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Can boxing training improve Parkinson reaction times?
NEW YORK – A small pilot study has shown that patients with Parkinson’s disease who participated in the Rock Steady Boxing non-contact training program may have faster reaction times than PD patients who did not participate in the program, according to a poster presented at the International Conference on Parkinson’s Disease and Movement Disorders.
“The novelty of this is that it shows how Rock Steady Boxing and exercise programs that use sequences and the learning of sequences could possibly help slow the decline, or maintain a level of functioning longer, in Parkinson’s disease,” said Christopher McLeod, a second-year medical student at New York Institute of Technology (NYIT) College of Osteopathic Medicine, Old Westbury, N.Y.
Rock Steady Boxing is a non-contact program tailored to Parkinson’s patients founded in 2006 by Scott Newman, an Indiana lawyer who was diagnosed with early onset Parkinson’s at age 40. The regimen involves intense one-on-one training centered around boxing. Rock Steady Boxing offers classes from coast to coast in the United States and in 13 other countries. Mr. McLeod is a volunteer at the NYIT chapter of Rock Steady Boxing in Old Westbury, N.Y.
Mr. McLeod studied 28 PD patients – 14 who had been taking Rock Steady Boxing classes at NYIT for at least 6 months and 14 controls. The goal of the study was to evaluate if the Rock Steady Boxing participants showed any improvement in procedural motor learning. His coauthor was Adena Leder, DO, a faculty neurologist and movement disorder specialist at NYIT,
“What’s new about this research is the procedural memory component and the Rock Steady Boxing program is just more of the vessel, so to speak,” Mr. McLeod said. “This is a pilot study. We wanted to see if Rock Steady Boxing would show benefits in these patients. There are some trends in my research that [indicate] it would; it did not have statistical significance, but we did see trend lines.”
The researchers used a modified Serial Reaction Time Test (SRTT) composed of seven blocks of 10 stimuli each with 30-second breaks between blocks. Blocks consisted of a random familiarization block, four learning blocks repeating the same sequence of stimuli, a transfer block of random stimuli, and a posttransfer block presenting the same sequence of stimuli from the four learning blocks.
They assessed procedural learning by comparing the reduction in response time over the four identical learning blocks as well as by comparing changes in response time when the subjects were subsequently exposed to the random transfer block.
Experienced boxers demonstrated faster reaction time over the four learning blocks, ranging from 795.32 vs. 906.89 ms in the first learning block to 674.79 vs. 787.32 ms in the fourth learning block (P = .19). In the random sequence transfer block, controls showed a 93.5-ms decrease in median reaction time vs. a 27.3-ms increase in reaction time of experienced boxers. One possible explanation the investigators noted is that the controls simply got better at reading the stimuli over time without actually learning the repeated sequence.
Mr. McLeod noted that a typical Rock Steady Boxing session starts with a warmup and stretch, then learning the boxing stance with the nondominant foot back, shoulders over the body and the head over the feet. The boxing moves involve sequences of different punching combinations — jab, jab, cross; left, left, right; jab, cross, hook. Then the class divides into separate circuits for boxing and exercise. The boxing circuit involves punching the speed bag – the small, air-filled, pear-shaped bag attached to a hook at eye level – as well as heavy bag and partner-held focus mitts, all with the aim of reinforcing the learned sequences. The exercise circuit focuses on muscle training and exercise with the goal of improving balance and gait.
“The boxing sequences help not only with cognitive ability but motor control,” Mr. McLeod said. “The program also helps with some of the nonmotor aspects of Parkinson’s disease. Depression is almost synonymous with Parkinson’s disease; this brings people together and builds camaraderie.”
Mr. McLeod said he hopes the research continues. “I’m hoping that this can be a jumping-off point for research going forward with procedural memory, Parkinson’s, and Rock Steady Boxing or programs like it,” he said. Future research should involve more subjects, measure improvement within same subjects who participate in the program, and account for variables such as age and gender.
Mr. McLeod and Dr. Leder reported having no relevant financial disclosures.
NEW YORK – A small pilot study has shown that patients with Parkinson’s disease who participated in the Rock Steady Boxing non-contact training program may have faster reaction times than PD patients who did not participate in the program, according to a poster presented at the International Conference on Parkinson’s Disease and Movement Disorders.
“The novelty of this is that it shows how Rock Steady Boxing and exercise programs that use sequences and the learning of sequences could possibly help slow the decline, or maintain a level of functioning longer, in Parkinson’s disease,” said Christopher McLeod, a second-year medical student at New York Institute of Technology (NYIT) College of Osteopathic Medicine, Old Westbury, N.Y.
Rock Steady Boxing is a non-contact program tailored to Parkinson’s patients founded in 2006 by Scott Newman, an Indiana lawyer who was diagnosed with early onset Parkinson’s at age 40. The regimen involves intense one-on-one training centered around boxing. Rock Steady Boxing offers classes from coast to coast in the United States and in 13 other countries. Mr. McLeod is a volunteer at the NYIT chapter of Rock Steady Boxing in Old Westbury, N.Y.
Mr. McLeod studied 28 PD patients – 14 who had been taking Rock Steady Boxing classes at NYIT for at least 6 months and 14 controls. The goal of the study was to evaluate if the Rock Steady Boxing participants showed any improvement in procedural motor learning. His coauthor was Adena Leder, DO, a faculty neurologist and movement disorder specialist at NYIT,
“What’s new about this research is the procedural memory component and the Rock Steady Boxing program is just more of the vessel, so to speak,” Mr. McLeod said. “This is a pilot study. We wanted to see if Rock Steady Boxing would show benefits in these patients. There are some trends in my research that [indicate] it would; it did not have statistical significance, but we did see trend lines.”
The researchers used a modified Serial Reaction Time Test (SRTT) composed of seven blocks of 10 stimuli each with 30-second breaks between blocks. Blocks consisted of a random familiarization block, four learning blocks repeating the same sequence of stimuli, a transfer block of random stimuli, and a posttransfer block presenting the same sequence of stimuli from the four learning blocks.
They assessed procedural learning by comparing the reduction in response time over the four identical learning blocks as well as by comparing changes in response time when the subjects were subsequently exposed to the random transfer block.
Experienced boxers demonstrated faster reaction time over the four learning blocks, ranging from 795.32 vs. 906.89 ms in the first learning block to 674.79 vs. 787.32 ms in the fourth learning block (P = .19). In the random sequence transfer block, controls showed a 93.5-ms decrease in median reaction time vs. a 27.3-ms increase in reaction time of experienced boxers. One possible explanation the investigators noted is that the controls simply got better at reading the stimuli over time without actually learning the repeated sequence.
Mr. McLeod noted that a typical Rock Steady Boxing session starts with a warmup and stretch, then learning the boxing stance with the nondominant foot back, shoulders over the body and the head over the feet. The boxing moves involve sequences of different punching combinations — jab, jab, cross; left, left, right; jab, cross, hook. Then the class divides into separate circuits for boxing and exercise. The boxing circuit involves punching the speed bag – the small, air-filled, pear-shaped bag attached to a hook at eye level – as well as heavy bag and partner-held focus mitts, all with the aim of reinforcing the learned sequences. The exercise circuit focuses on muscle training and exercise with the goal of improving balance and gait.
“The boxing sequences help not only with cognitive ability but motor control,” Mr. McLeod said. “The program also helps with some of the nonmotor aspects of Parkinson’s disease. Depression is almost synonymous with Parkinson’s disease; this brings people together and builds camaraderie.”
Mr. McLeod said he hopes the research continues. “I’m hoping that this can be a jumping-off point for research going forward with procedural memory, Parkinson’s, and Rock Steady Boxing or programs like it,” he said. Future research should involve more subjects, measure improvement within same subjects who participate in the program, and account for variables such as age and gender.
Mr. McLeod and Dr. Leder reported having no relevant financial disclosures.
NEW YORK – A small pilot study has shown that patients with Parkinson’s disease who participated in the Rock Steady Boxing non-contact training program may have faster reaction times than PD patients who did not participate in the program, according to a poster presented at the International Conference on Parkinson’s Disease and Movement Disorders.
“The novelty of this is that it shows how Rock Steady Boxing and exercise programs that use sequences and the learning of sequences could possibly help slow the decline, or maintain a level of functioning longer, in Parkinson’s disease,” said Christopher McLeod, a second-year medical student at New York Institute of Technology (NYIT) College of Osteopathic Medicine, Old Westbury, N.Y.
Rock Steady Boxing is a non-contact program tailored to Parkinson’s patients founded in 2006 by Scott Newman, an Indiana lawyer who was diagnosed with early onset Parkinson’s at age 40. The regimen involves intense one-on-one training centered around boxing. Rock Steady Boxing offers classes from coast to coast in the United States and in 13 other countries. Mr. McLeod is a volunteer at the NYIT chapter of Rock Steady Boxing in Old Westbury, N.Y.
Mr. McLeod studied 28 PD patients – 14 who had been taking Rock Steady Boxing classes at NYIT for at least 6 months and 14 controls. The goal of the study was to evaluate if the Rock Steady Boxing participants showed any improvement in procedural motor learning. His coauthor was Adena Leder, DO, a faculty neurologist and movement disorder specialist at NYIT,
“What’s new about this research is the procedural memory component and the Rock Steady Boxing program is just more of the vessel, so to speak,” Mr. McLeod said. “This is a pilot study. We wanted to see if Rock Steady Boxing would show benefits in these patients. There are some trends in my research that [indicate] it would; it did not have statistical significance, but we did see trend lines.”
The researchers used a modified Serial Reaction Time Test (SRTT) composed of seven blocks of 10 stimuli each with 30-second breaks between blocks. Blocks consisted of a random familiarization block, four learning blocks repeating the same sequence of stimuli, a transfer block of random stimuli, and a posttransfer block presenting the same sequence of stimuli from the four learning blocks.
They assessed procedural learning by comparing the reduction in response time over the four identical learning blocks as well as by comparing changes in response time when the subjects were subsequently exposed to the random transfer block.
Experienced boxers demonstrated faster reaction time over the four learning blocks, ranging from 795.32 vs. 906.89 ms in the first learning block to 674.79 vs. 787.32 ms in the fourth learning block (P = .19). In the random sequence transfer block, controls showed a 93.5-ms decrease in median reaction time vs. a 27.3-ms increase in reaction time of experienced boxers. One possible explanation the investigators noted is that the controls simply got better at reading the stimuli over time without actually learning the repeated sequence.
Mr. McLeod noted that a typical Rock Steady Boxing session starts with a warmup and stretch, then learning the boxing stance with the nondominant foot back, shoulders over the body and the head over the feet. The boxing moves involve sequences of different punching combinations — jab, jab, cross; left, left, right; jab, cross, hook. Then the class divides into separate circuits for boxing and exercise. The boxing circuit involves punching the speed bag – the small, air-filled, pear-shaped bag attached to a hook at eye level – as well as heavy bag and partner-held focus mitts, all with the aim of reinforcing the learned sequences. The exercise circuit focuses on muscle training and exercise with the goal of improving balance and gait.
“The boxing sequences help not only with cognitive ability but motor control,” Mr. McLeod said. “The program also helps with some of the nonmotor aspects of Parkinson’s disease. Depression is almost synonymous with Parkinson’s disease; this brings people together and builds camaraderie.”
Mr. McLeod said he hopes the research continues. “I’m hoping that this can be a jumping-off point for research going forward with procedural memory, Parkinson’s, and Rock Steady Boxing or programs like it,” he said. Future research should involve more subjects, measure improvement within same subjects who participate in the program, and account for variables such as age and gender.
Mr. McLeod and Dr. Leder reported having no relevant financial disclosures.
REPORTING FROM ICPDMD 2018
Key clinical point: Exercise programs may help improve procedural learning in individuals with Parkinson’s disease.
Major finding: Rock Steady Boxing experienced boxers demonstrated reaction times ranging from 795.32 vs. 906.89 ms to 674.79 vs. 787.32 ms across four test blocks.
Study details: Pilot study of 14 Parkinson’s patients who participated in Rock Steady Boxing vs. 14 controls.
Disclosures: Mr. McLeod reported no relevant financial disclosures.
Novel imaging may differentiate dementia in Parkinson’s
NEW YORK – Making the clinical diagnosis of dementia in Parkinson’s patients has been confounding because of the difficulty of differentiating it from dementia in Alzheimer’s disease, but researchers have developed a novel imaging technique, known as single-scan dynamic molecular imaging, which uses positron emission tomography to identify the key differentiating factor between the two types of dementia, as reported at the International Conference on Parkinson’s Disease and Movement Disorders.
