful for differential diagnosis in early-onset dementia, particularly if the goal is to rule in AD dementia,” they said.
The Amyloid PET Study was funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, the Alzheimer’s Association, and numerous other organizations and industry sources.
The prevalence of amyloid pathology on PET imaging varies according to what type of dementia the patient has, patient age, and apolipoprotein E epsilon-4 (APOE e4) allele status, according to a report published online May 19 in JAMA.
“To correctly interpret the clinical significance of amyloid PET results, clinicians need to understand the prevalence of amyloid positivity across different types of dementia and how this is associated with demographic, genetic, and cognitive factors. Most amyloid PET studies to date come from single centers with modest sample sizes. Therefore, we conducted an individual participant meta-analysis to estimate the prevalence of amyloid positivity in a large sample encompassing a variety of dementia syndromes,” said Rik Ossenkoppele, Ph.D., of the department of neurology and the Alzheimer Center at V.U. University Medical Center, Amsterdam, and his associates (JAMA 2015;313:1939-49).
The investigators pooled data from 29 cohorts involving 1,897 participants with clinical diagnoses of Alzheimer’s disease (1,359 patients), frontotemporal dementia (288), dementia with Lewy bodies (51), vascular dementia (138), and corticobasal syndrome (61), as well as 1,849 healthy control subjects. They found that the prevalence of amyloid pathology on PET decreased with advancing age in Alzheimer’s disease, from 93% at age 50 to 79% at age 90. However, the prevalence of amyloid pathology increased with advancing age in the other dementias.
This suggests that amyloid PET “might have the potential to be most helpful for differential diagnosis in early-onset dementia, particularly if the goal is to rule in AD dementia,” they said.
The Amyloid PET Study was funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, the Alzheimer’s Association, and numerous other organizations and industry sources.
The prevalence of amyloid pathology on PET imaging varies according to what type of dementia the patient has, patient age, and apolipoprotein E epsilon-4 (APOE e4) allele status, according to a report published online May 19 in JAMA.
“To correctly interpret the clinical significance of amyloid PET results, clinicians need to understand the prevalence of amyloid positivity across different types of dementia and how this is associated with demographic, genetic, and cognitive factors. Most amyloid PET studies to date come from single centers with modest sample sizes. Therefore, we conducted an individual participant meta-analysis to estimate the prevalence of amyloid positivity in a large sample encompassing a variety of dementia syndromes,” said Rik Ossenkoppele, Ph.D., of the department of neurology and the Alzheimer Center at V.U. University Medical Center, Amsterdam, and his associates (JAMA 2015;313:1939-49).
The investigators pooled data from 29 cohorts involving 1,897 participants with clinical diagnoses of Alzheimer’s disease (1,359 patients), frontotemporal dementia (288), dementia with Lewy bodies (51), vascular dementia (138), and corticobasal syndrome (61), as well as 1,849 healthy control subjects. They found that the prevalence of amyloid pathology on PET decreased with advancing age in Alzheimer’s disease, from 93% at age 50 to 79% at age 90. However, the prevalence of amyloid pathology increased with advancing age in the other dementias.
This suggests that amyloid PET “might have the potential to be most helpful for differential diagnosis in early-onset dementia, particularly if the goal is to rule in AD dementia,” they said.
The Amyloid PET Study was funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, the Alzheimer’s Association, and numerous other organizations and industry sources.
FROM JAMA
Key clinical point: Researchers have characterized the prevalence of amyloid pathology on PET imaging across five different forms of dementia and according to age and APOE e4 status.
Major finding: The prevalence of amyloid pathology on PET decreased with advancing age in Alzheimer’s disease, from 93% at age 50 to 79% at age 90, but increased with advancing age in the other dementias.
Data source: A meta-analysis of 29 study cohorts (1,897 patients) in which PET imaging showed the presence or absence of amyloid pathology.
Disclosures: The Amyloid PET Study was funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, the Alzheimer’s Association, and numerous other organizations and industry sources.
A quarter of women with dense breasts at high interval cancer risk
About a quarter of women with dense breasts are at high risk for interval cancer, so mandating supplemental or alternative screening methods for all such women is not justified, according to a report published May 18 in Annals of Internal Medicine.
Twenty-one states currently have some type of breast density notification law, with most requiring that women be informed if their breasts are heterogeneously or extremely dense on screening digital mammography and suggesting that they discuss the need for supplemental imaging with their health care providers. To assess the real-world risk of interval cancers in women with dense breasts, the researchers analyzed 831,455 digital screening mammographies performed from January 2002 through October 2011 on 365,426 women across the country who were aged 40-74 years and whose medical records included complete demographic and breast health information.
Overall, 47% of the study participants had extremely dense or heterogeneously dense breasts. A total of 2,696 of these women were diagnosed as having invasive breast cancer within 1 year of undergoing screening mammography, according to Dr. Karla Kerlikowske of the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center, and her associates.
The researchers observed interval cancer rates greater than 1 case per 1,000 mammography exams among 24% of women aged 40-74 years with dense breasts. The 5-year risk was categorized as low to average for 51.0% of those with heterogeneously dense breasts and 52.5% of those with extremely dense breasts, with interval cancer rates of 0.58 to 0.63 and 0.72 to 0.89 case per 1,000 mammography examinations, respectively (Ann. Intern. Med. 2015 May 18 [doi:10.7326/M14-1465]).
Breast density alone was not a good predictor of interval cancer risk. Other factors, such as patient age, race and ethnicity, and family history, should be combined with breast density to determine whether supplemental or alternative imaging is warranted, the investigators wrote.
“Digital mammography has sufficiently high breast cancer detection and reasonably low rates of false-positive results for routine use, even among women with dense breasts,” Dr. Kerlikowske and her associates wrote.
The study was funded primarily by the National Cancer Institute, as well as by many state public health departments and cancer registries. One of the authors reported being a consultant for GE and Bayer and receiving grants or having pending grants from GE.
The study by Kerlikowske et al. provides compelling evidence that breast density shouldn’t be the sole criterion to guide decisions about supplemental breast cancer screening.
The findings suggest that legislation regarding this issue is premature. Fully enacting this legislation would require considerable additional screening resources for approximately half the screening population, with high costs and unclear long-term benefit.
Instead, combining breast density information with a risk assessment, such as the BCSC 5-year risk model, into the mammography report would assist primary care providers to counsel patients on the appropriateness of supplemental screening. At present, many of these physicians are ill-prepared to discuss breast density with their patients, even in states that have already enacted these laws.
Nancy C. Dolan, M.D., and Mita Sanghavi Goel, M.D., are at Northwestern University, Chicago. Dr. Goel reported receiving grants from the Avon Foundation. These comments are adapted from an editorial in Annals of Internal Medicine (Ann. Intern. Med. 2015 May 18 [doi:10.7326/M15-0821]).
The study by Kerlikowske et al. provides compelling evidence that breast density shouldn’t be the sole criterion to guide decisions about supplemental breast cancer screening.
The findings suggest that legislation regarding this issue is premature. Fully enacting this legislation would require considerable additional screening resources for approximately half the screening population, with high costs and unclear long-term benefit.
