Ted Bosworth

NEW YORK – Strategies for growing the pool of academic vascular surgeons might help avert the expected scarcity of physicians in this specialty, according to Peter K. Henke, MD, a professor of vascular surgery at the University of Michigan, Ann Arbor.
 

Dr. Henke recounted in a video interview key messages he delivered at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. He argued for going back to basics to enlist residents and fellows completing their training to stay in the specialty and consider an academic position.

Many of these steps are known, such as verifying that mentors are available to encourage skill acquisition and providing adequate time to achieve an acceptable balance of research and clinical work.

However, a successful program would not solely focus on luring young and promising junior faculty, he said. A supportive atmosphere requires collaboration and support to flow both up and down the ranks of seniority where everyone benefits.As an example, he singled out midlevel faculty as vulnerable when programs are not developed to ensure support is equally distributed. He explained that midlevel faculty members denied the encouragement available to surgeons just initiating their career can feel abandoned when they are skilled but not yet leaders in their program.

The Society of Vascular Surgery is pursing several initiatives to address the projected shortage within this specialty, according to Dr. Henke, but he argues that leaders of academic programs have a role to play in helping make the specialty attractive, particularly for those considering an academic career.

NEW YORK – Strategies for growing the pool of academic vascular surgeons might help avert the expected scarcity of physicians in this specialty, according to Peter K. Henke, MD, a professor of vascular surgery at the University of Michigan, Ann Arbor.
 

Dr. Henke recounted in a video interview key messages he delivered at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. He argued for going back to basics to enlist residents and fellows completing their training to stay in the specialty and consider an academic position.

Many of these steps are known, such as verifying that mentors are available to encourage skill acquisition and providing adequate time to achieve an acceptable balance of research and clinical work.

However, a successful program would not solely focus on luring young and promising junior faculty, he said. A supportive atmosphere requires collaboration and support to flow both up and down the ranks of seniority where everyone benefits.As an example, he singled out midlevel faculty as vulnerable when programs are not developed to ensure support is equally distributed. He explained that midlevel faculty members denied the encouragement available to surgeons just initiating their career can feel abandoned when they are skilled but not yet leaders in their program.

The Society of Vascular Surgery is pursing several initiatives to address the projected shortage within this specialty, according to Dr. Henke, but he argues that leaders of academic programs have a role to play in helping make the specialty attractive, particularly for those considering an academic career.

NEW YORK – Strategies for growing the pool of academic vascular surgeons might help avert the expected scarcity of physicians in this specialty, according to Peter K. Henke, MD, a professor of vascular surgery at the University of Michigan, Ann Arbor.
 

Dr. Henke recounted in a video interview key messages he delivered at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. He argued for going back to basics to enlist residents and fellows completing their training to stay in the specialty and consider an academic position.

Many of these steps are known, such as verifying that mentors are available to encourage skill acquisition and providing adequate time to achieve an acceptable balance of research and clinical work.

However, a successful program would not solely focus on luring young and promising junior faculty, he said. A supportive atmosphere requires collaboration and support to flow both up and down the ranks of seniority where everyone benefits.As an example, he singled out midlevel faculty as vulnerable when programs are not developed to ensure support is equally distributed. He explained that midlevel faculty members denied the encouragement available to surgeons just initiating their career can feel abandoned when they are skilled but not yet leaders in their program.

The Society of Vascular Surgery is pursing several initiatives to address the projected shortage within this specialty, according to Dr. Henke, but he argues that leaders of academic programs have a role to play in helping make the specialty attractive, particularly for those considering an academic career.

NEW YORK – Follow-up to 5 years is now available for a drug-coated balloon (DCB) device used to treat superficial femoral artery (SFA) occlusion. John Laird, MD, of the Adventist Heart Institute, St. Helena, Calif., presented the data at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

The data were drawn from the IN.PACT trial. In this trial, 331 patients were randomized to a paclitaxel-coated DCB device or standard percutaneous balloon angioplasty (PCBA), Dr. Laird explained.

The 5-year results are consistent with those previously reported at 1, 2, and 3 years. According to Dr. Laird, DCB continues to show an advantage for major outcomes over PCBA, and adverse events remain low.

Three DCB devices now available in the United States for dilatation of narrowed SFA. Although all have been associated with a reduced risk of target lesion revascularization relative to standard PCBA, the long-term follow-up presented from IN.PACT by Dr. Laird are the first to document 5-year outcomes.

In a video interview, Dr. Laird reported that there have been no thrombotic events since the 3-year results were presented.

Overall, he explains that the long-term outcomes provide additional confirmation that DCB is a safe procedure that reduces the need for stenting in SFA occlusions. Although he believes there might be clinically significant differences between available DCB devices, he concludes that DCB can be considered the first-line therapy for treating occluded femoral-popliteal arteries.

NEW YORK – Follow-up to 5 years is now available for a drug-coated balloon (DCB) device used to treat superficial femoral artery (SFA) occlusion. John Laird, MD, of the Adventist Heart Institute, St. Helena, Calif., presented the data at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

The data were drawn from the IN.PACT trial. In this trial, 331 patients were randomized to a paclitaxel-coated DCB device or standard percutaneous balloon angioplasty (PCBA), Dr. Laird explained.

The 5-year results are consistent with those previously reported at 1, 2, and 3 years. According to Dr. Laird, DCB continues to show an advantage for major outcomes over PCBA, and adverse events remain low.