“We have a technique with which we can detect neurotransmitters in the brain, particularly in patients with dementia,” said Rajendra D. Badgaiyan, PhD, professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York. “This is important to not only understand the type of dementia you’re dealing with but also to understand the underlying neurocognitive problem.”
The technique is called single-scan dynamic molecular imaging technique (SDMIT) and uses PET to detect and measure dopamine release activity in the brain during cognitive or behavioral functioning, he said. After patients are placed in the PET scanner, they receive an IV injection of the radio-labeled ligand fallypride. While in the PET scanner, patients are asked to perform a cognitive task, and PET measures the ligand concentration before and after the task in the dorsal striatum of the brain. The rate of ligand displacement before and after the task are compared to determine the levels of dopamine activity in the brain.
A significant dysregulation of dopaminergic neurotransmission would indicate a diagnosis of Parkinson’s dementia, while dysregulation of acetylcholine neurotransmission is characteristic of Alzheimer’s dementia, Dr. Badgaiyan said.
He described the experimentation that went into developing SDMIT, including its use in patients with ADHD and how the technique evolved from obtaining two PET scans to measure dopamine levels. His research also found that fallypride was the most effective ligand because it has a high affinity for the dopamine-2 receptor.
“The bottom line is that this technique can be used to study those conditions that are dopamine dependent” Dr. Badgaiyan said. “We can also use this technique to study the neurocognitive basis of the clinical symptoms in dementia and other cognitive deficits.”
SDMIT can also help to identify novel therapeutics targets for dementia, he said. “Today there is no medication that can reverse dementia; all the drugs that we use can only reduce the progression,” he said. “But this technique can help us identify which area of the brain should be targeted and what symptoms should be targeted to reverse dementia, treat dementia, or to cure dementia.”
Dr. Badgaiyan disclosed receiving funding for his research from the National Institutes of Mental Health, Department of Veterans Affairs, the Dana Foundation and Shriners Foundation.
NEW YORK – Making the clinical diagnosis of dementia in Parkinson’s patients has been confounding because of the difficulty of differentiating it from dementia in Alzheimer’s disease, but researchers have developed a novel imaging technique, known as single-scan dynamic molecular imaging, which uses positron emission tomography to identify the key differentiating factor between the two types of dementia, as reported at the International Conference on Parkinson’s Disease and Movement Disorders.
“We have a technique with which we can detect neurotransmitters in the brain, particularly in patients with dementia,” said Rajendra D. Badgaiyan, PhD, professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York. “This is important to not only understand the type of dementia you’re dealing with but also to understand the underlying neurocognitive problem.”
The technique is called single-scan dynamic molecular imaging technique (SDMIT) and uses PET to detect and measure dopamine release activity in the brain during cognitive or behavioral functioning, he said. After patients are placed in the PET scanner, they receive an IV injection of the radio-labeled ligand fallypride. While in the PET scanner, patients are asked to perform a cognitive task, and PET measures the ligand concentration before and after the task in the dorsal striatum of the brain. The rate of ligand displacement before and after the task are compared to determine the levels of dopamine activity in the brain.
A significant dysregulation of dopaminergic neurotransmission would indicate a diagnosis of Parkinson’s dementia, while dysregulation of acetylcholine neurotransmission is characteristic of Alzheimer’s dementia, Dr. Badgaiyan said.
He described the experimentation that went into developing SDMIT, including its use in patients with ADHD and how the technique evolved from obtaining two PET scans to measure dopamine levels. His research also found that fallypride was the most effective ligand because it has a high affinity for the dopamine-2 receptor.
“The bottom line is that this technique can be used to study those conditions that are dopamine dependent” Dr. Badgaiyan said. “We can also use this technique to study the neurocognitive basis of the clinical symptoms in dementia and other cognitive deficits.”
SDMIT can also help to identify novel therapeutics targets for dementia, he said. “Today there is no medication that can reverse dementia; all the drugs that we use can only reduce the progression,” he said. “But this technique can help us identify which area of the brain should be targeted and what symptoms should be targeted to reverse dementia, treat dementia, or to cure dementia.”
Dr. Badgaiyan disclosed receiving funding for his research from the National Institutes of Mental Health, Department of Veterans Affairs, the Dana Foundation and Shriners Foundation.
NEW YORK – Making the clinical diagnosis of dementia in Parkinson’s patients has been confounding because of the difficulty of differentiating it from dementia in Alzheimer’s disease, but researchers have developed a novel imaging technique, known as single-scan dynamic molecular imaging, which uses positron emission tomography to identify the key differentiating factor between the two types of dementia, as reported at the International Conference on Parkinson’s Disease and Movement Disorders.
“We have a technique with which we can detect neurotransmitters in the brain, particularly in patients with dementia,” said Rajendra D. Badgaiyan, PhD, professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York. “This is important to not only understand the type of dementia you’re dealing with but also to understand the underlying neurocognitive problem.”
The technique is called single-scan dynamic molecular imaging technique (SDMIT) and uses PET to detect and measure dopamine release activity in the brain during cognitive or behavioral functioning, he said. After patients are placed in the PET scanner, they receive an IV injection of the radio-labeled ligand fallypride. While in the PET scanner, patients are asked to perform a cognitive task, and PET measures the ligand concentration before and after the task in the dorsal striatum of the brain. The rate of ligand displacement before and after the task are compared to determine the levels of dopamine activity in the brain.
A significant dysregulation of dopaminergic neurotransmission would indicate a diagnosis of Parkinson’s dementia, while dysregulation of acetylcholine neurotransmission is characteristic of Alzheimer’s dementia, Dr. Badgaiyan said.
He described the experimentation that went into developing SDMIT, including its use in patients with ADHD and how the technique evolved from obtaining two PET scans to measure dopamine levels. His research also found that fallypride was the most effective ligand because it has a high affinity for the dopamine-2 receptor.
“The bottom line is that this technique can be used to study those conditions that are dopamine dependent” Dr. Badgaiyan said. “We can also use this technique to study the neurocognitive basis of the clinical symptoms in dementia and other cognitive deficits.”
SDMIT can also help to identify novel therapeutics targets for dementia, he said. “Today there is no medication that can reverse dementia; all the drugs that we use can only reduce the progression,” he said. “But this technique can help us identify which area of the brain should be targeted and what symptoms should be targeted to reverse dementia, treat dementia, or to cure dementia.”
Dr. Badgaiyan disclosed receiving funding for his research from the National Institutes of Mental Health, Department of Veterans Affairs, the Dana Foundation and Shriners Foundation.
REPORTING FROM ICPDMD 2018
Key clinical point: A novel neuroimaging technique can differential dementia in Parkinson’s from that in Alzheimer’s disease.
Major finding: PET has been shown to detect dopamine levels in human brains.
Study details: Ongoing research involving humans at Icahn School of Medicine at Mount Sinai, N.Y.
Disclosures: Dr. Badgaiyan disclosed receiving funding for his research from the National Institutes of Mental Health, Department of Veterans Affairs, the Dana Foundation and Shriners Foundation.
Antiepileptic drug shows neuroprotection in Parkinson’s
NEW YORK – The loss of dopaminergic neurons is known to be a pivotal mechanism in Parkinson’s disease (PD), but early research into the anticonvulsant drug valproic acid has found it may produce antioxidant and neuroprotective actions that enhance the effects of levodopa, as reported at the International Conference on Parkinson’s Disease and Movement Disorders.
“Levodopa had better activity than valproic aside, but when they are used together, they have really very effective results,” said Ece Genç, PhD, of Yeditepe University in Istanbul, who reported on the research conducted in her laboratory.
Dr. Genç noted her research in rats has focused on the possible mechanisms of neurodegeneration in Parkinson’s disease: mitochondrial dysfunction, oxidative stress and tissue damage, disruption in protein organization, and cell death caused by inflammatory changes. “Dopamine metabolism can itself be a toxic compound for the neurons,” she said, explaining that dopamine is critical for stabilizing nerve synapses, but its dysregulation can cause oxidative stress of the neurons, leading to cell death.
A key mechanism in the tremors PD patients experience is histone deacetylase, Dr. Genç said. “Histone acetylation and deacetylation are extremely important in these processes,” she said (Neurosci Lett. 2018 Feb 14;666:48-57). “Valproic acid is an antiepileptic drug; it is used in bipolar disorder and migraine complexes, but one of the major actions of valproic acid is that it caused histone deacetylase in the patients.”
Previous research that has shown the rotenone model of valproic acid provided neuroprotection helped drive her research, she said (Neurotox Res. 2010;17:130-41).
Future directions in her research would aim to synchronize cell cultures and in-vivo studies, and try to develop a method to measure alpha-synucleinopathy – abnormal levels of alpha-synuclein protein in the nerves of people with neurodegenerative diseases. “I think that alpha-synucleinopathy is the key word here,” Dr. Genç said. “We have to be very careful with alpha-synuclein proteins and their presence in individuals and, of course, with the successful use of valproic acid and histone deacetylase in patients, we can look for new drugs with less adverse effects.”
One of the drawbacks of valproic acid is that it affects so many different channels in the body. “We have to find some drugs with more targeted action.” Dr. Genç said.
Dr. Genç did not report any relevant disclosures.
NEW YORK – The loss of dopaminergic neurons is known to be a pivotal mechanism in Parkinson’s disease (PD), but early research into the anticonvulsant drug valproic acid has found it may produce antioxidant and neuroprotective actions that enhance the effects of levodopa, as reported at the International Conference on Parkinson’s Disease and Movement Disorders.
“Levodopa had better activity than valproic aside, but when they are used together, they have really very effective results,” said Ece Genç, PhD, of Yeditepe University in Istanbul, who reported on the research conducted in her laboratory.
Dr. Genç noted her research in rats has focused on the possible mechanisms of neurodegeneration in Parkinson’s disease: mitochondrial dysfunction, oxidative stress and tissue damage, disruption in protein organization, and cell death caused by inflammatory changes. “Dopamine metabolism can itself be a toxic compound for the neurons,” she said, explaining that dopamine is critical for stabilizing nerve synapses, but its dysregulation can cause oxidative stress of the neurons, leading to cell death.
A key mechanism in the tremors PD patients experience is histone deacetylase, Dr. Genç said. “Histone acetylation and deacetylation are extremely important in these processes,” she said (Neurosci Lett. 2018 Feb 14;666:48-57). “Valproic acid is an antiepileptic drug; it is used in bipolar disorder and migraine complexes, but one of the major actions of valproic acid is that it caused histone deacetylase in the patients.”
Previous research that has shown the rotenone model of valproic acid provided neuroprotection helped drive her research, she said (Neurotox Res. 2010;17:130-41).
Future directions in her research would aim to synchronize cell cultures and in-vivo studies, and try to develop a method to measure alpha-synucleinopathy – abnormal levels of alpha-synuclein protein in the nerves of people with neurodegenerative diseases. “I think that alpha-synucleinopathy is the key word here,” Dr. Genç said. “We have to be very careful with alpha-synuclein proteins and their presence in individuals and, of course, with the successful use of valproic acid and histone deacetylase in patients, we can look for new drugs with less adverse effects.”
One of the drawbacks of valproic acid is that it affects so many different channels in the body. “We have to find some drugs with more targeted action.” Dr. Genç said.
Dr. Genç did not report any relevant disclosures.
NEW YORK – The loss of dopaminergic neurons is known to be a pivotal mechanism in Parkinson’s disease (PD), but early research into the anticonvulsant drug valproic acid has found it may produce antioxidant and neuroprotective actions that enhance the effects of levodopa, as reported at the International Conference on Parkinson’s Disease and Movement Disorders.
“Levodopa had better activity than valproic aside, but when they are used together, they have really very effective results,” said Ece Genç, PhD, of Yeditepe University in Istanbul, who reported on the research conducted in her laboratory.
Dr. Genç noted her research in rats has focused on the possible mechanisms of neurodegeneration in Parkinson’s disease: mitochondrial dysfunction, oxidative stress and tissue damage, disruption in protein organization, and cell death caused by inflammatory changes. “Dopamine metabolism can itself be a toxic compound for the neurons,” she said, explaining that dopamine is critical for stabilizing nerve synapses, but its dysregulation can cause oxidative stress of the neurons, leading to cell death.