Instead, combining breast density information with a risk assessment, such as the BCSC 5-year risk model, into the mammography report would assist primary care providers to counsel patients on the appropriateness of supplemental screening. At present, many of these physicians are ill-prepared to discuss breast density with their patients, even in states that have already enacted these laws.
Nancy C. Dolan, M.D., and Mita Sanghavi Goel, M.D., are at Northwestern University, Chicago. Dr. Goel reported receiving grants from the Avon Foundation. These comments are adapted from an editorial in Annals of Internal Medicine (Ann. Intern. Med. 2015 May 18 [doi:10.7326/M15-0821]).
The study by Kerlikowske et al. provides compelling evidence that breast density shouldn’t be the sole criterion to guide decisions about supplemental breast cancer screening.
The findings suggest that legislation regarding this issue is premature. Fully enacting this legislation would require considerable additional screening resources for approximately half the screening population, with high costs and unclear long-term benefit.
Instead, combining breast density information with a risk assessment, such as the BCSC 5-year risk model, into the mammography report would assist primary care providers to counsel patients on the appropriateness of supplemental screening. At present, many of these physicians are ill-prepared to discuss breast density with their patients, even in states that have already enacted these laws.
Nancy C. Dolan, M.D., and Mita Sanghavi Goel, M.D., are at Northwestern University, Chicago. Dr. Goel reported receiving grants from the Avon Foundation. These comments are adapted from an editorial in Annals of Internal Medicine (Ann. Intern. Med. 2015 May 18 [doi:10.7326/M15-0821]).
About a quarter of women with dense breasts are at high risk for interval cancer, so mandating supplemental or alternative screening methods for all such women is not justified, according to a report published May 18 in Annals of Internal Medicine.
Twenty-one states currently have some type of breast density notification law, with most requiring that women be informed if their breasts are heterogeneously or extremely dense on screening digital mammography and suggesting that they discuss the need for supplemental imaging with their health care providers. To assess the real-world risk of interval cancers in women with dense breasts, the researchers analyzed 831,455 digital screening mammographies performed from January 2002 through October 2011 on 365,426 women across the country who were aged 40-74 years and whose medical records included complete demographic and breast health information.
Overall, 47% of the study participants had extremely dense or heterogeneously dense breasts. A total of 2,696 of these women were diagnosed as having invasive breast cancer within 1 year of undergoing screening mammography, according to Dr. Karla Kerlikowske of the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center, and her associates.
The researchers observed interval cancer rates greater than 1 case per 1,000 mammography exams among 24% of women aged 40-74 years with dense breasts. The 5-year risk was categorized as low to average for 51.0% of those with heterogeneously dense breasts and 52.5% of those with extremely dense breasts, with interval cancer rates of 0.58 to 0.63 and 0.72 to 0.89 case per 1,000 mammography examinations, respectively (Ann. Intern. Med. 2015 May 18 [doi:10.7326/M14-1465]).
Breast density alone was not a good predictor of interval cancer risk. Other factors, such as patient age, race and ethnicity, and family history, should be combined with breast density to determine whether supplemental or alternative imaging is warranted, the investigators wrote.
“Digital mammography has sufficiently high breast cancer detection and reasonably low rates of false-positive results for routine use, even among women with dense breasts,” Dr. Kerlikowske and her associates wrote.
The study was funded primarily by the National Cancer Institute, as well as by many state public health departments and cancer registries. One of the authors reported being a consultant for GE and Bayer and receiving grants or having pending grants from GE.
About a quarter of women with dense breasts are at high risk for interval cancer, so mandating supplemental or alternative screening methods for all such women is not justified, according to a report published May 18 in Annals of Internal Medicine.
Twenty-one states currently have some type of breast density notification law, with most requiring that women be informed if their breasts are heterogeneously or extremely dense on screening digital mammography and suggesting that they discuss the need for supplemental imaging with their health care providers. To assess the real-world risk of interval cancers in women with dense breasts, the researchers analyzed 831,455 digital screening mammographies performed from January 2002 through October 2011 on 365,426 women across the country who were aged 40-74 years and whose medical records included complete demographic and breast health information.
Overall, 47% of the study participants had extremely dense or heterogeneously dense breasts. A total of 2,696 of these women were diagnosed as having invasive breast cancer within 1 year of undergoing screening mammography, according to Dr. Karla Kerlikowske of the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center, and her associates.
The researchers observed interval cancer rates greater than 1 case per 1,000 mammography exams among 24% of women aged 40-74 years with dense breasts. The 5-year risk was categorized as low to average for 51.0% of those with heterogeneously dense breasts and 52.5% of those with extremely dense breasts, with interval cancer rates of 0.58 to 0.63 and 0.72 to 0.89 case per 1,000 mammography examinations, respectively (Ann. Intern. Med. 2015 May 18 [doi:10.7326/M14-1465]).
Breast density alone was not a good predictor of interval cancer risk. Other factors, such as patient age, race and ethnicity, and family history, should be combined with breast density to determine whether supplemental or alternative imaging is warranted, the investigators wrote.
“Digital mammography has sufficiently high breast cancer detection and reasonably low rates of false-positive results for routine use, even among women with dense breasts,” Dr. Kerlikowske and her associates wrote.
The study was funded primarily by the National Cancer Institute, as well as by many state public health departments and cancer registries. One of the authors reported being a consultant for GE and Bayer and receiving grants or having pending grants from GE.
FROM ANNALS OF INTERNAL MEDICINE
Key clinical point: Among women with dense breasts, 24% are at risk for interval cancer.
Major finding: Risk of interval cancer was categorized as low to average for 51.0% of women with heterogeneously dense breasts and 52.5% of those with extremely dense breasts.
Data source: A prospective cohort analysis of 831,455 digital screening mammographies in Breast Cancer Surveillance Consortium registries across the country.
Disclosures: This study was funded primarily by the National Cancer Institute, as well as by many state public health departments and cancer registries. One of the authors reported being a consultant for GE and Bayer and grants or pending grants from GE.
Chest Pain: Risks of Evaluation May Outweigh Benefits
The chance that chest pain signals a cardiac event is “exceedingly low” – only 0.06% – in adults who have two negative results on troponin testing, nonconcerning vital signs, and nonischemic ECG findings in the emergency department, according to a report published online May 18 in JAMA Internal Medicine.
More than 7 million ED visits for chest pain occurred in the United States during the most recent year for which data are available, and only a tiny fraction of them were found to have a serious cardiac cause. Both inpatient admission and extended observation for these cases represent a considerable burden to the health care system and to the patient, who often is exposed to unnecessary testing, hospital-acquired infections, venous thromboembolism, pneumonia, falls, and other iatrogenic events, said Dr. Michael B. Weinstock of the department of emergency medicine, Ohio State University, Columbus, and his associates.
To quantify the incidence of truly life-threatening cardiac events among patients admitted or observed for chest pain, the researchers analyzed the medical records of 45,416 ED cases seen at three Midwestern hospitals during a 5-year period. Roughly half were admitted to an inpatient unit or an extended observation unit.