Three DCB devices now available in the United States for dilatation of narrowed SFA. Although all have been associated with a reduced risk of target lesion revascularization relative to standard PCBA, the long-term follow-up presented from IN.PACT by Dr. Laird are the first to document 5-year outcomes.

In a video interview, Dr. Laird reported that there have been no thrombotic events since the 3-year results were presented.

Overall, he explains that the long-term outcomes provide additional confirmation that DCB is a safe procedure that reduces the need for stenting in SFA occlusions. Although he believes there might be clinically significant differences between available DCB devices, he concludes that DCB can be considered the first-line therapy for treating occluded femoral-popliteal arteries.

NEW YORK – Follow-up to 5 years is now available for a drug-coated balloon (DCB) device used to treat superficial femoral artery (SFA) occlusion. John Laird, MD, of the Adventist Heart Institute, St. Helena, Calif., presented the data at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

The data were drawn from the IN.PACT trial. In this trial, 331 patients were randomized to a paclitaxel-coated DCB device or standard percutaneous balloon angioplasty (PCBA), Dr. Laird explained.

The 5-year results are consistent with those previously reported at 1, 2, and 3 years. According to Dr. Laird, DCB continues to show an advantage for major outcomes over PCBA, and adverse events remain low.

Three DCB devices now available in the United States for dilatation of narrowed SFA. Although all have been associated with a reduced risk of target lesion revascularization relative to standard PCBA, the long-term follow-up presented from IN.PACT by Dr. Laird are the first to document 5-year outcomes.

In a video interview, Dr. Laird reported that there have been no thrombotic events since the 3-year results were presented.

Overall, he explains that the long-term outcomes provide additional confirmation that DCB is a safe procedure that reduces the need for stenting in SFA occlusions. Although he believes there might be clinically significant differences between available DCB devices, he concludes that DCB can be considered the first-line therapy for treating occluded femoral-popliteal arteries.

Of the trials chosen for the six Late-Breaking Clinical Trial sessions, all being presented in the first 2 days of the American Heart Association scientific sessions in Chicago Nov. 10-12. Here are some of the most potentially practice-changing studies to look out for.

Courtesy of the Chicago Architecture Foundation.

Saturday

• REDUCE-IT: Relative to placebo, the fish oil derivative AMR101 (icosapent-ethyl) evaluated in the REDUCE-IT trial was associated with a 25% reduction in a primary composite endpoint of major adverse cardiovascular events (MACE), according top-line data released in September. A highly purified ethyl ester of eicosapentaenoic acid (EPA), AMR101 (Vascepa, Amarin) was studied on top of statin therapy in both primary and secondary prevention cohorts among the 8,000 patients randomized. Relative efficacy for primary and secondary prevention was not described in the initial release of data and will be of particular when the full results are released on Saturday, Nov. 10 at 2:00 p.m.

• DECLARE TIMI58: In top line results from DECLARE TIMI58, which randomized more than 17,000 participants with type 2 diabetes an experimental arm or placebo, the SGLT2 inhibitor dapagliflozin (Farxiga, AstraZeneca) was linked to a reduction in the composite endpoint of hospitalization for heart failure or cardiovascular death. In the early release of results, no mention was made of the effect of this agent on a composite of cardiovascular death, MI, or ischemic stroke, which was a secondary co-primary endpoint. This and the impact of dapagliflozin on an array of secondary endpoints will be revealed when the full results are made available in the Saturday late-breaker session at 2:00 p.m.

• VITAL: The relative effect of vitamin D, fish oil, or both on body composition was compared in the VITAL study, which randomized more than 20,000 patients. Fish oil plus vitamin D, fish oil plus placebo, vitamin D plus placebo, and two placebos were compared in a 2 x 2 factorial design. The primary outcome includes total body fat and lean mass as well as these components in the abdomen and other anatomic sites. Body mass index, waist circumference, and waist-to-hip ratio are among secondary outcomes. In addition, the relative effects of these treatments on lipids, blood glucose, and other aspects of metabolism were followed over the 2 years of the study, to presented at 2 p.m. on Saturday.

• CIRT: Responding to the evidence that inflammation is a crucial contributor to atherothrombosis, the CIRT trial tested whether the anti-inflammatory agent methotrexate reduces rates of MI, stroke, and cardiovascular death relative to placebo in patients with stable coronary artery disease and either type 2 diabetes or metabolic syndrome. The study enrolled about 7,000 patients and will have follow-up of nearly 6 years. Secondary endpoints, such as the impact of methotrexate on rates of coronary revascularization, peripheral artery disease, venous thromboembolism, and aortic stenosis, may provide insight about the ways in which control of inflammation affects vascular pathology. The presentation is at 2 p.m. on Saturday.

• Also on Saturday, diverse trial hypotheses are being tested. For example, the cost effectiveness of a PCSK9 inhibitor will be the focus of the ODYSSEY OUTCOMES economics study, presented at the 2:00 session. The results of YOGA-CaRe, a multicenter trial of a yoga-based cardiac rehabilitation program, will be presented in a subsequent Saturday late-breaking session. Of highlights of the third Saturday late-breaking session, ALERT-AF will determine whether a computerized decision protocol affected anticoagulation management in hospitalized patients with atrial fibrillation.