A key mechanism in the tremors PD patients experience is histone deacetylase, Dr. Genç said. “Histone acetylation and deacetylation are extremely important in these processes,” she said (Neurosci Lett. 2018 Feb 14;666:48-57). “Valproic acid is an antiepileptic drug; it is used in bipolar disorder and migraine complexes, but one of the major actions of valproic acid is that it caused histone deacetylase in the patients.”
Previous research that has shown the rotenone model of valproic acid provided neuroprotection helped drive her research, she said (Neurotox Res. 2010;17:130-41).
Future directions in her research would aim to synchronize cell cultures and in-vivo studies, and try to develop a method to measure alpha-synucleinopathy – abnormal levels of alpha-synuclein protein in the nerves of people with neurodegenerative diseases. “I think that alpha-synucleinopathy is the key word here,” Dr. Genç said. “We have to be very careful with alpha-synuclein proteins and their presence in individuals and, of course, with the successful use of valproic acid and histone deacetylase in patients, we can look for new drugs with less adverse effects.”
One of the drawbacks of valproic acid is that it affects so many different channels in the body. “We have to find some drugs with more targeted action.” Dr. Genç said.
Dr. Genç did not report any relevant disclosures.
REPORTING FROM ICPDMD 2018
Key clinical point: Valproic acid may complement levodopa in Parkinson’s treatment.
Major finding: Valproic acid was found to produce antioxidant and cell-preserving effects.
Study details: Early results of laboratory studies and review of previously published studies.
Disclosures: Dr. Genç did not report any relevant disclosures.
Can ultrasound screening improve survival in ovarian cancer?
Annual ultrasound screening of asymptomatic women at risk of epithelial ovarian cancer can lead to lower staging of cancer at detection and improved survival, compared with no screening, according to a prospective clinical trial that followed more than 46,000 women over 2 decades.
“The findings of this study support the concept that a major predictor of ovarian cancer survival is stage at detection,” said John R. van Nagell Jr., MD, of the University of Kentucky–Markey Cancer Center, Lexington, and his coauthors. “The 10-year survival of women whose ovarian cancer was detected at an early stage (I or II) was 35% higher than that of women diagnosed with stage III cancer.” Study results were published in the November issue of Obstetrics & Gynecology.
The study evaluated 46,101 women enrolled in the University of Kentucky Ovarian Cancer Screening Trial over 30.5 years. Trial participants, all of whom had annual ultrasound screening, were age 50 and older, or 25 and older with a family history of ovarian cancer. Overall, 23% and 44% of the women had a family history of either ovarian or breast cancer, respectively. Women in the study had an average of seven scans each. The unscreened comparator group was women with ovarian cancer referred to the UK Markey Cancer Center.
The study detected 71 cases of invasive epithelial ovarian cancers and 17 epithelial ovarian tumors of low malignant potential. None of the women with these tumors had a recurrence. Among the invasive cancers, the majority were either stage I (42%) or II (21%), and none were stage IV. The median age of these patients was 66 years. Of the low-malignancy tumors, 27% were stage I and 73% stage II, with none stage III or IV. A total of 699 women (1.5%) with persistent ovarian tumors had surgery.
Screened women also had improved survival compared to unscreened women: 86% vs. 45% at 5 years, 68% vs. 31% at 10 years (P less than .001).
However, the study also showed a high overall incidence rate for ovarian cancer, including false-positive and false-negative cases, compared with National Cancer Institute reports in the Kentucky state cancer profile: 271 per 100,000 vs. 10.4/100,000.
The study also looked at the economics of annual screening. “Ovarian screening reduced the 10-year mortality by 37% and produced 416 life years gained,” Dr. van Nagell and his coauthors said. Based on an estimated cost of $56 for each transvaginal ultrasound scan, that translates into a cost of $40,731 for each life year gained.
One concern of screening ultrasound is the high false-positive rate. “Although the sensitivity of transvaginal ultrasonography in detecting an ovarian abnormality is high, it has been unreliable in differentiating benign from malignant ovarian tumors,” they said. While they noted the accuracy of assessing malignancy has improved, the risk of complications in women who have surgery for benign tumors is an ongoing concern. “Additional research is necessary to identify high-risk populations who will benefit most from screening.”
Dr. van Nagell and his coauthors reported having no financial relationships. The study was supported by research grants from the Kentucky Department of Health and Human Services and the Telford Foundation.
SOURCE: Van Nagell JR Jr et al. Obstet Gynecol. 2018 Nov;132[5]:1091-100. doi: 10.1097/AOG.0000000000002921.
Use a measure of caution when interpreting the results of the study by van Nagell et al., Sharon E. Robertson, MD, MPH, and Jeffery E. Peipert, MD, PhD, said in an invited commentary. First, they noted the “surprisingly high” rate of ovarian cancer (271 per 100,000) – although it may improve the predictive value of ultrasound screening, when one applies the test sensitivity and specificity the trial reported to the general population, “the positive predictive value falls to an unacceptable 0.7%.”
They also questioned the rationale for comparing the study population to an unscreened cohort of women with ovarian cancer referred to the University of Kentucky. “However, are we really comparing apples to apples?” they asked, noting “important key baseline differences” between the two groups, including that the screened cohort “could have contained an unbalanced proportion of genetically related ovarian cancers.” They also noted the risk profile of the unscreened cohort is unknown.
Addressing the differences in survival rates between screened and unscreened patients, Dr. Robertson and Dr. Peipert noted the study population had a higher rate of type I tumors than that seen in National Cancer Institute data for the general population (27% vs. 11%), along with the absence of genetic analysis. “For these reasons, we cannot confidently agree with the authors’ conclusion that the ultrasound screening reduced ovarian cancer mortality,” they stated.
They commended the Kentucky group for a “landmark study,” but added, “the evidence that screening for ovarian cancer improves survival remains elusive.” They called for more evidence before widespread screening programs are implemented.
Dr. Robertson and Dr. Peipert of Indiana University, Indianapolis, commented on the article by van Nagell et al. in Obstetrics and Gynecology (2018 Nov;132[5]:1089-90. doi: 10.1097/AOG.0000000000002962). Dr. Peipert disclosed relationships with Cooper Surgical/Teva, Merck, and Bayer. Dr. Robertson had no relevant financial relationships.
Use a measure of caution when interpreting the results of the study by van Nagell et al., Sharon E. Robertson, MD, MPH, and Jeffery E. Peipert, MD, PhD, said in an invited commentary. First, they noted the “surprisingly high” rate of ovarian cancer (271 per 100,000) – although it may improve the predictive value of ultrasound screening, when one applies the test sensitivity and specificity the trial reported to the general population, “the positive predictive value falls to an unacceptable 0.7%.”
They also questioned the rationale for comparing the study population to an unscreened cohort of women with ovarian cancer referred to the University of Kentucky. “However, are we really comparing apples to apples?” they asked, noting “important key baseline differences” between the two groups, including that the screened cohort “could have contained an unbalanced proportion of genetically related ovarian cancers.” They also noted the risk profile of the unscreened cohort is unknown.
Addressing the differences in survival rates between screened and unscreened patients, Dr. Robertson and Dr. Peipert noted the study population had a higher rate of type I tumors than that seen in National Cancer Institute data for the general population (27% vs. 11%), along with the absence of genetic analysis. “For these reasons, we cannot confidently agree with the authors’ conclusion that the ultrasound screening reduced ovarian cancer mortality,” they stated.
They commended the Kentucky group for a “landmark study,” but added, “the evidence that screening for ovarian cancer improves survival remains elusive.” They called for more evidence before widespread screening programs are implemented.
Dr. Robertson and Dr. Peipert of Indiana University, Indianapolis, commented on the article by van Nagell et al. in Obstetrics and Gynecology (2018 Nov;132[5]:1089-90. doi: 10.1097/AOG.0000000000002962). Dr. Peipert disclosed relationships with Cooper Surgical/Teva, Merck, and Bayer. Dr. Robertson had no relevant financial relationships.
Use a measure of caution when interpreting the results of the study by van Nagell et al., Sharon E. Robertson, MD, MPH, and Jeffery E. Peipert, MD, PhD, said in an invited commentary. First, they noted the “surprisingly high” rate of ovarian cancer (271 per 100,000) – although it may improve the predictive value of ultrasound screening, when one applies the test sensitivity and specificity the trial reported to the general population, “the positive predictive value falls to an unacceptable 0.7%.”
They also questioned the rationale for comparing the study population to an unscreened cohort of women with ovarian cancer referred to the University of Kentucky. “However, are we really comparing apples to apples?” they asked, noting “important key baseline differences” between the two groups, including that the screened cohort “could have contained an unbalanced proportion of genetically related ovarian cancers.” They also noted the risk profile of the unscreened cohort is unknown.
Addressing the differences in survival rates between screened and unscreened patients, Dr. Robertson and Dr. Peipert noted the study population had a higher rate of type I tumors than that seen in National Cancer Institute data for the general population (27% vs. 11%), along with the absence of genetic analysis. “For these reasons, we cannot confidently agree with the authors’ conclusion that the ultrasound screening reduced ovarian cancer mortality,” they stated.
They commended the Kentucky group for a “landmark study,” but added, “the evidence that screening for ovarian cancer improves survival remains elusive.” They called for more evidence before widespread screening programs are implemented.
Dr. Robertson and Dr. Peipert of Indiana University, Indianapolis, commented on the article by van Nagell et al. in Obstetrics and Gynecology (2018 Nov;132[5]:1089-90. doi: 10.1097/AOG.0000000000002962). Dr. Peipert disclosed relationships with Cooper Surgical/Teva, Merck, and Bayer. Dr. Robertson had no relevant financial relationships.
Annual ultrasound screening of asymptomatic women at risk of epithelial ovarian cancer can lead to lower staging of cancer at detection and improved survival, compared with no screening, according to a prospective clinical trial that followed more than 46,000 women over 2 decades.
“The findings of this study support the concept that a major predictor of ovarian cancer survival is stage at detection,” said John R. van Nagell Jr., MD, of the University of Kentucky–Markey Cancer Center, Lexington, and his coauthors. “The 10-year survival of women whose ovarian cancer was detected at an early stage (I or II) was 35% higher than that of women diagnosed with stage III cancer.” Study results were published in the November issue of Obstetrics & Gynecology.
The study evaluated 46,101 women enrolled in the University of Kentucky Ovarian Cancer Screening Trial over 30.5 years. Trial participants, all of whom had annual ultrasound screening, were age 50 and older, or 25 and older with a family history of ovarian cancer. Overall, 23% and 44% of the women had a family history of either ovarian or breast cancer, respectively. Women in the study had an average of seven scans each. The unscreened comparator group was women with ovarian cancer referred to the UK Markey Cancer Center.
The study detected 71 cases of invasive epithelial ovarian cancers and 17 epithelial ovarian tumors of low malignant potential. None of the women with these tumors had a recurrence. Among the invasive cancers, the majority were either stage I (42%) or II (21%), and none were stage IV. The median age of these patients was 66 years. Of the low-malignancy tumors, 27% were stage I and 73% stage II, with none stage III or IV. A total of 699 women (1.5%) with persistent ovarian tumors had surgery.
Screened women also had improved survival compared to unscreened women: 86% vs. 45% at 5 years, 68% vs. 31% at 10 years (P less than .001).
However, the study also showed a high overall incidence rate for ovarian cancer, including false-positive and false-negative cases, compared with National Cancer Institute reports in the Kentucky state cancer profile: 271 per 100,000 vs. 10.4/100,000.
The study also looked at the economics of annual screening. “Ovarian screening reduced the 10-year mortality by 37% and produced 416 life years gained,” Dr. van Nagell and his coauthors said. Based on an estimated cost of $56 for each transvaginal ultrasound scan, that translates into a cost of $40,731 for each life year gained.
One concern of screening ultrasound is the high false-positive rate. “Although the sensitivity of transvaginal ultrasonography in detecting an ovarian abnormality is high, it has been unreliable in differentiating benign from malignant ovarian tumors,” they said. While they noted the accuracy of assessing malignancy has improved, the risk of complications in women who have surgery for benign tumors is an ongoing concern. “Additional research is necessary to identify high-risk populations who will benefit most from screening.”
Dr. van Nagell and his coauthors reported having no financial relationships. The study was supported by research grants from the Kentucky Department of Health and Human Services and the Telford Foundation.