The study focused on the 7,266 patients who presented with chest pain, tightness, burning, or pressure, and who had negative results on serial troponin testing, normal vital signs, and normal ECG findings. Only four of these patients (0.06%) had a life-threatening outcome of interest: arrhythmia, ST-elevation myocardial infarction, cardiac or respiratory arrest, or death. Notably, one patient had a periprocedural MI and another had a STEMI during a stress test. A third patient, an 80-year-old man with coronary artery disease, hypertension, diabetes, obesity, chronic heart failure, chronic obstructive pulmonary disease, and renal failure, had noncardiac chest pain from massive GI bleeding secondary to warfarin coagulopathy. And a woman with hypertension, CAD, and a coronary artery bypass graft developed bradyasystolic cardiac arrest when given nitroglycerin, the investigators said (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1674]).
“Our findings support the notion that adverse iatrogenic events as a result of admission may eclipse potential benefits” in chest pain patients who are at low risk for a cardiac event. “We believe that current recommendations to admit, observe, or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered,” they said.
The findings of Weinstock et al. are consistent with our own results from focus groups of internists and cardiologists: Physicians often anticipate they’ll regret missing a cardiac diagnosis and reflexively value taking some action over inaction, cognitive biases that ultimately lead to unnecessary testing and invasive treatment of patients with chest pain.
|
Dr. Rita Redberg |
For their part, patients also greatly overestimate the benefits of tests and treatments while greatly underestimating their risks. Given accurate and complete information about harms and benefits of certain interventions, many chest pain patients would make different choices.
Grace A. Lin, M.D., is in the department of medicine at the University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies. Rita F. Redberg, M.D., is professor and director of women’s cardiovascular services at University of California, San Francisco, and is chief editor of JAMA Internal Medicine. Dr. Lin and Dr. Redberg reported having no financial conflicts of interest. They made these remarks in an editorial accompanying Dr. Weinstock’s report (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1693]).
The findings of Weinstock et al. are consistent with our own results from focus groups of internists and cardiologists: Physicians often anticipate they’ll regret missing a cardiac diagnosis and reflexively value taking some action over inaction, cognitive biases that ultimately lead to unnecessary testing and invasive treatment of patients with chest pain.
|
|
Dr. Rita Redberg |
For their part, patients also greatly overestimate the benefits of tests and treatments while greatly underestimating their risks. Given accurate and complete information about harms and benefits of certain interventions, many chest pain patients would make different choices.
Grace A. Lin, M.D., is in the department of medicine at the University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies. Rita F. Redberg, M.D., is professor and director of women’s cardiovascular services at University of California, San Francisco, and is chief editor of JAMA Internal Medicine. Dr. Lin and Dr. Redberg reported having no financial conflicts of interest. They made these remarks in an editorial accompanying Dr. Weinstock’s report (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1693]).
The findings of Weinstock et al. are consistent with our own results from focus groups of internists and cardiologists: Physicians often anticipate they’ll regret missing a cardiac diagnosis and reflexively value taking some action over inaction, cognitive biases that ultimately lead to unnecessary testing and invasive treatment of patients with chest pain.
|
|
Dr. Rita Redberg |
For their part, patients also greatly overestimate the benefits of tests and treatments while greatly underestimating their risks. Given accurate and complete information about harms and benefits of certain interventions, many chest pain patients would make different choices.
Grace A. Lin, M.D., is in the department of medicine at the University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies. Rita F. Redberg, M.D., is professor and director of women’s cardiovascular services at University of California, San Francisco, and is chief editor of JAMA Internal Medicine. Dr. Lin and Dr. Redberg reported having no financial conflicts of interest. They made these remarks in an editorial accompanying Dr. Weinstock’s report (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1693]).
The chance that chest pain signals a cardiac event is “exceedingly low” – only 0.06% – in adults who have two negative results on troponin testing, nonconcerning vital signs, and nonischemic ECG findings in the emergency department, according to a report published online May 18 in JAMA Internal Medicine.
More than 7 million ED visits for chest pain occurred in the United States during the most recent year for which data are available, and only a tiny fraction of them were found to have a serious cardiac cause. Both inpatient admission and extended observation for these cases represent a considerable burden to the health care system and to the patient, who often is exposed to unnecessary testing, hospital-acquired infections, venous thromboembolism, pneumonia, falls, and other iatrogenic events, said Dr. Michael B. Weinstock of the department of emergency medicine, Ohio State University, Columbus, and his associates.
To quantify the incidence of truly life-threatening cardiac events among patients admitted or observed for chest pain, the researchers analyzed the medical records of 45,416 ED cases seen at three Midwestern hospitals during a 5-year period. Roughly half were admitted to an inpatient unit or an extended observation unit.
The study focused on the 7,266 patients who presented with chest pain, tightness, burning, or pressure, and who had negative results on serial troponin testing, normal vital signs, and normal ECG findings. Only four of these patients (0.06%) had a life-threatening outcome of interest: arrhythmia, ST-elevation myocardial infarction, cardiac or respiratory arrest, or death. Notably, one patient had a periprocedural MI and another had a STEMI during a stress test. A third patient, an 80-year-old man with coronary artery disease, hypertension, diabetes, obesity, chronic heart failure, chronic obstructive pulmonary disease, and renal failure, had noncardiac chest pain from massive GI bleeding secondary to warfarin coagulopathy. And a woman with hypertension, CAD, and a coronary artery bypass graft developed bradyasystolic cardiac arrest when given nitroglycerin, the investigators said (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1674]).
“Our findings support the notion that adverse iatrogenic events as a result of admission may eclipse potential benefits” in chest pain patients who are at low risk for a cardiac event. “We believe that current recommendations to admit, observe, or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered,” they said.
The chance that chest pain signals a cardiac event is “exceedingly low” – only 0.06% – in adults who have two negative results on troponin testing, nonconcerning vital signs, and nonischemic ECG findings in the emergency department, according to a report published online May 18 in JAMA Internal Medicine.
More than 7 million ED visits for chest pain occurred in the United States during the most recent year for which data are available, and only a tiny fraction of them were found to have a serious cardiac cause. Both inpatient admission and extended observation for these cases represent a considerable burden to the health care system and to the patient, who often is exposed to unnecessary testing, hospital-acquired infections, venous thromboembolism, pneumonia, falls, and other iatrogenic events, said Dr. Michael B. Weinstock of the department of emergency medicine, Ohio State University, Columbus, and his associates.
To quantify the incidence of truly life-threatening cardiac events among patients admitted or observed for chest pain, the researchers analyzed the medical records of 45,416 ED cases seen at three Midwestern hospitals during a 5-year period. Roughly half were admitted to an inpatient unit or an extended observation unit.