Sunday

• PIONEER-HF: It has been previously shown that sacubitril/valsartan improves outcome in stable heart failure patients with a reduced ejection fraction (HRrEF), but PIONEER-HF will test the tolerability of this strategy when this treatment is initiated prior to hospital discharge. Patients with a left ventricular ejection fraction of 40% or less and elevated N-terminal pro hormone BNP (NT-proBNP) will be randomized to sacubitril/valsartan (Entresto, Novartis) or the ACE inhibitor enalapril. The primary outcome of the trial, which enrolled more than 700 patients, is the time-averaged percentage change in NT-proBNP from baseline. Secondary outcome measures included the proportion of patients with symptomatic hypotension, hyperkalemia, and angioedema. Presentation will be at the Sunday 10:45 a.m. session.

• TICAB: The hypothesis that ticagrelor is superior to aspirin for preventing a composite MACE endpoint of CV death, myocardial infarction, target vessel revascularization, and stroke in patients undergoing coronary artery bypass grafting is the basis for the TICAB trial. The nearly 1,900 patients were randomized to 90 mg of ticagrelor twice daily or 100 mg of aspirin twice daily. Major bleeding events, CV death, and all cause death are key secondary outcomes. Relative benefit in context of safety, particularly bleeding risk, will be of interest when the final results are revealed at 5:30 p.m. on Sunday.

All-in-all, the Sunday late-breaking sessions are no less crowded with potentially practice-changing studies, including T-TIME, an evaluation of low-dose alteplase during primary percutaneous intervention at 9:00 a.m., TRED-HF, a study of withdrawal of heart failure therapy in patients who have recovered from dilated cardiomyopathy at 10:45 a.m., and ISAR TEST 4, which will provide 10-year outcomes after coronary stents with biodegradable versus permanent polymer coated devices, at 5:30 p.m.
 

Of the trials chosen for the six Late-Breaking Clinical Trial sessions, all being presented in the first 2 days of the American Heart Association scientific sessions in Chicago Nov. 10-12. Here are some of the most potentially practice-changing studies to look out for.

Courtesy of the Chicago Architecture Foundation.

Saturday

• REDUCE-IT: Relative to placebo, the fish oil derivative AMR101 (icosapent-ethyl) evaluated in the REDUCE-IT trial was associated with a 25% reduction in a primary composite endpoint of major adverse cardiovascular events (MACE), according top-line data released in September. A highly purified ethyl ester of eicosapentaenoic acid (EPA), AMR101 (Vascepa, Amarin) was studied on top of statin therapy in both primary and secondary prevention cohorts among the 8,000 patients randomized. Relative efficacy for primary and secondary prevention was not described in the initial release of data and will be of particular when the full results are released on Saturday, Nov. 10 at 2:00 p.m.

• DECLARE TIMI58: In top line results from DECLARE TIMI58, which randomized more than 17,000 participants with type 2 diabetes an experimental arm or placebo, the SGLT2 inhibitor dapagliflozin (Farxiga, AstraZeneca) was linked to a reduction in the composite endpoint of hospitalization for heart failure or cardiovascular death. In the early release of results, no mention was made of the effect of this agent on a composite of cardiovascular death, MI, or ischemic stroke, which was a secondary co-primary endpoint. This and the impact of dapagliflozin on an array of secondary endpoints will be revealed when the full results are made available in the Saturday late-breaker session at 2:00 p.m.

• VITAL: The relative effect of vitamin D, fish oil, or both on body composition was compared in the VITAL study, which randomized more than 20,000 patients. Fish oil plus vitamin D, fish oil plus placebo, vitamin D plus placebo, and two placebos were compared in a 2 x 2 factorial design. The primary outcome includes total body fat and lean mass as well as these components in the abdomen and other anatomic sites. Body mass index, waist circumference, and waist-to-hip ratio are among secondary outcomes. In addition, the relative effects of these treatments on lipids, blood glucose, and other aspects of metabolism were followed over the 2 years of the study, to presented at 2 p.m. on Saturday.

• CIRT: Responding to the evidence that inflammation is a crucial contributor to atherothrombosis, the CIRT trial tested whether the anti-inflammatory agent methotrexate reduces rates of MI, stroke, and cardiovascular death relative to placebo in patients with stable coronary artery disease and either type 2 diabetes or metabolic syndrome. The study enrolled about 7,000 patients and will have follow-up of nearly 6 years. Secondary endpoints, such as the impact of methotrexate on rates of coronary revascularization, peripheral artery disease, venous thromboembolism, and aortic stenosis, may provide insight about the ways in which control of inflammation affects vascular pathology. The presentation is at 2 p.m. on Saturday.

• Also on Saturday, diverse trial hypotheses are being tested. For example, the cost effectiveness of a PCSK9 inhibitor will be the focus of the ODYSSEY OUTCOMES economics study, presented at the 2:00 session. The results of YOGA-CaRe, a multicenter trial of a yoga-based cardiac rehabilitation program, will be presented in a subsequent Saturday late-breaking session. Of highlights of the third Saturday late-breaking session, ALERT-AF will determine whether a computerized decision protocol affected anticoagulation management in hospitalized patients with atrial fibrillation.

Sunday

• PIONEER-HF: It has been previously shown that sacubitril/valsartan improves outcome in stable heart failure patients with a reduced ejection fraction (HRrEF), but PIONEER-HF will test the tolerability of this strategy when this treatment is initiated prior to hospital discharge. Patients with a left ventricular ejection fraction of 40% or less and elevated N-terminal pro hormone BNP (NT-proBNP) will be randomized to sacubitril/valsartan (Entresto, Novartis) or the ACE inhibitor enalapril. The primary outcome of the trial, which enrolled more than 700 patients, is the time-averaged percentage change in NT-proBNP from baseline. Secondary outcome measures included the proportion of patients with symptomatic hypotension, hyperkalemia, and angioedema. Presentation will be at the Sunday 10:45 a.m. session.