SOURCE: Van Nagell JR Jr et al. Obstet Gynecol. 2018 Nov;132[5]:1091-100. doi: 10.1097/AOG.0000000000002921.
Annual ultrasound screening of asymptomatic women at risk of epithelial ovarian cancer can lead to lower staging of cancer at detection and improved survival, compared with no screening, according to a prospective clinical trial that followed more than 46,000 women over 2 decades.
“The findings of this study support the concept that a major predictor of ovarian cancer survival is stage at detection,” said John R. van Nagell Jr., MD, of the University of Kentucky–Markey Cancer Center, Lexington, and his coauthors. “The 10-year survival of women whose ovarian cancer was detected at an early stage (I or II) was 35% higher than that of women diagnosed with stage III cancer.” Study results were published in the November issue of Obstetrics & Gynecology.
The study evaluated 46,101 women enrolled in the University of Kentucky Ovarian Cancer Screening Trial over 30.5 years. Trial participants, all of whom had annual ultrasound screening, were age 50 and older, or 25 and older with a family history of ovarian cancer. Overall, 23% and 44% of the women had a family history of either ovarian or breast cancer, respectively. Women in the study had an average of seven scans each. The unscreened comparator group was women with ovarian cancer referred to the UK Markey Cancer Center.
The study detected 71 cases of invasive epithelial ovarian cancers and 17 epithelial ovarian tumors of low malignant potential. None of the women with these tumors had a recurrence. Among the invasive cancers, the majority were either stage I (42%) or II (21%), and none were stage IV. The median age of these patients was 66 years. Of the low-malignancy tumors, 27% were stage I and 73% stage II, with none stage III or IV. A total of 699 women (1.5%) with persistent ovarian tumors had surgery.
Screened women also had improved survival compared to unscreened women: 86% vs. 45% at 5 years, 68% vs. 31% at 10 years (P less than .001).
However, the study also showed a high overall incidence rate for ovarian cancer, including false-positive and false-negative cases, compared with National Cancer Institute reports in the Kentucky state cancer profile: 271 per 100,000 vs. 10.4/100,000.
The study also looked at the economics of annual screening. “Ovarian screening reduced the 10-year mortality by 37% and produced 416 life years gained,” Dr. van Nagell and his coauthors said. Based on an estimated cost of $56 for each transvaginal ultrasound scan, that translates into a cost of $40,731 for each life year gained.
One concern of screening ultrasound is the high false-positive rate. “Although the sensitivity of transvaginal ultrasonography in detecting an ovarian abnormality is high, it has been unreliable in differentiating benign from malignant ovarian tumors,” they said. While they noted the accuracy of assessing malignancy has improved, the risk of complications in women who have surgery for benign tumors is an ongoing concern. “Additional research is necessary to identify high-risk populations who will benefit most from screening.”
Dr. van Nagell and his coauthors reported having no financial relationships. The study was supported by research grants from the Kentucky Department of Health and Human Services and the Telford Foundation.
SOURCE: Van Nagell JR Jr et al. Obstet Gynecol. 2018 Nov;132[5]:1091-100. doi: 10.1097/AOG.0000000000002921.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point: Annual ultrasound may improve outcomes for women at risk for epithelial ovarian cancer.
Major finding: Five-year survival was 86% for screened women vs. 45% for unscreened women (P less than .001).
Study details: Analysis of 46,101 at-risk women enrolled in the University of Kentucky Ovarian Cancer Screening Trial, a prospective cohort trial, from January 1987 to June 2017.
Disclosures: Dr. van Nagell and coauthors reported having no financial relationships. The study was supported by research grants from the Kentucky Department of Health and Human Services and the Telford Foundation.
Source: Van Nagell JR Jr et al. Obstet Gynecol. 2018 Nov;132[5]:1091-100. doi: 10.1097/AOG.0000000000002921.
Corporal punishment bans may reduce youth violence
with males in those countries about 30% less likely to engage in fighting and females almost 60% less likely to do so, according to a study of school-based health surveys completed by 403,604 adolescents in 88 different countries published in BMJ Open.
“These findings add to a growing body of evidence on links between corporal punishment and adolescent health and safety. A growing number of countries have banned corporal punishment as an acceptable means of child discipline, and this is an important step that should be encouraged,” said Frank J. Elgar, PhD, of McGill University in Montreal and his colleagues. “Health providers are well positioned to offer practical and effective tools that support such approaches to child discipline. Cultural shifts from punitive to positive discipline happen slowly.”
The researchers placed countries into three categories: those that have banned corporate punishment in the home and at school; those that have banned it in school only (which include the United States, Canada, and the United Kingdom); and those that have not banned corporal punishment in either setting.
Frequent fighting rates varied widely, Dr. Elgar and his colleagues noted, ranging from a low of less than 1% among females in Costa Rica, which bans all forms of corporal punishment, to a high of 35% among males in Samoa, which allows corporal punishment in both settings.
The 30 countries with full bans had rates of fighting 31% lower in males and 58% lower in females than the 20 countries with no ban. Thirty-eight countries with bans in schools but not in the home reported less fighting in females only – 44% lower than countries without bans.
The reasons for the gender difference in fighting rates among countries with partial bans is unclear, the authors said. “It could be that males, compared with females, experience more physical violence outside school settings or are affected differently by corporal punishment by teachers,” Dr. Elgar and his coauthors said. “Further investigation is needed.”
The study analyzed findings of two well-established surveys used internationally to measure fighting among adolescents: the World Health Organization Health Behavior in School-aged Children (HBSC) study and the Global School-based Health Survey (GSHS). The former is conducted among children ages 11, 13, and 15 in Canada, the United States, and most European countries every 4 years. The GSHS measures fighting among children aged 13-17 years in 55 low- and middle-income countries.
Among the limitations the study authors acknowledged was the inability to account for when the surveys were completed and when the bans were implemented, enforced, or modified, but they also pointed out the large and diverse sample of countries as a strength of the study.
Dr. Elgar and coauthors reported having no financial relationships. The work was supported by grants from the Canadian Institutes for Health Research, the Social Sciences and Humanities Research Council, and the Canada Research Chairs programme.
SOURCE: Elgar FJ et al. BMJ Open. 2018;8:e021616.
with males in those countries about 30% less likely to engage in fighting and females almost 60% less likely to do so, according to a study of school-based health surveys completed by 403,604 adolescents in 88 different countries published in BMJ Open.
“These findings add to a growing body of evidence on links between corporal punishment and adolescent health and safety. A growing number of countries have banned corporal punishment as an acceptable means of child discipline, and this is an important step that should be encouraged,” said Frank J. Elgar, PhD, of McGill University in Montreal and his colleagues. “Health providers are well positioned to offer practical and effective tools that support such approaches to child discipline. Cultural shifts from punitive to positive discipline happen slowly.”
The researchers placed countries into three categories: those that have banned corporate punishment in the home and at school; those that have banned it in school only (which include the United States, Canada, and the United Kingdom); and those that have not banned corporal punishment in either setting.
Frequent fighting rates varied widely, Dr. Elgar and his colleagues noted, ranging from a low of less than 1% among females in Costa Rica, which bans all forms of corporal punishment, to a high of 35% among males in Samoa, which allows corporal punishment in both settings.
The 30 countries with full bans had rates of fighting 31% lower in males and 58% lower in females than the 20 countries with no ban. Thirty-eight countries with bans in schools but not in the home reported less fighting in females only – 44% lower than countries without bans.
The reasons for the gender difference in fighting rates among countries with partial bans is unclear, the authors said. “It could be that males, compared with females, experience more physical violence outside school settings or are affected differently by corporal punishment by teachers,” Dr. Elgar and his coauthors said. “Further investigation is needed.”
The study analyzed findings of two well-established surveys used internationally to measure fighting among adolescents: the World Health Organization Health Behavior in School-aged Children (HBSC) study and the Global School-based Health Survey (GSHS). The former is conducted among children ages 11, 13, and 15 in Canada, the United States, and most European countries every 4 years. The GSHS measures fighting among children aged 13-17 years in 55 low- and middle-income countries.
Among the limitations the study authors acknowledged was the inability to account for when the surveys were completed and when the bans were implemented, enforced, or modified, but they also pointed out the large and diverse sample of countries as a strength of the study.
Dr. Elgar and coauthors reported having no financial relationships. The work was supported by grants from the Canadian Institutes for Health Research, the Social Sciences and Humanities Research Council, and the Canada Research Chairs programme.
SOURCE: Elgar FJ et al. BMJ Open. 2018;8:e021616.
with males in those countries about 30% less likely to engage in fighting and females almost 60% less likely to do so, according to a study of school-based health surveys completed by 403,604 adolescents in 88 different countries published in BMJ Open.
“These findings add to a growing body of evidence on links between corporal punishment and adolescent health and safety. A growing number of countries have banned corporal punishment as an acceptable means of child discipline, and this is an important step that should be encouraged,” said Frank J. Elgar, PhD, of McGill University in Montreal and his colleagues. “Health providers are well positioned to offer practical and effective tools that support such approaches to child discipline. Cultural shifts from punitive to positive discipline happen slowly.”
The researchers placed countries into three categories: those that have banned corporate punishment in the home and at school; those that have banned it in school only (which include the United States, Canada, and the United Kingdom); and those that have not banned corporal punishment in either setting.
Frequent fighting rates varied widely, Dr. Elgar and his colleagues noted, ranging from a low of less than 1% among females in Costa Rica, which bans all forms of corporal punishment, to a high of 35% among males in Samoa, which allows corporal punishment in both settings.
The 30 countries with full bans had rates of fighting 31% lower in males and 58% lower in females than the 20 countries with no ban. Thirty-eight countries with bans in schools but not in the home reported less fighting in females only – 44% lower than countries without bans.
The reasons for the gender difference in fighting rates among countries with partial bans is unclear, the authors said. “It could be that males, compared with females, experience more physical violence outside school settings or are affected differently by corporal punishment by teachers,” Dr. Elgar and his coauthors said. “Further investigation is needed.”
The study analyzed findings of two well-established surveys used internationally to measure fighting among adolescents: the World Health Organization Health Behavior in School-aged Children (HBSC) study and the Global School-based Health Survey (GSHS). The former is conducted among children ages 11, 13, and 15 in Canada, the United States, and most European countries every 4 years. The GSHS measures fighting among children aged 13-17 years in 55 low- and middle-income countries.
Among the limitations the study authors acknowledged was the inability to account for when the surveys were completed and when the bans were implemented, enforced, or modified, but they also pointed out the large and diverse sample of countries as a strength of the study.
Dr. Elgar and coauthors reported having no financial relationships. The work was supported by grants from the Canadian Institutes for Health Research, the Social Sciences and Humanities Research Council, and the Canada Research Chairs programme.
SOURCE: Elgar FJ et al. BMJ Open. 2018;8:e021616.
FROM BMJ OPEN
Key clinical point: Nations that ban corporal punishment of children have lower rates of youth violence.
Major finding: Countries with total bans on corporal punishment reported rates of fighting in males 31% lower than countries with no bans.
Study details: An ecological study evaluating school-based health surveys of 403,604 adolescents from 88 low- to high-income countries.
Disclosures: Dr. Elgar and coauthors reported having no financial relationships. The work was supported by grants from the Canadian Institutes for Health Research, the Social Sciences and Humanities Research Council, and the Canada Research Chairs programme.
Source: Elgar FJ et al. BMJ Open. 2018;8:e021616.
DIVA results similar for drug-eluting, bare-metal stents
Drug-eluting stents (DESs) and less-expensive bare-metal stents (BMSs) performed equally well in patients with failed saphenous vein grafts after coronary artery bypass graft surgery, based on an analysis of patients in the DIVA trial.
The findings run counter to those of previous clinical trials, which had found drug-eluting stents perform better than bare-metal stents in these situations. “The study results have important economic implications in countries with high DES prices, such as the USA, because they suggest that the lower-cost BMS can be used in SVG [saphenous vein graft] lesions without compromising either safety or efficacy,” lead author Emmanouil S. Brilakis, MD, PhD, of Minneapolis Heart Institute and his coauthors said in reporting the results for the DIVA trial investigators in the Lancet.
The DIVA trial was a randomized, double-blind, controlled trial done at 25 U.S. Department of Veterans Affairs centers. Researchers randomly assigned 599 patients who had previous coronary artery bypass surgery to either the DES or BMS groups, and the study reported data from 597 patients. The combined endpoint comprised cardiac death, target vessel MI, or target vessel revascularization at 12 months and then over the entire length of follow-up, which ranged from 2 to 7 years. Operators used the DES or BMS of their choice.