The study focused on the 7,266 patients who presented with chest pain, tightness, burning, or pressure, and who had negative results on serial troponin testing, normal vital signs, and normal ECG findings. Only four of these patients (0.06%) had a life-threatening outcome of interest: arrhythmia, ST-elevation myocardial infarction, cardiac or respiratory arrest, or death. Notably, one patient had a periprocedural MI and another had a STEMI during a stress test. A third patient, an 80-year-old man with coronary artery disease, hypertension, diabetes, obesity, chronic heart failure, chronic obstructive pulmonary disease, and renal failure, had noncardiac chest pain from massive GI bleeding secondary to warfarin coagulopathy. And a woman with hypertension, CAD, and a coronary artery bypass graft developed bradyasystolic cardiac arrest when given nitroglycerin, the investigators said (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1674]).
“Our findings support the notion that adverse iatrogenic events as a result of admission may eclipse potential benefits” in chest pain patients who are at low risk for a cardiac event. “We believe that current recommendations to admit, observe, or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered,” they said.
FROM JAMA INTERNAL MEDICINE
Chest pain: Risks of evaluation may outweigh benefits
The chance that chest pain signals a cardiac event is “exceedingly low” – only 0.06% – in adults who have two negative results on troponin testing, nonconcerning vital signs, and nonischemic ECG findings in the emergency department, according to a report published online May 18 in JAMA Internal Medicine.
More than 7 million ED visits for chest pain occurred in the United States during the most recent year for which data are available, and only a tiny fraction of them were found to have a serious cardiac cause. Both inpatient admission and extended observation for these cases represent a considerable burden to the health care system and to the patient, who often is exposed to unnecessary testing, hospital-acquired infections, venous thromboembolism, pneumonia, falls, and other iatrogenic events, said Dr. Michael B. Weinstock of the department of emergency medicine, Ohio State University, Columbus, and his associates.
To quantify the incidence of truly life-threatening cardiac events among patients admitted or observed for chest pain, the researchers analyzed the medical records of 45,416 ED cases seen at three Midwestern hospitals during a 5-year period. Roughly half were admitted to an inpatient unit or an extended observation unit.
The study focused on the 7,266 patients who presented with chest pain, tightness, burning, or pressure, and who had negative results on serial troponin testing, normal vital signs, and normal ECG findings. Only four of these patients (0.06%) had a life-threatening outcome of interest: arrhythmia, ST-elevation myocardial infarction, cardiac or respiratory arrest, or death. Notably, one patient had a periprocedural MI and another had a STEMI during a stress test. A third patient, an 80-year-old man with coronary artery disease, hypertension, diabetes, obesity, chronic heart failure, chronic obstructive pulmonary disease, and renal failure, had noncardiac chest pain from massive GI bleeding secondary to warfarin coagulopathy. And a woman with hypertension, CAD, and a coronary artery bypass graft developed bradyasystolic cardiac arrest when given nitroglycerin, the investigators said (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1674]).
“Our findings support the notion that adverse iatrogenic events as a result of admission may eclipse potential benefits” in chest pain patients who are at low risk for a cardiac event. “We believe that current recommendations to admit, observe, or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered,” they said.
The findings of Weinstock et al. are consistent with our own results from focus groups of internists and cardiologists: Physicians often anticipate they’ll regret missing a cardiac diagnosis and reflexively value taking some action over inaction, cognitive biases that ultimately lead to unnecessary testing and invasive treatment of patients with chest pain.
|
|
Dr. Rita Redberg |
For their part, patients also greatly overestimate the benefits of tests and treatments while greatly underestimating their risks. Given accurate and complete information about harms and benefits of certain interventions, many chest pain patients would make different choices.
Grace A. Lin, M.D., is in the department of medicine at the University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies. Rita F. Redberg, M.D., is professor and director of women’s cardiovascular services at University of California, San Francisco, and is chief editor of JAMA Internal Medicine. Dr. Lin and Dr. Redberg reported having no financial conflicts of interest. They made these remarks in an editorial accompanying Dr. Weinstock’s report (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1693]).
The findings of Weinstock et al. are consistent with our own results from focus groups of internists and cardiologists: Physicians often anticipate they’ll regret missing a cardiac diagnosis and reflexively value taking some action over inaction, cognitive biases that ultimately lead to unnecessary testing and invasive treatment of patients with chest pain.
|
|
Dr. Rita Redberg |
For their part, patients also greatly overestimate the benefits of tests and treatments while greatly underestimating their risks. Given accurate and complete information about harms and benefits of certain interventions, many chest pain patients would make different choices.
Grace A. Lin, M.D., is in the department of medicine at the University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies. Rita F. Redberg, M.D., is professor and director of women’s cardiovascular services at University of California, San Francisco, and is chief editor of JAMA Internal Medicine. Dr. Lin and Dr. Redberg reported having no financial conflicts of interest. They made these remarks in an editorial accompanying Dr. Weinstock’s report (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1693]).
The findings of Weinstock et al. are consistent with our own results from focus groups of internists and cardiologists: Physicians often anticipate they’ll regret missing a cardiac diagnosis and reflexively value taking some action over inaction, cognitive biases that ultimately lead to unnecessary testing and invasive treatment of patients with chest pain.
|
|
Dr. Rita Redberg |
For their part, patients also greatly overestimate the benefits of tests and treatments while greatly underestimating their risks. Given accurate and complete information about harms and benefits of certain interventions, many chest pain patients would make different choices.
Grace A. Lin, M.D., is in the department of medicine at the University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies. Rita F. Redberg, M.D., is professor and director of women’s cardiovascular services at University of California, San Francisco, and is chief editor of JAMA Internal Medicine. Dr. Lin and Dr. Redberg reported having no financial conflicts of interest. They made these remarks in an editorial accompanying Dr. Weinstock’s report (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1693]).
The chance that chest pain signals a cardiac event is “exceedingly low” – only 0.06% – in adults who have two negative results on troponin testing, nonconcerning vital signs, and nonischemic ECG findings in the emergency department, according to a report published online May 18 in JAMA Internal Medicine.
More than 7 million ED visits for chest pain occurred in the United States during the most recent year for which data are available, and only a tiny fraction of them were found to have a serious cardiac cause. Both inpatient admission and extended observation for these cases represent a considerable burden to the health care system and to the patient, who often is exposed to unnecessary testing, hospital-acquired infections, venous thromboembolism, pneumonia, falls, and other iatrogenic events, said Dr. Michael B. Weinstock of the department of emergency medicine, Ohio State University, Columbus, and his associates.
To quantify the incidence of truly life-threatening cardiac events among patients admitted or observed for chest pain, the researchers analyzed the medical records of 45,416 ED cases seen at three Midwestern hospitals during a 5-year period. Roughly half were admitted to an inpatient unit or an extended observation unit.
The study focused on the 7,266 patients who presented with chest pain, tightness, burning, or pressure, and who had negative results on serial troponin testing, normal vital signs, and normal ECG findings. Only four of these patients (0.06%) had a life-threatening outcome of interest: arrhythmia, ST-elevation myocardial infarction, cardiac or respiratory arrest, or death. Notably, one patient had a periprocedural MI and another had a STEMI during a stress test. A third patient, an 80-year-old man with coronary artery disease, hypertension, diabetes, obesity, chronic heart failure, chronic obstructive pulmonary disease, and renal failure, had noncardiac chest pain from massive GI bleeding secondary to warfarin coagulopathy. And a woman with hypertension, CAD, and a coronary artery bypass graft developed bradyasystolic cardiac arrest when given nitroglycerin, the investigators said (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1674]).