• TICAB: The hypothesis that ticagrelor is superior to aspirin for preventing a composite MACE endpoint of CV death, myocardial infarction, target vessel revascularization, and stroke in patients undergoing coronary artery bypass grafting is the basis for the TICAB trial. The nearly 1,900 patients were randomized to 90 mg of ticagrelor twice daily or 100 mg of aspirin twice daily. Major bleeding events, CV death, and all cause death are key secondary outcomes. Relative benefit in context of safety, particularly bleeding risk, will be of interest when the final results are revealed at 5:30 p.m. on Sunday.

All-in-all, the Sunday late-breaking sessions are no less crowded with potentially practice-changing studies, including T-TIME, an evaluation of low-dose alteplase during primary percutaneous intervention at 9:00 a.m., TRED-HF, a study of withdrawal of heart failure therapy in patients who have recovered from dilated cardiomyopathy at 10:45 a.m., and ISAR TEST 4, which will provide 10-year outcomes after coronary stents with biodegradable versus permanent polymer coated devices, at 5:30 p.m.
 

Of the trials chosen for the six Late-Breaking Clinical Trial sessions, all being presented in the first 2 days of the American Heart Association scientific sessions in Chicago Nov. 10-12. Here are some of the most potentially practice-changing studies to look out for.

Courtesy of the Chicago Architecture Foundation.

Saturday

• REDUCE-IT: Relative to placebo, the fish oil derivative AMR101 (icosapent-ethyl) evaluated in the REDUCE-IT trial was associated with a 25% reduction in a primary composite endpoint of major adverse cardiovascular events (MACE), according top-line data released in September. A highly purified ethyl ester of eicosapentaenoic acid (EPA), AMR101 (Vascepa, Amarin) was studied on top of statin therapy in both primary and secondary prevention cohorts among the 8,000 patients randomized. Relative efficacy for primary and secondary prevention was not described in the initial release of data and will be of particular when the full results are released on Saturday, Nov. 10 at 2:00 p.m.

• DECLARE TIMI58: In top line results from DECLARE TIMI58, which randomized more than 17,000 participants with type 2 diabetes an experimental arm or placebo, the SGLT2 inhibitor dapagliflozin (Farxiga, AstraZeneca) was linked to a reduction in the composite endpoint of hospitalization for heart failure or cardiovascular death. In the early release of results, no mention was made of the effect of this agent on a composite of cardiovascular death, MI, or ischemic stroke, which was a secondary co-primary endpoint. This and the impact of dapagliflozin on an array of secondary endpoints will be revealed when the full results are made available in the Saturday late-breaker session at 2:00 p.m.

• VITAL: The relative effect of vitamin D, fish oil, or both on body composition was compared in the VITAL study, which randomized more than 20,000 patients. Fish oil plus vitamin D, fish oil plus placebo, vitamin D plus placebo, and two placebos were compared in a 2 x 2 factorial design. The primary outcome includes total body fat and lean mass as well as these components in the abdomen and other anatomic sites. Body mass index, waist circumference, and waist-to-hip ratio are among secondary outcomes. In addition, the relative effects of these treatments on lipids, blood glucose, and other aspects of metabolism were followed over the 2 years of the study, to presented at 2 p.m. on Saturday.

• CIRT: Responding to the evidence that inflammation is a crucial contributor to atherothrombosis, the CIRT trial tested whether the anti-inflammatory agent methotrexate reduces rates of MI, stroke, and cardiovascular death relative to placebo in patients with stable coronary artery disease and either type 2 diabetes or metabolic syndrome. The study enrolled about 7,000 patients and will have follow-up of nearly 6 years. Secondary endpoints, such as the impact of methotrexate on rates of coronary revascularization, peripheral artery disease, venous thromboembolism, and aortic stenosis, may provide insight about the ways in which control of inflammation affects vascular pathology. The presentation is at 2 p.m. on Saturday.

• Also on Saturday, diverse trial hypotheses are being tested. For example, the cost effectiveness of a PCSK9 inhibitor will be the focus of the ODYSSEY OUTCOMES economics study, presented at the 2:00 session. The results of YOGA-CaRe, a multicenter trial of a yoga-based cardiac rehabilitation program, will be presented in a subsequent Saturday late-breaking session. Of highlights of the third Saturday late-breaking session, ALERT-AF will determine whether a computerized decision protocol affected anticoagulation management in hospitalized patients with atrial fibrillation.

Sunday

• PIONEER-HF: It has been previously shown that sacubitril/valsartan improves outcome in stable heart failure patients with a reduced ejection fraction (HRrEF), but PIONEER-HF will test the tolerability of this strategy when this treatment is initiated prior to hospital discharge. Patients with a left ventricular ejection fraction of 40% or less and elevated N-terminal pro hormone BNP (NT-proBNP) will be randomized to sacubitril/valsartan (Entresto, Novartis) or the ACE inhibitor enalapril. The primary outcome of the trial, which enrolled more than 700 patients, is the time-averaged percentage change in NT-proBNP from baseline. Secondary outcome measures included the proportion of patients with symptomatic hypotension, hyperkalemia, and angioedema. Presentation will be at the Sunday 10:45 a.m. session.