While BMSs are presumed to be less expensive than DESs, the study authors did not provide prices or price ranges for the stents. Dr. Brilakis and his coauthors acknowledged that the financial implications depend on local stent pricing practices.
The cost-effectiveness of using DESs vs. BMSs has been controversial, with many studies reporting that BMS are cost-effective over the long-term because of the lower incidence of revascularization and later hospitalization. These studies did not differentiate between SVG and native vessels, however. Multiple studies have reported that the overall costs, including the cost for reintervention, are lower for DESs than for BMSs in native vessels. A Wake Forest study reported the average per procedure cost was $1,846 higher for a DES but the cost was offset after 3 years by lower revascularization rates (Circ Cardiovasc Qual Outcomes. 2011. doi: 10.1161/CIRCOUTCOMES.110.960187)
A recent Korean study found the total cost of DESs was about 5% higher (Yonsei Med J. 2014 Nov;55[6]:1533-41). A French study reported BMSs resulted in a cost reduction $217 per case (Open Heart. 2016 Aug 25;3[2]:e000445). But few, if any, studies have directly compared prices hospitals pay for DESs and BMSs.
Pricing aside, Dr. Brilakis and his coauthors reported no statistical differences in terms of outcomes between the DES and BMS groups. Baseline characteristics of both groups were similar, and the vessel failure rates were 17% in the DES group and 19% in the BMS group after 12 months of follow-up. After 2-7 years, “target vessel failure occurred in approximately one in three patients, with no difference between the bare-metal and drug-eluting stents,” Dr. Brilakis and his coauthors said.
There was no significant difference in cardiac death rates – 5% for DES patients and 4% for BMS patients – or in rates of target lesion revascularization, at 9% and 8%, respectively. Postprocedure medication rates were also similar between the two groups. For example, the rates of patients on P2Y12 inhibitors were 89% for both groups at 12 months and, among those who had follow-up at 36 months, 48% for DES and 44% for BMS.
Among the limitations of the study that Dr. Brilakis and his coauthors noted was the high proportion of men in the VA population – only two women, both in the DES group, participated in the study – and the interventionists doing the index SVG intervention were not masked to the type of stent used.
Dr. Brilakis disclosed relationships with Abbott Vascular, Amgen, Asahi, Boston Scientific, Cardinal Health, CSI, Elsevier, GE Healthcare, Medicure, Medtronic, Nitiloop, InfraRedx, and Osprey.
SOURCE: Brilakis ES et al. Lancet. 2018 May 19;391(10134);1997-2007.
The predominant use of second-generation drug-eluting stents in the DIVA study may explain why the researchers found no difference in outcomes for bare metal and drug-eluting stents.
Most patients in previous trials were treated with first-generation drug-eluting stents, but second-generation drug-eluting stents perform better than their first-generation counterparts in native coronary artery disease. One might think that this finding should also apply to saphenous vein bypass graft lesions in which atherosclerosis is more aggressive and the progress of the disease much faster, yet this was not the case in DIVA, and the study authors did not provide an explanation for this finding.
One possible reason for the comparability of outcomes in the drug-eluting stents and bare metal stents groups may be that saphenous vein bypass graft lesions may be more favorably disposed to paclitaxel, commonly used in first-generation drug-eluting stents, than the drugs found in the second-generation stents. The DIVA findings may indicate that the second-generation drug-eluting stents performed worse, not that the bare metal stents performed better.
Studies of only first-generation paclitaxel-eluting stents showed a sustained benefit. Any notion that the pathophysiology of saphenous vein grafts might make them more amenable to a bare metal stent while a drug-eluting stent is better suited for native vessels is purely speculative. Further research comparing the effect of different stent types in saphenous vein bypass graft failure is warranted.
Raban V. Jeger, MD, and Sven Möbius-Winkler, MD, made these remarks in an invited commentary. Dr. Jeger is with the University Hospital Basel (Switzerland), and Dr. Möbius-Winkler is with University Hospital Jena (Germany). Dr. Jeger disclosed he is the principal investigator of the BASKET-SAVAGE trial, which received funding from Boston Scientific Germany. Dr. Möbius-Winkler had no financial relationships to disclose.
The predominant use of second-generation drug-eluting stents in the DIVA study may explain why the researchers found no difference in outcomes for bare metal and drug-eluting stents.
Most patients in previous trials were treated with first-generation drug-eluting stents, but second-generation drug-eluting stents perform better than their first-generation counterparts in native coronary artery disease. One might think that this finding should also apply to saphenous vein bypass graft lesions in which atherosclerosis is more aggressive and the progress of the disease much faster, yet this was not the case in DIVA, and the study authors did not provide an explanation for this finding.
One possible reason for the comparability of outcomes in the drug-eluting stents and bare metal stents groups may be that saphenous vein bypass graft lesions may be more favorably disposed to paclitaxel, commonly used in first-generation drug-eluting stents, than the drugs found in the second-generation stents. The DIVA findings may indicate that the second-generation drug-eluting stents performed worse, not that the bare metal stents performed better.
Studies of only first-generation paclitaxel-eluting stents showed a sustained benefit. Any notion that the pathophysiology of saphenous vein grafts might make them more amenable to a bare metal stent while a drug-eluting stent is better suited for native vessels is purely speculative. Further research comparing the effect of different stent types in saphenous vein bypass graft failure is warranted.
Raban V. Jeger, MD, and Sven Möbius-Winkler, MD, made these remarks in an invited commentary. Dr. Jeger is with the University Hospital Basel (Switzerland), and Dr. Möbius-Winkler is with University Hospital Jena (Germany). Dr. Jeger disclosed he is the principal investigator of the BASKET-SAVAGE trial, which received funding from Boston Scientific Germany. Dr. Möbius-Winkler had no financial relationships to disclose.
The predominant use of second-generation drug-eluting stents in the DIVA study may explain why the researchers found no difference in outcomes for bare metal and drug-eluting stents.
Most patients in previous trials were treated with first-generation drug-eluting stents, but second-generation drug-eluting stents perform better than their first-generation counterparts in native coronary artery disease. One might think that this finding should also apply to saphenous vein bypass graft lesions in which atherosclerosis is more aggressive and the progress of the disease much faster, yet this was not the case in DIVA, and the study authors did not provide an explanation for this finding.
One possible reason for the comparability of outcomes in the drug-eluting stents and bare metal stents groups may be that saphenous vein bypass graft lesions may be more favorably disposed to paclitaxel, commonly used in first-generation drug-eluting stents, than the drugs found in the second-generation stents. The DIVA findings may indicate that the second-generation drug-eluting stents performed worse, not that the bare metal stents performed better.
Studies of only first-generation paclitaxel-eluting stents showed a sustained benefit. Any notion that the pathophysiology of saphenous vein grafts might make them more amenable to a bare metal stent while a drug-eluting stent is better suited for native vessels is purely speculative. Further research comparing the effect of different stent types in saphenous vein bypass graft failure is warranted.
Raban V. Jeger, MD, and Sven Möbius-Winkler, MD, made these remarks in an invited commentary. Dr. Jeger is with the University Hospital Basel (Switzerland), and Dr. Möbius-Winkler is with University Hospital Jena (Germany). Dr. Jeger disclosed he is the principal investigator of the BASKET-SAVAGE trial, which received funding from Boston Scientific Germany. Dr. Möbius-Winkler had no financial relationships to disclose.
Drug-eluting stents (DESs) and less-expensive bare-metal stents (BMSs) performed equally well in patients with failed saphenous vein grafts after coronary artery bypass graft surgery, based on an analysis of patients in the DIVA trial.
The findings run counter to those of previous clinical trials, which had found drug-eluting stents perform better than bare-metal stents in these situations. “The study results have important economic implications in countries with high DES prices, such as the USA, because they suggest that the lower-cost BMS can be used in SVG [saphenous vein graft] lesions without compromising either safety or efficacy,” lead author Emmanouil S. Brilakis, MD, PhD, of Minneapolis Heart Institute and his coauthors said in reporting the results for the DIVA trial investigators in the Lancet.
The DIVA trial was a randomized, double-blind, controlled trial done at 25 U.S. Department of Veterans Affairs centers. Researchers randomly assigned 599 patients who had previous coronary artery bypass surgery to either the DES or BMS groups, and the study reported data from 597 patients. The combined endpoint comprised cardiac death, target vessel MI, or target vessel revascularization at 12 months and then over the entire length of follow-up, which ranged from 2 to 7 years. Operators used the DES or BMS of their choice.
While BMSs are presumed to be less expensive than DESs, the study authors did not provide prices or price ranges for the stents. Dr. Brilakis and his coauthors acknowledged that the financial implications depend on local stent pricing practices.
The cost-effectiveness of using DESs vs. BMSs has been controversial, with many studies reporting that BMS are cost-effective over the long-term because of the lower incidence of revascularization and later hospitalization. These studies did not differentiate between SVG and native vessels, however. Multiple studies have reported that the overall costs, including the cost for reintervention, are lower for DESs than for BMSs in native vessels. A Wake Forest study reported the average per procedure cost was $1,846 higher for a DES but the cost was offset after 3 years by lower revascularization rates (Circ Cardiovasc Qual Outcomes. 2011. doi: 10.1161/CIRCOUTCOMES.110.960187)
A recent Korean study found the total cost of DESs was about 5% higher (Yonsei Med J. 2014 Nov;55[6]:1533-41). A French study reported BMSs resulted in a cost reduction $217 per case (Open Heart. 2016 Aug 25;3[2]:e000445). But few, if any, studies have directly compared prices hospitals pay for DESs and BMSs.
Pricing aside, Dr. Brilakis and his coauthors reported no statistical differences in terms of outcomes between the DES and BMS groups. Baseline characteristics of both groups were similar, and the vessel failure rates were 17% in the DES group and 19% in the BMS group after 12 months of follow-up. After 2-7 years, “target vessel failure occurred in approximately one in three patients, with no difference between the bare-metal and drug-eluting stents,” Dr. Brilakis and his coauthors said.
There was no significant difference in cardiac death rates – 5% for DES patients and 4% for BMS patients – or in rates of target lesion revascularization, at 9% and 8%, respectively. Postprocedure medication rates were also similar between the two groups. For example, the rates of patients on P2Y12 inhibitors were 89% for both groups at 12 months and, among those who had follow-up at 36 months, 48% for DES and 44% for BMS.
Among the limitations of the study that Dr. Brilakis and his coauthors noted was the high proportion of men in the VA population – only two women, both in the DES group, participated in the study – and the interventionists doing the index SVG intervention were not masked to the type of stent used.
Dr. Brilakis disclosed relationships with Abbott Vascular, Amgen, Asahi, Boston Scientific, Cardinal Health, CSI, Elsevier, GE Healthcare, Medicure, Medtronic, Nitiloop, InfraRedx, and Osprey.
SOURCE: Brilakis ES et al. Lancet. 2018 May 19;391(10134);1997-2007.
Drug-eluting stents (DESs) and less-expensive bare-metal stents (BMSs) performed equally well in patients with failed saphenous vein grafts after coronary artery bypass graft surgery, based on an analysis of patients in the DIVA trial.
The findings run counter to those of previous clinical trials, which had found drug-eluting stents perform better than bare-metal stents in these situations. “The study results have important economic implications in countries with high DES prices, such as the USA, because they suggest that the lower-cost BMS can be used in SVG [saphenous vein graft] lesions without compromising either safety or efficacy,” lead author Emmanouil S. Brilakis, MD, PhD, of Minneapolis Heart Institute and his coauthors said in reporting the results for the DIVA trial investigators in the Lancet.
The DIVA trial was a randomized, double-blind, controlled trial done at 25 U.S. Department of Veterans Affairs centers. Researchers randomly assigned 599 patients who had previous coronary artery bypass surgery to either the DES or BMS groups, and the study reported data from 597 patients. The combined endpoint comprised cardiac death, target vessel MI, or target vessel revascularization at 12 months and then over the entire length of follow-up, which ranged from 2 to 7 years. Operators used the DES or BMS of their choice.
While BMSs are presumed to be less expensive than DESs, the study authors did not provide prices or price ranges for the stents. Dr. Brilakis and his coauthors acknowledged that the financial implications depend on local stent pricing practices.