“Our findings support the notion that adverse iatrogenic events as a result of admission may eclipse potential benefits” in chest pain patients who are at low risk for a cardiac event. “We believe that current recommendations to admit, observe, or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered,” they said.
The chance that chest pain signals a cardiac event is “exceedingly low” – only 0.06% – in adults who have two negative results on troponin testing, nonconcerning vital signs, and nonischemic ECG findings in the emergency department, according to a report published online May 18 in JAMA Internal Medicine.
More than 7 million ED visits for chest pain occurred in the United States during the most recent year for which data are available, and only a tiny fraction of them were found to have a serious cardiac cause. Both inpatient admission and extended observation for these cases represent a considerable burden to the health care system and to the patient, who often is exposed to unnecessary testing, hospital-acquired infections, venous thromboembolism, pneumonia, falls, and other iatrogenic events, said Dr. Michael B. Weinstock of the department of emergency medicine, Ohio State University, Columbus, and his associates.
To quantify the incidence of truly life-threatening cardiac events among patients admitted or observed for chest pain, the researchers analyzed the medical records of 45,416 ED cases seen at three Midwestern hospitals during a 5-year period. Roughly half were admitted to an inpatient unit or an extended observation unit.
The study focused on the 7,266 patients who presented with chest pain, tightness, burning, or pressure, and who had negative results on serial troponin testing, normal vital signs, and normal ECG findings. Only four of these patients (0.06%) had a life-threatening outcome of interest: arrhythmia, ST-elevation myocardial infarction, cardiac or respiratory arrest, or death. Notably, one patient had a periprocedural MI and another had a STEMI during a stress test. A third patient, an 80-year-old man with coronary artery disease, hypertension, diabetes, obesity, chronic heart failure, chronic obstructive pulmonary disease, and renal failure, had noncardiac chest pain from massive GI bleeding secondary to warfarin coagulopathy. And a woman with hypertension, CAD, and a coronary artery bypass graft developed bradyasystolic cardiac arrest when given nitroglycerin, the investigators said (JAMA Intern. Med. 2015 May 18 [doi:10.1001/jamainternmed.2015.1674]).
“Our findings support the notion that adverse iatrogenic events as a result of admission may eclipse potential benefits” in chest pain patients who are at low risk for a cardiac event. “We believe that current recommendations to admit, observe, or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered,” they said.
FROM JAMA INTERNAL MEDICINE
Key clinical point: The chance that chest pain signals a cardiac event is “exceedingly low” in ED patients who have negative serial biomarker results, nonconcerning vital signs, and nonischemic ECG findings.
Major finding: Only 4 of the 7,266 patients (0.06%) who presented with chest pain, tightness, burning, or pressure, and who had negative results on serial troponin testing, normal vital signs, and normal ECG findings, had a life-threatening cardiac event.
Data source: An analysis of the medical records of 45,416 adults admitted or observed for chest pain at three Midwestern hospitals during a 5-year period.
Disclosures: Dr. Weinstock had no relevant disclosures; two of his associates reported ties to AstraZeneca and Callibra.
Biologics cut cholesterol, may reduce mortality
Monoclonal antibodies that target PCSK9 – namely evolocumab, alirocumab, and bococizumab – not only profoundly reduce LDL cholesterol and lipoprotein(a) in patients with hypercholesterolemia, but also appear to decrease all-cause mortality and the incidence of myocardial infarction, according to a meta-analysis.
To date, no single study of these agents has been powered to show an effect on mortality or cardiovascular events. But “our large-scale report” – a meta-analysis of 24 phase II and phase III randomized clinical trials comparing the biologics against placebo or ezetimibe – “is the first to show [such] a benefit with these novel agents,” said Dr. Eliano Pio Navarese of the division of cardiology, pulmonology, and vascular medicine, Heinrich Heine University, Dusseldorf, and his associates.
The results must be considered preliminary because this study is a meta-analysis of early-phase trials, not a prospective, randomized phase III trial. But because all the sensitivity analyses and subgroup analyses confirmed the main conclusions of the meta-analysis, it is likely that “the overall benefit is robust and justified,” they noted.
Two pharmaceutical companies have applied to the Food and Drug Administration for approval to use the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors evolocumab (Amgen) and alirocumab (Sanofi Aventis) to treat high cholesterol, and four large trials are underway to assess the anti-PCSK9 monoclonal antibodies’ effects on cardiovascular outcomes. If the findings of this meta-analysis are confirmed and these agents are approved, “it could have a profound effect on public health,” Dr. Navarese and his associates said.
All of the 24 trials included in the meta-analysis were funded by industry, and all were multicenter. They involved 10,159 patients with familial, nonfamilial, mixed, or unspecified hypercholesterolemia. Seventeen of the trials were of less than 6 months’ duration, and four were a year or more in length.
The PCSK9 inhibitors reduced LDL cholesterol by 47%, raised HDL cholesterol by 6%, and decreased lipoprotein(a) levels by 26%, compared with placebo or ezetimibe.
All-cause mortality was 0.31% among patients who took PCSK9-targeting monoclonal antibodies, significantly lower than the 0.53% all-cause mortality among patients who did not (odds ratio, 0.45). However, the “clinical event outcomes should be interpreted with caution because the data were derived from a small number of events.” There were 19 deaths among patients receiving the medications and 21 among those not receiving them, Dr. Navarese and his associates noted (Ann Intern. Med. 2015 [doi:10.7326/M14-2957]).
The difference between the two groups in cardiovascular mortality (0.19% vs. 0.33%) was nonsignificant. Again, the number of cardiovascular deaths was small: 12 among patients receiving the medications and 13 among those not receiving them.
Regarding MI, 10 of the reviewed trials (5,195 patients) reported data for this outcome. MI rates were 0.58% among patients receiving PCSK9 inhibitors and 1.00% among those who were not receiving them, a significant reduction. However, there were 19 MIs in each patient group.
The medications were associated with significantly lower rates of elevated serum creatine kinase (1.96% vs 2.31%). This suggests that anti-PCSK9 monoclonal antibodies may exert a muscle-sparing effect, the investigators said.
Overall rates of serious adverse events were 9.36% with the medications and 7.73% without them. Rates of treatment discontinuation were similar between the two study groups.
This study was supported in part by CRC 1116 Masterswitches in Myocardial Ischemia, funded by the German Research Council. Dr. Navarese reported having no disclosures; one of his associates reported receiving consulting fees from Sanofi.
This meta-analysis contributes important preliminary information as the Food and Drug Administration considers approving PCSK9 inhibitors for hypercholesterolemia, and can be met with cautious enthusiasm. But the findings must be confirmed in long-term trials with prespecified CVD endpoints and close monitoring of adverse events.