• TICAB: The hypothesis that ticagrelor is superior to aspirin for preventing a composite MACE endpoint of CV death, myocardial infarction, target vessel revascularization, and stroke in patients undergoing coronary artery bypass grafting is the basis for the TICAB trial. The nearly 1,900 patients were randomized to 90 mg of ticagrelor twice daily or 100 mg of aspirin twice daily. Major bleeding events, CV death, and all cause death are key secondary outcomes. Relative benefit in context of safety, particularly bleeding risk, will be of interest when the final results are revealed at 5:30 p.m. on Sunday.

All-in-all, the Sunday late-breaking sessions are no less crowded with potentially practice-changing studies, including T-TIME, an evaluation of low-dose alteplase during primary percutaneous intervention at 9:00 a.m., TRED-HF, a study of withdrawal of heart failure therapy in patients who have recovered from dilated cardiomyopathy at 10:45 a.m., and ISAR TEST 4, which will provide 10-year outcomes after coronary stents with biodegradable versus permanent polymer coated devices, at 5:30 p.m.
 

Two new guidelines are set to be presented at the American Heart Association scientific sessions in Chicago.

First up will be the first update to the controversial 2013 cholesterol guidelines, which will be presented on Saturday, Nov. 10, in two sessions.

Second, the U.S. Department of Health and Human Services will unveil its new national guidelines for physical activity on Monday, Nov. 12.

Based on new information that has become available since previous versions, both are expected to include substantial changes.
 

Cholesterol guidelines

For the cholesterol guidelines, the most important messages for clinical practice will be presented in a session beginning at 10:45 a.m. A second session, beginning at 5:30 p.m. on Saturday, can be considered more of a “deep dive” into the details and rationale, Donald M. Lloyd-Jones, MD, cochair of this year’s Committee on Scientific Sessions Program, said in a teleconference with reporters.

“In the 10:45 session, we plan to cover the most important take-home messages and top-line issues,” explained Dr. Lloyd-Jones, a professor of cardiology at Northwestern University, Chicago, as well as one of the authors of both the 2013 cholesterol guidelines and these updated ones.

This will include the key changes since the AHA/American College of Cardiology Guideline on the Assessment of Cardiovascular Risk guidelines were released 2013. One major update will be the inclusion of the role of PCSK9 inhibitors, which were introduced after the 2013 guidelines were written. Moreover, the new guidelines will devote attention to personalizing treatment choices, according to Dr. Lloyd-Jones.

“The deep-dive session later that day will cover such issues as risk assessment and cost effectiveness of drug treatments for specific populations,” said Dr. Lloyd-Jones, who added that case studies will be presented to illustrate how the new recommendations should affect practice.

Because of changes in risk assessment, the 2013 guidelines, which greatly expanded the candidates for lipid-lowering therapies, were labeled “controversial” in numerous critiques published in peer-reviewed journals and elsewhere. The authors of the new guidelines hope to avoid these problems.

“Since 2013, I think there have been questions about when we should use risk scores, whether there are risk scores that might be better than others, or if there are strategies of risk assessment we should be employing beyond just risk scores,” Dr. Lloyd-Jones acknowledged. “This was a big part of the discussion in developing these guidelines, and I think you will see some pretty significant advances in how we think about which patients are appropriate for treatment and which patients in whom we might think of withholding statin therapy when benefit is unlikely.”

Despite the large number of changes, Dr. Lloyd-Jones emphasized that the document will be more concise and easier to use than the guidelines from 2013.

“The organization is modular, meaning that if you have a question about a certain aspect of management, you can go straight to the recommendation, which is accompanied by very brief text to explain the rationale,” Dr. Lloyd-Jones reported. “The presentation has been very much streamlined.”
 

HHS Guidelines on Physical Activity

The HHS guidelines on physical activity will be presented at 9 a.m. on Monday, Nov. 12. The 2018 version will be the first update since the original guidelines were made available in 2008.

“It has been 10 years since the last set of guidelines, and I think we are all looking forward to what these new recommendations will offer,” Dr. Lloyd-Jones said. He believes that the science has progressed significantly over the past decade.

“In addition to our longstanding understanding that doing something is better than doing nothing and doing more is better than doing something, I think we have seen some really interesting data in the last 10 years on intensity and duration of exercise and how those can be considered when trying to improve health-related outcomes,” said Dr. Lloyd-Jones.

The specifics of these guidelines will not be known until they are presented on Monday, but there is abundant evidence that a healthy lifestyle is the first defense against illness in general and against cardiovascular disease in particular. Dr. Lloyd-Jones indicated that authoritative and evidence-based guidelines could prove to a useful tool for empowering patients to make changes that reduce an array of health risks not just those related to vascular disease.












 

Two new guidelines are set to be presented at the American Heart Association scientific sessions in Chicago.

First up will be the first update to the controversial 2013 cholesterol guidelines, which will be presented on Saturday, Nov. 10, in two sessions.

Second, the U.S. Department of Health and Human Services will unveil its new national guidelines for physical activity on Monday, Nov. 12.

Based on new information that has become available since previous versions, both are expected to include substantial changes.
 