The cost-effectiveness of using DESs vs. BMSs has been controversial, with many studies reporting that BMS are cost-effective over the long-term because of the lower incidence of revascularization and later hospitalization. These studies did not differentiate between SVG and native vessels, however. Multiple studies have reported that the overall costs, including the cost for reintervention, are lower for DESs than for BMSs in native vessels. A Wake Forest study reported the average per procedure cost was $1,846 higher for a DES but the cost was offset after 3 years by lower revascularization rates (Circ Cardiovasc Qual Outcomes. 2011. doi: 10.1161/CIRCOUTCOMES.110.960187)
A recent Korean study found the total cost of DESs was about 5% higher (Yonsei Med J. 2014 Nov;55[6]:1533-41). A French study reported BMSs resulted in a cost reduction $217 per case (Open Heart. 2016 Aug 25;3[2]:e000445). But few, if any, studies have directly compared prices hospitals pay for DESs and BMSs.
Pricing aside, Dr. Brilakis and his coauthors reported no statistical differences in terms of outcomes between the DES and BMS groups. Baseline characteristics of both groups were similar, and the vessel failure rates were 17% in the DES group and 19% in the BMS group after 12 months of follow-up. After 2-7 years, “target vessel failure occurred in approximately one in three patients, with no difference between the bare-metal and drug-eluting stents,” Dr. Brilakis and his coauthors said.
There was no significant difference in cardiac death rates – 5% for DES patients and 4% for BMS patients – or in rates of target lesion revascularization, at 9% and 8%, respectively. Postprocedure medication rates were also similar between the two groups. For example, the rates of patients on P2Y12 inhibitors were 89% for both groups at 12 months and, among those who had follow-up at 36 months, 48% for DES and 44% for BMS.
Among the limitations of the study that Dr. Brilakis and his coauthors noted was the high proportion of men in the VA population – only two women, both in the DES group, participated in the study – and the interventionists doing the index SVG intervention were not masked to the type of stent used.
Dr. Brilakis disclosed relationships with Abbott Vascular, Amgen, Asahi, Boston Scientific, Cardinal Health, CSI, Elsevier, GE Healthcare, Medicure, Medtronic, Nitiloop, InfraRedx, and Osprey.
SOURCE: Brilakis ES et al. Lancet. 2018 May 19;391(10134);1997-2007.
FROM THE LANCET
Key clinical point: Drug-eluting and bare-metal stents had similar outcomes for saphenous vein bypass lesions.
Major finding: Target vessel failure was 17% for drug-eluting stents and 19% for bare metal stents.
Study details: The DIVA trial randomly assigned 599 patients with post-CABG saphenous vein bypass graft failure to drug-eluting or bare metal stents between Jan. 1, 2012, and Dec. 31, 2015.
Disclosures: Dr. Brilakis disclosed relationships with Abbott Vascular, Amgen, Asahi, Boston Scientific, Cardinal Health, CSI, Elsevier, GE Healthcare, Medicure, Medtronic, Nitiloop, InfraRedx, and Osprey.
Source: Brilakis ES et al. Lancet. 2018 May 19;391(10134);1997-2007.
Treating sleep disorders in chronic opioid users
BALTIMORE – Given the prevalence of opioid use in the general population, sleep specialists need to be alert to the effects of opioid use on sleep and the link between chronic use and sleep disorders, a pulmonologist recommended at the annual meeting of the Associated Professional Sleep Societies.
Chronic opioid use has multiple effects on sleep that render continuous positive airway pressure (CPAP) all but ineffective, said Bernardo J. Selim, MD, of Mayo Clinic, Rochester, Minn. Characteristic signs of the effects of chronic opioid use on sleep include ataxic central sleep apnea (CSA) and sustained hypoxemia, for which CPAP is generally not effective. Obtaining arterial blood gas measures in these patients is also important to rule out a hypoventilative condition, he added.
In his review of opioid-induced sleep disorders, Dr. Selim cited a small “landmark” study of 24 chronic pain patients on opioids that found 46% had sleep disordered breathing and that the risk rose with the morphine equivalent dose they were taking (J Clin Sleep Med. 2014 Aug 15; 10[8]:847-52).
A meta-analysis also found a dose-dependent relationship with the severity of CSA in patients on opioids, Dr. Selim noted (Anesth Analg. 2015 Jun;120[6]:1273-85). The prevalence of CSA was 24% in the study, which defined two risk factors for CSA severity: a morphine equivalent dose exceeding 200 mg/day and a low or normal body mass index.
Dr. Selim noted that opioids reduce respiration rate more than tidal volume and cause changes to respiratory rhythm. “[Opioids] decrease hypercapnia but increase hypoxic ventilatory response, decrease the arousal index, decrease upper-airway muscle tone, and decrease and also act on chest and abdominal wall compliance.”
Further, different opioids and injection methods can influence breathing. For example, REM and slow-wave sleep decreased across all three categories – intravenous morphine, oral morphine or methadone, and heroin use.
Sleep specialists should be aware that all opioid receptor agonists, whether legal or illegal, have respiratory side effects, Dr. Selim said. “They can present in any way, in any form – CSA, obstructive sleep apnea [OSA], ataxic breathing or sustained hypoxemia. Most of the time [respiratory side effects] present as a combination of complex respiratory patterns.”
In one meta-analysis, CSA was significantly more prevalent in OSA patients on opioids than it was in nonusers, Dr. Selim said, with increased sleep apnea severity as well (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25). Another study found that ataxic breathing was more frequent in non-REM sleep in chronic opioid users (odds ratio, 15.4; P = .017; J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).
The key rule for treating sleep disorders in opioid-dependent patients is to change to nonopioid analgesics, Dr. Selim said. In that regard, ampakines are experimental drugs which have been shown to improve opioid-induced ventilation without loss of the analgesic effect (Clin Pharmacol Ther. 2010 Feb;87[2]:204-11). “Ampakines modulate the action of the glutamate neurotransmitter, decreasing opiate-induced respiratory depression,” Dr. Selim said. An emerging technology, adaptive servo-ventilation (ASV), has been as effective in the treatment of central and complex sleep apnea in chronic opioid users as it is in patients with congestive heart failure, Dr. Selim said (J Clin Sleep Med. 2016 May 15;12[5]:757-61). “ASV can be very effective in these patients; lower body mass index being a predictor for ASV success,” he said.
Dr. Selim reported having no financial relationships.
BALTIMORE – Given the prevalence of opioid use in the general population, sleep specialists need to be alert to the effects of opioid use on sleep and the link between chronic use and sleep disorders, a pulmonologist recommended at the annual meeting of the Associated Professional Sleep Societies.
Chronic opioid use has multiple effects on sleep that render continuous positive airway pressure (CPAP) all but ineffective, said Bernardo J. Selim, MD, of Mayo Clinic, Rochester, Minn. Characteristic signs of the effects of chronic opioid use on sleep include ataxic central sleep apnea (CSA) and sustained hypoxemia, for which CPAP is generally not effective. Obtaining arterial blood gas measures in these patients is also important to rule out a hypoventilative condition, he added.
In his review of opioid-induced sleep disorders, Dr. Selim cited a small “landmark” study of 24 chronic pain patients on opioids that found 46% had sleep disordered breathing and that the risk rose with the morphine equivalent dose they were taking (J Clin Sleep Med. 2014 Aug 15; 10[8]:847-52).
A meta-analysis also found a dose-dependent relationship with the severity of CSA in patients on opioids, Dr. Selim noted (Anesth Analg. 2015 Jun;120[6]:1273-85). The prevalence of CSA was 24% in the study, which defined two risk factors for CSA severity: a morphine equivalent dose exceeding 200 mg/day and a low or normal body mass index.
Dr. Selim noted that opioids reduce respiration rate more than tidal volume and cause changes to respiratory rhythm. “[Opioids] decrease hypercapnia but increase hypoxic ventilatory response, decrease the arousal index, decrease upper-airway muscle tone, and decrease and also act on chest and abdominal wall compliance.”
Further, different opioids and injection methods can influence breathing. For example, REM and slow-wave sleep decreased across all three categories – intravenous morphine, oral morphine or methadone, and heroin use.
Sleep specialists should be aware that all opioid receptor agonists, whether legal or illegal, have respiratory side effects, Dr. Selim said. “They can present in any way, in any form – CSA, obstructive sleep apnea [OSA], ataxic breathing or sustained hypoxemia. Most of the time [respiratory side effects] present as a combination of complex respiratory patterns.”
In one meta-analysis, CSA was significantly more prevalent in OSA patients on opioids than it was in nonusers, Dr. Selim said, with increased sleep apnea severity as well (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25). Another study found that ataxic breathing was more frequent in non-REM sleep in chronic opioid users (odds ratio, 15.4; P = .017; J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).
The key rule for treating sleep disorders in opioid-dependent patients is to change to nonopioid analgesics, Dr. Selim said. In that regard, ampakines are experimental drugs which have been shown to improve opioid-induced ventilation without loss of the analgesic effect (Clin Pharmacol Ther. 2010 Feb;87[2]:204-11). “Ampakines modulate the action of the glutamate neurotransmitter, decreasing opiate-induced respiratory depression,” Dr. Selim said. An emerging technology, adaptive servo-ventilation (ASV), has been as effective in the treatment of central and complex sleep apnea in chronic opioid users as it is in patients with congestive heart failure, Dr. Selim said (J Clin Sleep Med. 2016 May 15;12[5]:757-61). “ASV can be very effective in these patients; lower body mass index being a predictor for ASV success,” he said.
Dr. Selim reported having no financial relationships.
BALTIMORE – Given the prevalence of opioid use in the general population, sleep specialists need to be alert to the effects of opioid use on sleep and the link between chronic use and sleep disorders, a pulmonologist recommended at the annual meeting of the Associated Professional Sleep Societies.
Chronic opioid use has multiple effects on sleep that render continuous positive airway pressure (CPAP) all but ineffective, said Bernardo J. Selim, MD, of Mayo Clinic, Rochester, Minn. Characteristic signs of the effects of chronic opioid use on sleep include ataxic central sleep apnea (CSA) and sustained hypoxemia, for which CPAP is generally not effective. Obtaining arterial blood gas measures in these patients is also important to rule out a hypoventilative condition, he added.
In his review of opioid-induced sleep disorders, Dr. Selim cited a small “landmark” study of 24 chronic pain patients on opioids that found 46% had sleep disordered breathing and that the risk rose with the morphine equivalent dose they were taking (J Clin Sleep Med. 2014 Aug 15; 10[8]:847-52).
A meta-analysis also found a dose-dependent relationship with the severity of CSA in patients on opioids, Dr. Selim noted (Anesth Analg. 2015 Jun;120[6]:1273-85). The prevalence of CSA was 24% in the study, which defined two risk factors for CSA severity: a morphine equivalent dose exceeding 200 mg/day and a low or normal body mass index.
Dr. Selim noted that opioids reduce respiration rate more than tidal volume and cause changes to respiratory rhythm. “[Opioids] decrease hypercapnia but increase hypoxic ventilatory response, decrease the arousal index, decrease upper-airway muscle tone, and decrease and also act on chest and abdominal wall compliance.”
Further, different opioids and injection methods can influence breathing. For example, REM and slow-wave sleep decreased across all three categories – intravenous morphine, oral morphine or methadone, and heroin use.
Sleep specialists should be aware that all opioid receptor agonists, whether legal or illegal, have respiratory side effects, Dr. Selim said. “They can present in any way, in any form – CSA, obstructive sleep apnea [OSA], ataxic breathing or sustained hypoxemia. Most of the time [respiratory side effects] present as a combination of complex respiratory patterns.”
In one meta-analysis, CSA was significantly more prevalent in OSA patients on opioids than it was in nonusers, Dr. Selim said, with increased sleep apnea severity as well (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25). Another study found that ataxic breathing was more frequent in non-REM sleep in chronic opioid users (odds ratio, 15.4; P = .017; J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).
The key rule for treating sleep disorders in opioid-dependent patients is to change to nonopioid analgesics, Dr. Selim said. In that regard, ampakines are experimental drugs which have been shown to improve opioid-induced ventilation without loss of the analgesic effect (Clin Pharmacol Ther. 2010 Feb;87[2]:204-11). “Ampakines modulate the action of the glutamate neurotransmitter, decreasing opiate-induced respiratory depression,” Dr. Selim said. An emerging technology, adaptive servo-ventilation (ASV), has been as effective in the treatment of central and complex sleep apnea in chronic opioid users as it is in patients with congestive heart failure, Dr. Selim said (J Clin Sleep Med. 2016 May 15;12[5]:757-61). “ASV can be very effective in these patients; lower body mass index being a predictor for ASV success,” he said.