The encouraging results regarding mortality and myocardial infarctions in particular warrant caution, because most of the trials were of small or moderate size, had short follow-up periods, and were not specifically designed to detect differences in clinical outcomes or rare adverse events. Longer follow-up under real-world conditions is necessary to better characterize the safety profile of these medications.
Miguel Cainzos-Achirica, M.D., of Johns Hopkins Bloomberg School of Public Health, Baltimore, and four other contributors made these remarks in an editorial accompanying Dr. Navarese’s report (Ann. Intern. Med. 2015 [doi:10.7326/M14-2957]). Their financial disclosures are available at www.acponline.org.
This meta-analysis contributes important preliminary information as the Food and Drug Administration considers approving PCSK9 inhibitors for hypercholesterolemia, and can be met with cautious enthusiasm. But the findings must be confirmed in long-term trials with prespecified CVD endpoints and close monitoring of adverse events.
The encouraging results regarding mortality and myocardial infarctions in particular warrant caution, because most of the trials were of small or moderate size, had short follow-up periods, and were not specifically designed to detect differences in clinical outcomes or rare adverse events. Longer follow-up under real-world conditions is necessary to better characterize the safety profile of these medications.
Miguel Cainzos-Achirica, M.D., of Johns Hopkins Bloomberg School of Public Health, Baltimore, and four other contributors made these remarks in an editorial accompanying Dr. Navarese’s report (Ann. Intern. Med. 2015 [doi:10.7326/M14-2957]). Their financial disclosures are available at www.acponline.org.
This meta-analysis contributes important preliminary information as the Food and Drug Administration considers approving PCSK9 inhibitors for hypercholesterolemia, and can be met with cautious enthusiasm. But the findings must be confirmed in long-term trials with prespecified CVD endpoints and close monitoring of adverse events.
The encouraging results regarding mortality and myocardial infarctions in particular warrant caution, because most of the trials were of small or moderate size, had short follow-up periods, and were not specifically designed to detect differences in clinical outcomes or rare adverse events. Longer follow-up under real-world conditions is necessary to better characterize the safety profile of these medications.
Miguel Cainzos-Achirica, M.D., of Johns Hopkins Bloomberg School of Public Health, Baltimore, and four other contributors made these remarks in an editorial accompanying Dr. Navarese’s report (Ann. Intern. Med. 2015 [doi:10.7326/M14-2957]). Their financial disclosures are available at www.acponline.org.
Monoclonal antibodies that target PCSK9 – namely evolocumab, alirocumab, and bococizumab – not only profoundly reduce LDL cholesterol and lipoprotein(a) in patients with hypercholesterolemia, but also appear to decrease all-cause mortality and the incidence of myocardial infarction, according to a meta-analysis.
To date, no single study of these agents has been powered to show an effect on mortality or cardiovascular events. But “our large-scale report” – a meta-analysis of 24 phase II and phase III randomized clinical trials comparing the biologics against placebo or ezetimibe – “is the first to show [such] a benefit with these novel agents,” said Dr. Eliano Pio Navarese of the division of cardiology, pulmonology, and vascular medicine, Heinrich Heine University, Dusseldorf, and his associates.
The results must be considered preliminary because this study is a meta-analysis of early-phase trials, not a prospective, randomized phase III trial. But because all the sensitivity analyses and subgroup analyses confirmed the main conclusions of the meta-analysis, it is likely that “the overall benefit is robust and justified,” they noted.
Two pharmaceutical companies have applied to the Food and Drug Administration for approval to use the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors evolocumab (Amgen) and alirocumab (Sanofi Aventis) to treat high cholesterol, and four large trials are underway to assess the anti-PCSK9 monoclonal antibodies’ effects on cardiovascular outcomes. If the findings of this meta-analysis are confirmed and these agents are approved, “it could have a profound effect on public health,” Dr. Navarese and his associates said.
All of the 24 trials included in the meta-analysis were funded by industry, and all were multicenter. They involved 10,159 patients with familial, nonfamilial, mixed, or unspecified hypercholesterolemia. Seventeen of the trials were of less than 6 months’ duration, and four were a year or more in length.
The PCSK9 inhibitors reduced LDL cholesterol by 47%, raised HDL cholesterol by 6%, and decreased lipoprotein(a) levels by 26%, compared with placebo or ezetimibe.
All-cause mortality was 0.31% among patients who took PCSK9-targeting monoclonal antibodies, significantly lower than the 0.53% all-cause mortality among patients who did not (odds ratio, 0.45). However, the “clinical event outcomes should be interpreted with caution because the data were derived from a small number of events.” There were 19 deaths among patients receiving the medications and 21 among those not receiving them, Dr. Navarese and his associates noted (Ann Intern. Med. 2015 [doi:10.7326/M14-2957]).
The difference between the two groups in cardiovascular mortality (0.19% vs. 0.33%) was nonsignificant. Again, the number of cardiovascular deaths was small: 12 among patients receiving the medications and 13 among those not receiving them.
Regarding MI, 10 of the reviewed trials (5,195 patients) reported data for this outcome. MI rates were 0.58% among patients receiving PCSK9 inhibitors and 1.00% among those who were not receiving them, a significant reduction. However, there were 19 MIs in each patient group.
The medications were associated with significantly lower rates of elevated serum creatine kinase (1.96% vs 2.31%). This suggests that anti-PCSK9 monoclonal antibodies may exert a muscle-sparing effect, the investigators said.
Overall rates of serious adverse events were 9.36% with the medications and 7.73% without them. Rates of treatment discontinuation were similar between the two study groups.
This study was supported in part by CRC 1116 Masterswitches in Myocardial Ischemia, funded by the German Research Council. Dr. Navarese reported having no disclosures; one of his associates reported receiving consulting fees from Sanofi.
Monoclonal antibodies that target PCSK9 – namely evolocumab, alirocumab, and bococizumab – not only profoundly reduce LDL cholesterol and lipoprotein(a) in patients with hypercholesterolemia, but also appear to decrease all-cause mortality and the incidence of myocardial infarction, according to a meta-analysis.
To date, no single study of these agents has been powered to show an effect on mortality or cardiovascular events. But “our large-scale report” – a meta-analysis of 24 phase II and phase III randomized clinical trials comparing the biologics against placebo or ezetimibe – “is the first to show [such] a benefit with these novel agents,” said Dr. Eliano Pio Navarese of the division of cardiology, pulmonology, and vascular medicine, Heinrich Heine University, Dusseldorf, and his associates.
The results must be considered preliminary because this study is a meta-analysis of early-phase trials, not a prospective, randomized phase III trial. But because all the sensitivity analyses and subgroup analyses confirmed the main conclusions of the meta-analysis, it is likely that “the overall benefit is robust and justified,” they noted.
Two pharmaceutical companies have applied to the Food and Drug Administration for approval to use the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors evolocumab (Amgen) and alirocumab (Sanofi Aventis) to treat high cholesterol, and four large trials are underway to assess the anti-PCSK9 monoclonal antibodies’ effects on cardiovascular outcomes. If the findings of this meta-analysis are confirmed and these agents are approved, “it could have a profound effect on public health,” Dr. Navarese and his associates said.