Cholesterol guidelines

For the cholesterol guidelines, the most important messages for clinical practice will be presented in a session beginning at 10:45 a.m. A second session, beginning at 5:30 p.m. on Saturday, can be considered more of a “deep dive” into the details and rationale, Donald M. Lloyd-Jones, MD, cochair of this year’s Committee on Scientific Sessions Program, said in a teleconference with reporters.

“In the 10:45 session, we plan to cover the most important take-home messages and top-line issues,” explained Dr. Lloyd-Jones, a professor of cardiology at Northwestern University, Chicago, as well as one of the authors of both the 2013 cholesterol guidelines and these updated ones.

This will include the key changes since the AHA/American College of Cardiology Guideline on the Assessment of Cardiovascular Risk guidelines were released 2013. One major update will be the inclusion of the role of PCSK9 inhibitors, which were introduced after the 2013 guidelines were written. Moreover, the new guidelines will devote attention to personalizing treatment choices, according to Dr. Lloyd-Jones.

“The deep-dive session later that day will cover such issues as risk assessment and cost effectiveness of drug treatments for specific populations,” said Dr. Lloyd-Jones, who added that case studies will be presented to illustrate how the new recommendations should affect practice.

Because of changes in risk assessment, the 2013 guidelines, which greatly expanded the candidates for lipid-lowering therapies, were labeled “controversial” in numerous critiques published in peer-reviewed journals and elsewhere. The authors of the new guidelines hope to avoid these problems.

“Since 2013, I think there have been questions about when we should use risk scores, whether there are risk scores that might be better than others, or if there are strategies of risk assessment we should be employing beyond just risk scores,” Dr. Lloyd-Jones acknowledged. “This was a big part of the discussion in developing these guidelines, and I think you will see some pretty significant advances in how we think about which patients are appropriate for treatment and which patients in whom we might think of withholding statin therapy when benefit is unlikely.”

Despite the large number of changes, Dr. Lloyd-Jones emphasized that the document will be more concise and easier to use than the guidelines from 2013.

“The organization is modular, meaning that if you have a question about a certain aspect of management, you can go straight to the recommendation, which is accompanied by very brief text to explain the rationale,” Dr. Lloyd-Jones reported. “The presentation has been very much streamlined.”
 

HHS Guidelines on Physical Activity

The HHS guidelines on physical activity will be presented at 9 a.m. on Monday, Nov. 12. The 2018 version will be the first update since the original guidelines were made available in 2008.

“It has been 10 years since the last set of guidelines, and I think we are all looking forward to what these new recommendations will offer,” Dr. Lloyd-Jones said. He believes that the science has progressed significantly over the past decade.

“In addition to our longstanding understanding that doing something is better than doing nothing and doing more is better than doing something, I think we have seen some really interesting data in the last 10 years on intensity and duration of exercise and how those can be considered when trying to improve health-related outcomes,” said Dr. Lloyd-Jones.

The specifics of these guidelines will not be known until they are presented on Monday, but there is abundant evidence that a healthy lifestyle is the first defense against illness in general and against cardiovascular disease in particular. Dr. Lloyd-Jones indicated that authoritative and evidence-based guidelines could prove to a useful tool for empowering patients to make changes that reduce an array of health risks not just those related to vascular disease.












 

Two new guidelines are set to be presented at the American Heart Association scientific sessions in Chicago.

First up will be the first update to the controversial 2013 cholesterol guidelines, which will be presented on Saturday, Nov. 10, in two sessions.

Second, the U.S. Department of Health and Human Services will unveil its new national guidelines for physical activity on Monday, Nov. 12.

Based on new information that has become available since previous versions, both are expected to include substantial changes.
 

Cholesterol guidelines

For the cholesterol guidelines, the most important messages for clinical practice will be presented in a session beginning at 10:45 a.m. A second session, beginning at 5:30 p.m. on Saturday, can be considered more of a “deep dive” into the details and rationale, Donald M. Lloyd-Jones, MD, cochair of this year’s Committee on Scientific Sessions Program, said in a teleconference with reporters.

“In the 10:45 session, we plan to cover the most important take-home messages and top-line issues,” explained Dr. Lloyd-Jones, a professor of cardiology at Northwestern University, Chicago, as well as one of the authors of both the 2013 cholesterol guidelines and these updated ones.

This will include the key changes since the AHA/American College of Cardiology Guideline on the Assessment of Cardiovascular Risk guidelines were released 2013. One major update will be the inclusion of the role of PCSK9 inhibitors, which were introduced after the 2013 guidelines were written. Moreover, the new guidelines will devote attention to personalizing treatment choices, according to Dr. Lloyd-Jones.

“The deep-dive session later that day will cover such issues as risk assessment and cost effectiveness of drug treatments for specific populations,” said Dr. Lloyd-Jones, who added that case studies will be presented to illustrate how the new recommendations should affect practice.

Because of changes in risk assessment, the 2013 guidelines, which greatly expanded the candidates for lipid-lowering therapies, were labeled “controversial” in numerous critiques published in peer-reviewed journals and elsewhere. The authors of the new guidelines hope to avoid these problems.

“Since 2013, I think there have been questions about when we should use risk scores, whether there are risk scores that might be better than others, or if there are strategies of risk assessment we should be employing beyond just risk scores,” Dr. Lloyd-Jones acknowledged. “This was a big part of the discussion in developing these guidelines, and I think you will see some pretty significant advances in how we think about which patients are appropriate for treatment and which patients in whom we might think of withholding statin therapy when benefit is unlikely.”