Dr. Selim reported having no financial relationships.
EXPERT ANALYSIS FROM SLEEP 2018
Surgical outcomes for UC worse since introduction of biologics
Since the approval of more UC patients are having multiple operations to manage their disease and their surgical outcomes tend to be worse, according to a study published in Annals of Surgery.
“Encouragingly, early randomized controlled trials demonstrated that infliximab may reduce the short-term need for surgery,” wrote Jonathan Abelson, MD, of the department of surgery, Cornell University, New York, and his coauthors. “However, even after the development and approval of several other biologic agents to treat UC, 30%-66% of patients treated with biologic agents still ultimately require surgical intervention.”
The study reviewed records of 7,070 patients with UC in a New York State Department of Health database who had colorectal surgery in two comparative time periods: 3,803 from 1995 to 2005, before biologics were available, and 3,267 from 2006 to 2013, after infliximab was approved. Dr. Abelson and coauthors said this is the first study to look at long-term surgical outcomes in a large group of patients with UC over an extended time period. Previous studies have reported conflicting results of how biologic agents for UC can impact surgical outcomes. The researchers set out to explore two hypotheses: whether staged procedures increased after 2005 and whether UC patients had worse outcomes over the past decade. The study results validated both hypotheses. Up until 2005, the proportion of patients who underwent at least three procedures after the index hospitalization was 9%; after 2006, that proportion was 14% (P less than .01).
A potential explanation for trends in postsurgery death may be higher rates of Clostridium difficile after 2005 (10.6% vs. 5.8%; P less than .01), but that was accounted for in the adjusted analysis and is probably not a major factor, the researchers said. After 2006 patients were slightly older and more likely to be on Medicare and nonwhite; they also were sicker, with 28% having two or more comorbidities vs. 10% before 2006.
The investigators offered another explanation: “It is also possible that the immunosuppressive effect of biologic agents ... predisposes patients to worse postoperative outcomes. In addition, it is possible that patients are referred for surgery too late in their disease course because of prolonged medical therapy.”
Dr. Abelson and coauthors reported having no financial relationships.
SOURCE: Abelson JS et al. Ann Surg. 2018:268;311-7.
Since the approval of more UC patients are having multiple operations to manage their disease and their surgical outcomes tend to be worse, according to a study published in Annals of Surgery.
“Encouragingly, early randomized controlled trials demonstrated that infliximab may reduce the short-term need for surgery,” wrote Jonathan Abelson, MD, of the department of surgery, Cornell University, New York, and his coauthors. “However, even after the development and approval of several other biologic agents to treat UC, 30%-66% of patients treated with biologic agents still ultimately require surgical intervention.”
The study reviewed records of 7,070 patients with UC in a New York State Department of Health database who had colorectal surgery in two comparative time periods: 3,803 from 1995 to 2005, before biologics were available, and 3,267 from 2006 to 2013, after infliximab was approved. Dr. Abelson and coauthors said this is the first study to look at long-term surgical outcomes in a large group of patients with UC over an extended time period. Previous studies have reported conflicting results of how biologic agents for UC can impact surgical outcomes. The researchers set out to explore two hypotheses: whether staged procedures increased after 2005 and whether UC patients had worse outcomes over the past decade. The study results validated both hypotheses. Up until 2005, the proportion of patients who underwent at least three procedures after the index hospitalization was 9%; after 2006, that proportion was 14% (P less than .01).
A potential explanation for trends in postsurgery death may be higher rates of Clostridium difficile after 2005 (10.6% vs. 5.8%; P less than .01), but that was accounted for in the adjusted analysis and is probably not a major factor, the researchers said. After 2006 patients were slightly older and more likely to be on Medicare and nonwhite; they also were sicker, with 28% having two or more comorbidities vs. 10% before 2006.
The investigators offered another explanation: “It is also possible that the immunosuppressive effect of biologic agents ... predisposes patients to worse postoperative outcomes. In addition, it is possible that patients are referred for surgery too late in their disease course because of prolonged medical therapy.”
Dr. Abelson and coauthors reported having no financial relationships.
SOURCE: Abelson JS et al. Ann Surg. 2018:268;311-7.
Since the approval of more UC patients are having multiple operations to manage their disease and their surgical outcomes tend to be worse, according to a study published in Annals of Surgery.
“Encouragingly, early randomized controlled trials demonstrated that infliximab may reduce the short-term need for surgery,” wrote Jonathan Abelson, MD, of the department of surgery, Cornell University, New York, and his coauthors. “However, even after the development and approval of several other biologic agents to treat UC, 30%-66% of patients treated with biologic agents still ultimately require surgical intervention.”
The study reviewed records of 7,070 patients with UC in a New York State Department of Health database who had colorectal surgery in two comparative time periods: 3,803 from 1995 to 2005, before biologics were available, and 3,267 from 2006 to 2013, after infliximab was approved. Dr. Abelson and coauthors said this is the first study to look at long-term surgical outcomes in a large group of patients with UC over an extended time period. Previous studies have reported conflicting results of how biologic agents for UC can impact surgical outcomes. The researchers set out to explore two hypotheses: whether staged procedures increased after 2005 and whether UC patients had worse outcomes over the past decade. The study results validated both hypotheses. Up until 2005, the proportion of patients who underwent at least three procedures after the index hospitalization was 9%; after 2006, that proportion was 14% (P less than .01).
A potential explanation for trends in postsurgery death may be higher rates of Clostridium difficile after 2005 (10.6% vs. 5.8%; P less than .01), but that was accounted for in the adjusted analysis and is probably not a major factor, the researchers said. After 2006 patients were slightly older and more likely to be on Medicare and nonwhite; they also were sicker, with 28% having two or more comorbidities vs. 10% before 2006.
The investigators offered another explanation: “It is also possible that the immunosuppressive effect of biologic agents ... predisposes patients to worse postoperative outcomes. In addition, it is possible that patients are referred for surgery too late in their disease course because of prolonged medical therapy.”
Dr. Abelson and coauthors reported having no financial relationships.
SOURCE: Abelson JS et al. Ann Surg. 2018:268;311-7.
FROM ANNALS OF SURGERY
Key clinical point: Rates of multiple surgeries for ulcerative colitis have increased since biologic agents were introduced.
Major finding: Fourteen percent of patients have had multiple operations since 2006 vs. 9% before that.
Study details: A longitudinal analysis of 7,070 patients in the New York State Department of Health of Health Statewide Planning and Research Cooperative System database who had surgery for UC from 1995 to 2013.
Disclosures: Dr. Abelson and coauthors reported having no financial relationships.
Source: Abelson JS et al. Ann Surg. 2018;268:311-7.
Trauma surgeons up for emergency pediatric appendectomy
But a study of 220 children who had emergency appendectomies found only minor differences in outcomes between those operated on by a trauma surgeon and those by a pediatric surgeon.
“These results may be useful in optimizing the surgical workforce to care for a community,” said Derek B. Wall, MD, FACS, and Carlos Ortega, MD, FACS, of NorthShore University HealthSystem in Skokie, Ill. They noted that trauma surgeons in their group were asked to cover appendicitis in children aged 5-10 years because of the surgeons’ in-house availability and because of the difficulty pediatric surgeons often had in getting to the hospital in a timely fashion.
The study was done at Evanston (Ill.) Hospital, a Level 1 trauma center in the northern suburbs of Chicago. This trauma group were all board certified in general surgery, but none had received formal pediatric surgery fellowship training.
The study, published in the Journal of Trauma and Acute Surgery, evaluated appendectomies in children aged 5-10 years from January 2007 to December 2016. A total of 138 were performed by trauma surgeons, while 82 were done by pediatric surgeons. The patients operated on by trauma surgeons were more likely to be female (47% vs. 32%; P = .03), get to surgery more quickly (214 minutes from diagnosis vs. 318 minutes; P = .01), have a laparoscopic operation (70% vs. 55%; P = .04), have a shorter operation (40 minutes vs. 49 minutes; P less than .0001), and leave the hospital sooner (32 hours vs. 41 hours; P less than .0001). They were also more likely to be transferred from an outside hospital (60% vs. 37%; P less than .001) and less likely to be diagnosed without imaging (2% vs. 26%; P less than .0001). The study found no significant differences in complications.
Among the 31 patients who had perforated appendix, the difference in length of stay was even more pronounced: 4 days in the trauma surgery group (n = 21) versus 7.2 days in the pediatric surgery patients.
The investigators explained the rationale for focusing on the population aged 5-10 years: “We focused on a younger, narrower age range than that in previous studies, allowing comparison of outcomes in children of the same age and with equal rates of perforated appendicitis.” They noted that patients younger than age 5 are “well accepted as the domain of the pediatric surgeon,” while children over than 10 are more frequently managed by general surgeons.
At Evanston Hospital, pediatric surgeons had typically performed appendectomy in the targeted age group. But, “they cannot always quickly get to our hospital because of distance and city traffic,” the study authors noted. Therefore, the trauma surgeons were asked to cover for this population group.
They acknowledged the population size of the study was probably too small to identify any significant difference in complication rates between the two surgery groups, especially for patients who had had perforated appendicitis. Also, because of the study’s retrospective nature, most of the pediatric surgery cases were from an earlier period; therefore, later cases may have reflected advances in minimally invasive technology. “Perhaps surgical practice in a more recent time period contributes more to outcomes than specialty,” investigators wrote.
Dr. Wall and Dr. Ortega reported having no financial relationships.
SOURCE: Wall DB, Ortega C. J Trauma Acute Care Surg. 2018:85;118-21.
But a study of 220 children who had emergency appendectomies found only minor differences in outcomes between those operated on by a trauma surgeon and those by a pediatric surgeon.
“These results may be useful in optimizing the surgical workforce to care for a community,” said Derek B. Wall, MD, FACS, and Carlos Ortega, MD, FACS, of NorthShore University HealthSystem in Skokie, Ill. They noted that trauma surgeons in their group were asked to cover appendicitis in children aged 5-10 years because of the surgeons’ in-house availability and because of the difficulty pediatric surgeons often had in getting to the hospital in a timely fashion.
The study was done at Evanston (Ill.) Hospital, a Level 1 trauma center in the northern suburbs of Chicago. This trauma group were all board certified in general surgery, but none had received formal pediatric surgery fellowship training.
The study, published in the Journal of Trauma and Acute Surgery, evaluated appendectomies in children aged 5-10 years from January 2007 to December 2016. A total of 138 were performed by trauma surgeons, while 82 were done by pediatric surgeons. The patients operated on by trauma surgeons were more likely to be female (47% vs. 32%; P = .03), get to surgery more quickly (214 minutes from diagnosis vs. 318 minutes; P = .01), have a laparoscopic operation (70% vs. 55%; P = .04), have a shorter operation (40 minutes vs. 49 minutes; P less than .0001), and leave the hospital sooner (32 hours vs. 41 hours; P less than .0001). They were also more likely to be transferred from an outside hospital (60% vs. 37%; P less than .001) and less likely to be diagnosed without imaging (2% vs. 26%; P less than .0001). The study found no significant differences in complications.
Among the 31 patients who had perforated appendix, the difference in length of stay was even more pronounced: 4 days in the trauma surgery group (n = 21) versus 7.2 days in the pediatric surgery patients.
The investigators explained the rationale for focusing on the population aged 5-10 years: “We focused on a younger, narrower age range than that in previous studies, allowing comparison of outcomes in children of the same age and with equal rates of perforated appendicitis.” They noted that patients younger than age 5 are “well accepted as the domain of the pediatric surgeon,” while children over than 10 are more frequently managed by general surgeons.
At Evanston Hospital, pediatric surgeons had typically performed appendectomy in the targeted age group. But, “they cannot always quickly get to our hospital because of distance and city traffic,” the study authors noted. Therefore, the trauma surgeons were asked to cover for this population group.
They acknowledged the population size of the study was probably too small to identify any significant difference in complication rates between the two surgery groups, especially for patients who had had perforated appendicitis. Also, because of the study’s retrospective nature, most of the pediatric surgery cases were from an earlier period; therefore, later cases may have reflected advances in minimally invasive technology. “Perhaps surgical practice in a more recent time period contributes more to outcomes than specialty,” investigators wrote.