All of the 24 trials included in the meta-analysis were funded by industry, and all were multicenter. They involved 10,159 patients with familial, nonfamilial, mixed, or unspecified hypercholesterolemia. Seventeen of the trials were of less than 6 months’ duration, and four were a year or more in length.
The PCSK9 inhibitors reduced LDL cholesterol by 47%, raised HDL cholesterol by 6%, and decreased lipoprotein(a) levels by 26%, compared with placebo or ezetimibe.
All-cause mortality was 0.31% among patients who took PCSK9-targeting monoclonal antibodies, significantly lower than the 0.53% all-cause mortality among patients who did not (odds ratio, 0.45). However, the “clinical event outcomes should be interpreted with caution because the data were derived from a small number of events.” There were 19 deaths among patients receiving the medications and 21 among those not receiving them, Dr. Navarese and his associates noted (Ann Intern. Med. 2015 [doi:10.7326/M14-2957]).
The difference between the two groups in cardiovascular mortality (0.19% vs. 0.33%) was nonsignificant. Again, the number of cardiovascular deaths was small: 12 among patients receiving the medications and 13 among those not receiving them.
Regarding MI, 10 of the reviewed trials (5,195 patients) reported data for this outcome. MI rates were 0.58% among patients receiving PCSK9 inhibitors and 1.00% among those who were not receiving them, a significant reduction. However, there were 19 MIs in each patient group.
The medications were associated with significantly lower rates of elevated serum creatine kinase (1.96% vs 2.31%). This suggests that anti-PCSK9 monoclonal antibodies may exert a muscle-sparing effect, the investigators said.
Overall rates of serious adverse events were 9.36% with the medications and 7.73% without them. Rates of treatment discontinuation were similar between the two study groups.
This study was supported in part by CRC 1116 Masterswitches in Myocardial Ischemia, funded by the German Research Council. Dr. Navarese reported having no disclosures; one of his associates reported receiving consulting fees from Sanofi.
FROM ANNALS OF INTERNAL MEDICINE
Key clinical point: Monoclonal antibodies that target PCSK9 cut LDL cholesterol by 47% and appear to reduce all-cause mortality.
Major finding: All-cause mortality was 0.31% in patients who took PCSK9-targeting monoclonal antibodies, compared with 0.53% in patients who did not (OR, 0.45).
Data source: A systematic review and meta-analysis of 24 phase II and III RCTs involving 10,159 patients with hypercholesterolemia.
Disclosures: This study was supported in part by CRC 1116 Masterswitches in Myocardial Ischemia, funded by the German Research Council. Dr. Navarese reported having no disclosures; one of his associates reported receiving consulting fees from Sanofi.
Football Practice a Major Source of Concussions
Football practice is a major source of concussions in all pediatric age groups, according to a report published online May 4 in JAMA Pediatrics.
“Concussions during practice might be mitigated and should prompt an evaluation of technique and head impact exposure. Although it is more difficult to change the intensity or conditions of a game, many strategies can be used during practice to limit player-to-player contact and other potentially injurious behaviors,” said Thomas P. Dompier, Ph.D., of the Datalys Center for Sports Injury Research and Prevention, Indianapolis, and his associates.
A recent Institute of Medicine report emphasized the need for better data regarding the incidence of concussion among athletes aged 5-23 years. In what they described as the first study of its kind, the investigators assessed information pertaining to concussion during two consecutive football seasons from three large injury surveillance programs: the Youth Football Safety Study, which included 118 teams of players aged 5-14 years; the National Athletic Treatment, Injury, and Outcomes Network, which included 96 teams of high school players; and the National Collegiate Athletic Association Injury Surveillance Program, which included 24 teams of college players.
A clear majority of concussions in the older age groups – 57.7% among high schoolers and 57.6% among college athletes – occurred during practice. A smaller but still substantial proportion of concussions (46% ) in the youngest age group occurred during practice. The lower percentage among players aged 5-14 years may be attributable to their lesser exposure. Youth football teams typically practice only once or twice per week and have only 20-25 players per team, while high school and college teams have many more practices per week and typically have 75-110 players per team, the investigators reported (JAMA Ped. 2015 May 4 [doi:10.1001/jamapediatrics.2015.0210]).
Based on these findings, an estimated 1 in 30 youth football players, 1 in 14 high school players, and 1 in 20 college players sustain at least one concussion every year, the investigators added. The study results indicate that limiting contact during practices would help control the risk of concussion among football players of all ages, Dr. Dompier and his associates said.
Football practice is a major source of concussions in all pediatric age groups, according to a report published online May 4 in JAMA Pediatrics.
“Concussions during practice might be mitigated and should prompt an evaluation of technique and head impact exposure. Although it is more difficult to change the intensity or conditions of a game, many strategies can be used during practice to limit player-to-player contact and other potentially injurious behaviors,” said Thomas P. Dompier, Ph.D., of the Datalys Center for Sports Injury Research and Prevention, Indianapolis, and his associates.
A recent Institute of Medicine report emphasized the need for better data regarding the incidence of concussion among athletes aged 5-23 years. In what they described as the first study of its kind, the investigators assessed information pertaining to concussion during two consecutive football seasons from three large injury surveillance programs: the Youth Football Safety Study, which included 118 teams of players aged 5-14 years; the National Athletic Treatment, Injury, and Outcomes Network, which included 96 teams of high school players; and the National Collegiate Athletic Association Injury Surveillance Program, which included 24 teams of college players.
A clear majority of concussions in the older age groups – 57.7% among high schoolers and 57.6% among college athletes – occurred during practice. A smaller but still substantial proportion of concussions (46% ) in the youngest age group occurred during practice. The lower percentage among players aged 5-14 years may be attributable to their lesser exposure. Youth football teams typically practice only once or twice per week and have only 20-25 players per team, while high school and college teams have many more practices per week and typically have 75-110 players per team, the investigators reported (JAMA Ped. 2015 May 4 [doi:10.1001/jamapediatrics.2015.0210]).
Based on these findings, an estimated 1 in 30 youth football players, 1 in 14 high school players, and 1 in 20 college players sustain at least one concussion every year, the investigators added. The study results indicate that limiting contact during practices would help control the risk of concussion among football players of all ages, Dr. Dompier and his associates said.
Football practice is a major source of concussions in all pediatric age groups, according to a report published online May 4 in JAMA Pediatrics.
“Concussions during practice might be mitigated and should prompt an evaluation of technique and head impact exposure. Although it is more difficult to change the intensity or conditions of a game, many strategies can be used during practice to limit player-to-player contact and other potentially injurious behaviors,” said Thomas P. Dompier, Ph.D., of the Datalys Center for Sports Injury Research and Prevention, Indianapolis, and his associates.
A recent Institute of Medicine report emphasized the need for better data regarding the incidence of concussion among athletes aged 5-23 years. In what they described as the first study of its kind, the investigators assessed information pertaining to concussion during two consecutive football seasons from three large injury surveillance programs: the Youth Football Safety Study, which included 118 teams of players aged 5-14 years; the National Athletic Treatment, Injury, and Outcomes Network, which included 96 teams of high school players; and the National Collegiate Athletic Association Injury Surveillance Program, which included 24 teams of college players.