Despite the large number of changes, Dr. Lloyd-Jones emphasized that the document will be more concise and easier to use than the guidelines from 2013.

“The organization is modular, meaning that if you have a question about a certain aspect of management, you can go straight to the recommendation, which is accompanied by very brief text to explain the rationale,” Dr. Lloyd-Jones reported. “The presentation has been very much streamlined.”
 

HHS Guidelines on Physical Activity

The HHS guidelines on physical activity will be presented at 9 a.m. on Monday, Nov. 12. The 2018 version will be the first update since the original guidelines were made available in 2008.

“It has been 10 years since the last set of guidelines, and I think we are all looking forward to what these new recommendations will offer,” Dr. Lloyd-Jones said. He believes that the science has progressed significantly over the past decade.

“In addition to our longstanding understanding that doing something is better than doing nothing and doing more is better than doing something, I think we have seen some really interesting data in the last 10 years on intensity and duration of exercise and how those can be considered when trying to improve health-related outcomes,” said Dr. Lloyd-Jones.

The specifics of these guidelines will not be known until they are presented on Monday, but there is abundant evidence that a healthy lifestyle is the first defense against illness in general and against cardiovascular disease in particular. Dr. Lloyd-Jones indicated that authoritative and evidence-based guidelines could prove to a useful tool for empowering patients to make changes that reduce an array of health risks not just those related to vascular disease.












 

Although a day shorter than meetings over recent years, more than 4,000 abstracts, keynote addresses, special sessions, and education programs have been squeezed into 800 sessions divided into 26 tracks of interest at the American Heart Association Scientific Sessions.

“We think that, for both for the presenters as well as for the attendees, this new format is going to be quite lively, exciting, and consistent with where scientific meetings should be going in the future,” explained Eric Peterson, MD, chair of this year’s Committee on Scientific Sessions Program in a teleconference with reporters.

The shorter program is just one of many substantive changes made by the program committee to enhance the value of attendance, according to Dr. Peterson, professor of medicine, Duke University, Durham, N.C. In particular, the committee worked to make the sessions more interactive.

“There will be much less of someone just standing up and delivering slides,” he said. Through phone apps that will allow the audience to pose questions and comments to speakers in every major session, “there will be more opportunities for the audience to give their impression of the science being delivered.”

From the beginning, it was the intention of the program committee “to do things differently,” according to Dr. Peterson as well as his cochair Donald M. Lloyd-Jones, MD, professor of cardiology at Northwestern University, Chicago.

“The 3-day format means full days, but I think that we have packed in some really exciting science,” said Dr. Lloyd-Jones, who described a diverse slate of programming goals. In addition to the traditional emphasis on new science, he said there will be more attention on “new management and new practice opportunities for clinicians to really hone their skills.”

Those coming to the Scientific Sessions will see a difference on the first day. In place of an awards ceremony and presidential address, which have long been staples of the opening sessions, this year’s meeting will begin with a series of simultaneous programs delving into key issues in cardiology and medical practice.

“We are starting things off with a bang with TED-like lectures given in multiple locations addressing the cutting edge of where we are with the hottest things in science,” Dr. Peterson said. “These will cover everything from how your microbiome might be affecting your risk for cardiovascular events to progress toward vaccines that might some day prevent cardiovascular disease.”

Innovative and forward-thinking programs unfold from there, according to Dr. Lloyd-Jones.

Health technology will be a common thread across all 3 days of the Scientific Sessions, according to Dr. Peterson. One of the 26 tracks of this year’s meeting, health technology is imposing fundamental shifts in medical practice and how health care is delivered.

“This is a topic that covers electronic medical records, your cell phone, and mobile wearable devices that can help us as clinicians better understand what is going on with cardiovascular disease as well as help ourselves as individuals modify our risks,” said Dr. Peterson. Within this track, session programs range from how-to instruction to a technology forum organized like the “Shark Tank” television program.

“Health technology is moving rapidly,” Dr. Peterson pointed out. He suggested that the AHA Scientific Sessions provide a unique opportunity for cardiologists to stay current with evolving strategies for efficient care.

Within the effort to update the meeting format, traditional forms of late-breaking science, particularly late-breaking trials with potentially practice changing data, will not be lost. However, Dr. Peterson indicated that he expects this year’s meeting to have a somewhat different pace and sensibility.

“We believe that what we have been doing will not work any longer, and we needed to do things differently,” Dr. Peterson said. While the shorter more concentrated program is one example, Dr. Peterson also believes that the effort to diminish the distance between those who are speaking and those who are listening will lead to a richer experience for everyone.
 

Although a day shorter than meetings over recent years, more than 4,000 abstracts, keynote addresses, special sessions, and education programs have been squeezed into 800 sessions divided into 26 tracks of interest at the American Heart Association Scientific Sessions.

“We think that, for both for the presenters as well as for the attendees, this new format is going to be quite lively, exciting, and consistent with where scientific meetings should be going in the future,” explained Eric Peterson, MD, chair of this year’s Committee on Scientific Sessions Program in a teleconference with reporters.

The shorter program is just one of many substantive changes made by the program committee to enhance the value of attendance, according to Dr. Peterson, professor of medicine, Duke University, Durham, N.C. In particular, the committee worked to make the sessions more interactive.

“There will be much less of someone just standing up and delivering slides,” he said. Through phone apps that will allow the audience to pose questions and comments to speakers in every major session, “there will be more opportunities for the audience to give their impression of the science being delivered.”