Dr. Wall and Dr. Ortega reported having no financial relationships.
SOURCE: Wall DB, Ortega C. J Trauma Acute Care Surg. 2018:85;118-21.
But a study of 220 children who had emergency appendectomies found only minor differences in outcomes between those operated on by a trauma surgeon and those by a pediatric surgeon.
“These results may be useful in optimizing the surgical workforce to care for a community,” said Derek B. Wall, MD, FACS, and Carlos Ortega, MD, FACS, of NorthShore University HealthSystem in Skokie, Ill. They noted that trauma surgeons in their group were asked to cover appendicitis in children aged 5-10 years because of the surgeons’ in-house availability and because of the difficulty pediatric surgeons often had in getting to the hospital in a timely fashion.
The study was done at Evanston (Ill.) Hospital, a Level 1 trauma center in the northern suburbs of Chicago. This trauma group were all board certified in general surgery, but none had received formal pediatric surgery fellowship training.
The study, published in the Journal of Trauma and Acute Surgery, evaluated appendectomies in children aged 5-10 years from January 2007 to December 2016. A total of 138 were performed by trauma surgeons, while 82 were done by pediatric surgeons. The patients operated on by trauma surgeons were more likely to be female (47% vs. 32%; P = .03), get to surgery more quickly (214 minutes from diagnosis vs. 318 minutes; P = .01), have a laparoscopic operation (70% vs. 55%; P = .04), have a shorter operation (40 minutes vs. 49 minutes; P less than .0001), and leave the hospital sooner (32 hours vs. 41 hours; P less than .0001). They were also more likely to be transferred from an outside hospital (60% vs. 37%; P less than .001) and less likely to be diagnosed without imaging (2% vs. 26%; P less than .0001). The study found no significant differences in complications.
Among the 31 patients who had perforated appendix, the difference in length of stay was even more pronounced: 4 days in the trauma surgery group (n = 21) versus 7.2 days in the pediatric surgery patients.
The investigators explained the rationale for focusing on the population aged 5-10 years: “We focused on a younger, narrower age range than that in previous studies, allowing comparison of outcomes in children of the same age and with equal rates of perforated appendicitis.” They noted that patients younger than age 5 are “well accepted as the domain of the pediatric surgeon,” while children over than 10 are more frequently managed by general surgeons.
At Evanston Hospital, pediatric surgeons had typically performed appendectomy in the targeted age group. But, “they cannot always quickly get to our hospital because of distance and city traffic,” the study authors noted. Therefore, the trauma surgeons were asked to cover for this population group.
They acknowledged the population size of the study was probably too small to identify any significant difference in complication rates between the two surgery groups, especially for patients who had had perforated appendicitis. Also, because of the study’s retrospective nature, most of the pediatric surgery cases were from an earlier period; therefore, later cases may have reflected advances in minimally invasive technology. “Perhaps surgical practice in a more recent time period contributes more to outcomes than specialty,” investigators wrote.
Dr. Wall and Dr. Ortega reported having no financial relationships.
SOURCE: Wall DB, Ortega C. J Trauma Acute Care Surg. 2018:85;118-21.
FROM THE JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
Key clinical point: Trauma surgeons performed emergency pediatric appendectomy as well as pediatric surgeons did.
Major finding: Hospital stays averaged 32 and 41 hours for patients treated by trauma surgeons and pediatric surgeons, respectively.
Study details: Retrospective chart review of 220 children aged 5-10 years who had emergency appendectomy at a suburban Level 1 trauma center during 2007-2016.
Disclosures: The investigators reported having no financial relationships.
Source: Wall DB et al. J Trauma Acute Care Surg. 2018:85;118-21.
Study quantifies occupational exposure risks of EDT
For trauma patients who are in extremis, but with the high rates of HIV/hepatitis among trauma patients, one that also carries what had been an unknown exposure risk for emergency staff.
“The most important findings of this prospective, multicenter study are that occupational exposures were reported in 7.2% of EDT resuscitations and 1.6% of EDT resuscitation participants and that occupational exposure risk appears to be further mitigated with strict PPE [personal protective equipment] compliance to universal precautions,” lead author Andrew Nunn, MD, and his colleagues wrote. Dr. Nunn is a trauma surgeon with Wake Forest Baptist Health in Winston-Salem, N.C.
The researchers surveyed 1,360 emergency department (ED) personnel after they performed 305 EDTs at 16 academic and community trauma centers nationwide in 2015 and 2016. The patients who had an EDT were mostly men ranging in age from 24 to 41 years (90.5%) with penetrating injuries (77.4%) and arrived at the ED after prehospital CPR (56.7%). Twenty-two occupational exposures occurred during 22 of the EDT resuscitations, with trainees sustaining most of them (68.2%). The most common source of injury was sharps, accounting for 86.4% (scalpels, 38.9%; fractured bone, 27.8%; needles, 16.7%; and scissors, 3%).
“Occupational exposures correlated with PPE utilization, as universal precautions during EDT were more often observed in providers who did not sustain occupational exposures, compared with those sustaining exposures,” Dr. Nunn and his coauthors wrote. For example, 98% of those reporting no exposure were gloved versus 91% of those who were exposed (P greater than .05).
Dr. Nunn and his coauthors called the risk of HIV or hepatitis C virus (HCV) transmission during EDT “extraordinarily low.” Based on data from their study, they determined the risk of blood-borne pathogen transmission during an EDT resuscitation is 6 in 1 million for HIV and 1 in 10,000 for HCV, and the individual risk is 1 in 1 million and 3 in 100,000, respectively. Compliance with PPE precautions further limited exposure risk, but the study found that more than 10% of surveyed personnel did not utilize one of the four components of PPE besides gloves – eyewear, mask, gown or hat.
Most – but not all – survey responders followed up after the incidence of exposure. “[A total of] 91.7% of providers reporting their exposures also reported following up with their institution specific occupational exposure protocol,” the investigators wrote.
“Our findings have particular implications for trainees,” the study authors noted, citing the high percentage of injuries in this group. The findings emphasized the need for universal PPE compliance and enforcement by resuscitation team leaders. Nonetheless, the study found that the exposure rates during EDT are no greater than other surgical procedures.
“Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with PPE is paramount and would further minimize occupational exposure risks to providers during EDT,” Dr. Nunn and his coauthors said.
Dr. Nunn and his coauthors reported having no financial relationships.
SOURCE: Nunn A et al. J Trauma Acute Care Surg. 2018:85;78-84.
For trauma patients who are in extremis, but with the high rates of HIV/hepatitis among trauma patients, one that also carries what had been an unknown exposure risk for emergency staff.
“The most important findings of this prospective, multicenter study are that occupational exposures were reported in 7.2% of EDT resuscitations and 1.6% of EDT resuscitation participants and that occupational exposure risk appears to be further mitigated with strict PPE [personal protective equipment] compliance to universal precautions,” lead author Andrew Nunn, MD, and his colleagues wrote. Dr. Nunn is a trauma surgeon with Wake Forest Baptist Health in Winston-Salem, N.C.
The researchers surveyed 1,360 emergency department (ED) personnel after they performed 305 EDTs at 16 academic and community trauma centers nationwide in 2015 and 2016. The patients who had an EDT were mostly men ranging in age from 24 to 41 years (90.5%) with penetrating injuries (77.4%) and arrived at the ED after prehospital CPR (56.7%). Twenty-two occupational exposures occurred during 22 of the EDT resuscitations, with trainees sustaining most of them (68.2%). The most common source of injury was sharps, accounting for 86.4% (scalpels, 38.9%; fractured bone, 27.8%; needles, 16.7%; and scissors, 3%).
“Occupational exposures correlated with PPE utilization, as universal precautions during EDT were more often observed in providers who did not sustain occupational exposures, compared with those sustaining exposures,” Dr. Nunn and his coauthors wrote. For example, 98% of those reporting no exposure were gloved versus 91% of those who were exposed (P greater than .05).
Dr. Nunn and his coauthors called the risk of HIV or hepatitis C virus (HCV) transmission during EDT “extraordinarily low.” Based on data from their study, they determined the risk of blood-borne pathogen transmission during an EDT resuscitation is 6 in 1 million for HIV and 1 in 10,000 for HCV, and the individual risk is 1 in 1 million and 3 in 100,000, respectively. Compliance with PPE precautions further limited exposure risk, but the study found that more than 10% of surveyed personnel did not utilize one of the four components of PPE besides gloves – eyewear, mask, gown or hat.
Most – but not all – survey responders followed up after the incidence of exposure. “[A total of] 91.7% of providers reporting their exposures also reported following up with their institution specific occupational exposure protocol,” the investigators wrote.
“Our findings have particular implications for trainees,” the study authors noted, citing the high percentage of injuries in this group. The findings emphasized the need for universal PPE compliance and enforcement by resuscitation team leaders. Nonetheless, the study found that the exposure rates during EDT are no greater than other surgical procedures.
“Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with PPE is paramount and would further minimize occupational exposure risks to providers during EDT,” Dr. Nunn and his coauthors said.
Dr. Nunn and his coauthors reported having no financial relationships.
SOURCE: Nunn A et al. J Trauma Acute Care Surg. 2018:85;78-84.
For trauma patients who are in extremis, but with the high rates of HIV/hepatitis among trauma patients, one that also carries what had been an unknown exposure risk for emergency staff.
“The most important findings of this prospective, multicenter study are that occupational exposures were reported in 7.2% of EDT resuscitations and 1.6% of EDT resuscitation participants and that occupational exposure risk appears to be further mitigated with strict PPE [personal protective equipment] compliance to universal precautions,” lead author Andrew Nunn, MD, and his colleagues wrote. Dr. Nunn is a trauma surgeon with Wake Forest Baptist Health in Winston-Salem, N.C.
The researchers surveyed 1,360 emergency department (ED) personnel after they performed 305 EDTs at 16 academic and community trauma centers nationwide in 2015 and 2016. The patients who had an EDT were mostly men ranging in age from 24 to 41 years (90.5%) with penetrating injuries (77.4%) and arrived at the ED after prehospital CPR (56.7%). Twenty-two occupational exposures occurred during 22 of the EDT resuscitations, with trainees sustaining most of them (68.2%). The most common source of injury was sharps, accounting for 86.4% (scalpels, 38.9%; fractured bone, 27.8%; needles, 16.7%; and scissors, 3%).
“Occupational exposures correlated with PPE utilization, as universal precautions during EDT were more often observed in providers who did not sustain occupational exposures, compared with those sustaining exposures,” Dr. Nunn and his coauthors wrote. For example, 98% of those reporting no exposure were gloved versus 91% of those who were exposed (P greater than .05).
Dr. Nunn and his coauthors called the risk of HIV or hepatitis C virus (HCV) transmission during EDT “extraordinarily low.” Based on data from their study, they determined the risk of blood-borne pathogen transmission during an EDT resuscitation is 6 in 1 million for HIV and 1 in 10,000 for HCV, and the individual risk is 1 in 1 million and 3 in 100,000, respectively. Compliance with PPE precautions further limited exposure risk, but the study found that more than 10% of surveyed personnel did not utilize one of the four components of PPE besides gloves – eyewear, mask, gown or hat.
Most – but not all – survey responders followed up after the incidence of exposure. “[A total of] 91.7% of providers reporting their exposures also reported following up with their institution specific occupational exposure protocol,” the investigators wrote.
“Our findings have particular implications for trainees,” the study authors noted, citing the high percentage of injuries in this group. The findings emphasized the need for universal PPE compliance and enforcement by resuscitation team leaders. Nonetheless, the study found that the exposure rates during EDT are no greater than other surgical procedures.
“Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with PPE is paramount and would further minimize occupational exposure risks to providers during EDT,” Dr. Nunn and his coauthors said.
Dr. Nunn and his coauthors reported having no financial relationships.
SOURCE: Nunn A et al. J Trauma Acute Care Surg. 2018:85;78-84.
FROM THE JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
Key clinical point: Occupational exposure risk of emergency department thoracotomy (EDT) is low for personnel.
Major finding: Occupational exposure rate to HIV/hepatitis in trauma undergoing EDT is 7.2% for personnel.
Study details: Prospective, observational study that included 1,360 personnel surveyed after they performed 305 EDTs in 2015 and 2016.
Disclosures: Dr. Nunn and his coauthors reported having no financial relationships.
Source: Nunn A et al. J Trauma Acute Care Surg. 2018:85;78-84.