A clear majority of concussions in the older age groups – 57.7% among high schoolers and 57.6% among college athletes – occurred during practice. A smaller but still substantial proportion of concussions (46% ) in the youngest age group occurred during practice. The lower percentage among players aged 5-14 years may be attributable to their lesser exposure. Youth football teams typically practice only once or twice per week and have only 20-25 players per team, while high school and college teams have many more practices per week and typically have 75-110 players per team, the investigators reported (JAMA Ped. 2015 May 4 [doi:10.1001/jamapediatrics.2015.0210]).
Based on these findings, an estimated 1 in 30 youth football players, 1 in 14 high school players, and 1 in 20 college players sustain at least one concussion every year, the investigators added. The study results indicate that limiting contact during practices would help control the risk of concussion among football players of all ages, Dr. Dompier and his associates said.
FROM JAMA PEDIATRICS
Football practice a major source of concussions
Football practice is a major source of concussions in all pediatric age groups, according to a report published online May 4 in JAMA Pediatrics.
“Concussions during practice might be mitigated and should prompt an evaluation of technique and head impact exposure. Although it is more difficult to change the intensity or conditions of a game, many strategies can be used during practice to limit player-to-player contact and other potentially injurious behaviors,” said Thomas P. Dompier, Ph.D., of the Datalys Center for Sports Injury Research and Prevention, Indianapolis, and his associates.
A recent Institute of Medicine report emphasized the need for better data regarding the incidence of concussion among athletes aged 5-23 years. In what they described as the first study of its kind, the investigators assessed information pertaining to concussion during two consecutive football seasons from three large injury surveillance programs: the Youth Football Safety Study, which included 118 teams of players aged 5-14 years; the National Athletic Treatment, Injury, and Outcomes Network, which included 96 teams of high school players; and the National Collegiate Athletic Association Injury Surveillance Program, which included 24 teams of college players.
A clear majority of concussions in the older age groups – 57.7% among high schoolers and 57.6% among college athletes – occurred during practice. A smaller but still substantial proportion of concussions (46% ) in the youngest age group occurred during practice. The lower percentage among players aged 5-14 years may be attributable to their lesser exposure. Youth football teams typically practice only once or twice per week and have only 20-25 players per team, while high school and college teams have many more practices per week and typically have 75-110 players per team, the investigators reported (JAMA Ped. 2015 May 4 [doi:10.1001/jamapediatrics.2015.0210]).
Based on these findings, an estimated 1 in 30 youth football players, 1 in 14 high school players, and 1 in 20 college players sustain at least one concussion every year, the investigators added. The study results indicate that limiting contact during practices would help control the risk of concussion among football players of all ages, Dr. Dompier and his associates said.
Football practice is a major source of concussions in all pediatric age groups, according to a report published online May 4 in JAMA Pediatrics.
“Concussions during practice might be mitigated and should prompt an evaluation of technique and head impact exposure. Although it is more difficult to change the intensity or conditions of a game, many strategies can be used during practice to limit player-to-player contact and other potentially injurious behaviors,” said Thomas P. Dompier, Ph.D., of the Datalys Center for Sports Injury Research and Prevention, Indianapolis, and his associates.
A recent Institute of Medicine report emphasized the need for better data regarding the incidence of concussion among athletes aged 5-23 years. In what they described as the first study of its kind, the investigators assessed information pertaining to concussion during two consecutive football seasons from three large injury surveillance programs: the Youth Football Safety Study, which included 118 teams of players aged 5-14 years; the National Athletic Treatment, Injury, and Outcomes Network, which included 96 teams of high school players; and the National Collegiate Athletic Association Injury Surveillance Program, which included 24 teams of college players.
A clear majority of concussions in the older age groups – 57.7% among high schoolers and 57.6% among college athletes – occurred during practice. A smaller but still substantial proportion of concussions (46% ) in the youngest age group occurred during practice. The lower percentage among players aged 5-14 years may be attributable to their lesser exposure. Youth football teams typically practice only once or twice per week and have only 20-25 players per team, while high school and college teams have many more practices per week and typically have 75-110 players per team, the investigators reported (JAMA Ped. 2015 May 4 [doi:10.1001/jamapediatrics.2015.0210]).
Based on these findings, an estimated 1 in 30 youth football players, 1 in 14 high school players, and 1 in 20 college players sustain at least one concussion every year, the investigators added. The study results indicate that limiting contact during practices would help control the risk of concussion among football players of all ages, Dr. Dompier and his associates said.
Football practice is a major source of concussions in all pediatric age groups, according to a report published online May 4 in JAMA Pediatrics.
“Concussions during practice might be mitigated and should prompt an evaluation of technique and head impact exposure. Although it is more difficult to change the intensity or conditions of a game, many strategies can be used during practice to limit player-to-player contact and other potentially injurious behaviors,” said Thomas P. Dompier, Ph.D., of the Datalys Center for Sports Injury Research and Prevention, Indianapolis, and his associates.
A recent Institute of Medicine report emphasized the need for better data regarding the incidence of concussion among athletes aged 5-23 years. In what they described as the first study of its kind, the investigators assessed information pertaining to concussion during two consecutive football seasons from three large injury surveillance programs: the Youth Football Safety Study, which included 118 teams of players aged 5-14 years; the National Athletic Treatment, Injury, and Outcomes Network, which included 96 teams of high school players; and the National Collegiate Athletic Association Injury Surveillance Program, which included 24 teams of college players.
A clear majority of concussions in the older age groups – 57.7% among high schoolers and 57.6% among college athletes – occurred during practice. A smaller but still substantial proportion of concussions (46% ) in the youngest age group occurred during practice. The lower percentage among players aged 5-14 years may be attributable to their lesser exposure. Youth football teams typically practice only once or twice per week and have only 20-25 players per team, while high school and college teams have many more practices per week and typically have 75-110 players per team, the investigators reported (JAMA Ped. 2015 May 4 [doi:10.1001/jamapediatrics.2015.0210]).
Based on these findings, an estimated 1 in 30 youth football players, 1 in 14 high school players, and 1 in 20 college players sustain at least one concussion every year, the investigators added. The study results indicate that limiting contact during practices would help control the risk of concussion among football players of all ages, Dr. Dompier and his associates said.
FROM JAMA PEDIATRICS
Key clinical point: Football practice is a major, and supposedly preventable, source of concussions in all age groups.
Major finding: 57.7% of concussions among high school football players, 57.6% among college players, and 46% among youth players occurred during practices.
Data source: An observational cohort study assessing concussions during two consecutive seasons among U.S. football players aged 5-23 years on 238 teams across the country.
Disclosures: This study was funded by USA Football, the National Athletic Trainers’ Association Research and Education Foundation, BioCrossroads, the Central Indiana Corporate Partnership Foundation, and the National Collegiate Athletic Association. Dr. Dompier reported having no relevant financial disclosures; one of his associates is the chief medical officer of the NCAA.