From the beginning, it was the intention of the program committee “to do things differently,” according to Dr. Peterson as well as his cochair Donald M. Lloyd-Jones, MD, professor of cardiology at Northwestern University, Chicago.

“The 3-day format means full days, but I think that we have packed in some really exciting science,” said Dr. Lloyd-Jones, who described a diverse slate of programming goals. In addition to the traditional emphasis on new science, he said there will be more attention on “new management and new practice opportunities for clinicians to really hone their skills.”

Those coming to the Scientific Sessions will see a difference on the first day. In place of an awards ceremony and presidential address, which have long been staples of the opening sessions, this year’s meeting will begin with a series of simultaneous programs delving into key issues in cardiology and medical practice.

“We are starting things off with a bang with TED-like lectures given in multiple locations addressing the cutting edge of where we are with the hottest things in science,” Dr. Peterson said. “These will cover everything from how your microbiome might be affecting your risk for cardiovascular events to progress toward vaccines that might some day prevent cardiovascular disease.”

Innovative and forward-thinking programs unfold from there, according to Dr. Lloyd-Jones.

Health technology will be a common thread across all 3 days of the Scientific Sessions, according to Dr. Peterson. One of the 26 tracks of this year’s meeting, health technology is imposing fundamental shifts in medical practice and how health care is delivered.

“This is a topic that covers electronic medical records, your cell phone, and mobile wearable devices that can help us as clinicians better understand what is going on with cardiovascular disease as well as help ourselves as individuals modify our risks,” said Dr. Peterson. Within this track, session programs range from how-to instruction to a technology forum organized like the “Shark Tank” television program.

“Health technology is moving rapidly,” Dr. Peterson pointed out. He suggested that the AHA Scientific Sessions provide a unique opportunity for cardiologists to stay current with evolving strategies for efficient care.

Within the effort to update the meeting format, traditional forms of late-breaking science, particularly late-breaking trials with potentially practice changing data, will not be lost. However, Dr. Peterson indicated that he expects this year’s meeting to have a somewhat different pace and sensibility.

“We believe that what we have been doing will not work any longer, and we needed to do things differently,” Dr. Peterson said. While the shorter more concentrated program is one example, Dr. Peterson also believes that the effort to diminish the distance between those who are speaking and those who are listening will lead to a richer experience for everyone.
 

Although a day shorter than meetings over recent years, more than 4,000 abstracts, keynote addresses, special sessions, and education programs have been squeezed into 800 sessions divided into 26 tracks of interest at the American Heart Association Scientific Sessions.

“We think that, for both for the presenters as well as for the attendees, this new format is going to be quite lively, exciting, and consistent with where scientific meetings should be going in the future,” explained Eric Peterson, MD, chair of this year’s Committee on Scientific Sessions Program in a teleconference with reporters.

The shorter program is just one of many substantive changes made by the program committee to enhance the value of attendance, according to Dr. Peterson, professor of medicine, Duke University, Durham, N.C. In particular, the committee worked to make the sessions more interactive.

“There will be much less of someone just standing up and delivering slides,” he said. Through phone apps that will allow the audience to pose questions and comments to speakers in every major session, “there will be more opportunities for the audience to give their impression of the science being delivered.”

From the beginning, it was the intention of the program committee “to do things differently,” according to Dr. Peterson as well as his cochair Donald M. Lloyd-Jones, MD, professor of cardiology at Northwestern University, Chicago.

“The 3-day format means full days, but I think that we have packed in some really exciting science,” said Dr. Lloyd-Jones, who described a diverse slate of programming goals. In addition to the traditional emphasis on new science, he said there will be more attention on “new management and new practice opportunities for clinicians to really hone their skills.”

Those coming to the Scientific Sessions will see a difference on the first day. In place of an awards ceremony and presidential address, which have long been staples of the opening sessions, this year’s meeting will begin with a series of simultaneous programs delving into key issues in cardiology and medical practice.

“We are starting things off with a bang with TED-like lectures given in multiple locations addressing the cutting edge of where we are with the hottest things in science,” Dr. Peterson said. “These will cover everything from how your microbiome might be affecting your risk for cardiovascular events to progress toward vaccines that might some day prevent cardiovascular disease.”

Innovative and forward-thinking programs unfold from there, according to Dr. Lloyd-Jones.

Health technology will be a common thread across all 3 days of the Scientific Sessions, according to Dr. Peterson. One of the 26 tracks of this year’s meeting, health technology is imposing fundamental shifts in medical practice and how health care is delivered.

“This is a topic that covers electronic medical records, your cell phone, and mobile wearable devices that can help us as clinicians better understand what is going on with cardiovascular disease as well as help ourselves as individuals modify our risks,” said Dr. Peterson. Within this track, session programs range from how-to instruction to a technology forum organized like the “Shark Tank” television program.

“Health technology is moving rapidly,” Dr. Peterson pointed out. He suggested that the AHA Scientific Sessions provide a unique opportunity for cardiologists to stay current with evolving strategies for efficient care.

Within the effort to update the meeting format, traditional forms of late-breaking science, particularly late-breaking trials with potentially practice changing data, will not be lost. However, Dr. Peterson indicated that he expects this year’s meeting to have a somewhat different pace and sensibility.

“We believe that what we have been doing will not work any longer, and we needed to do things differently,” Dr. Peterson said. While the shorter more concentrated program is one example, Dr. Peterson also believes that the effort to diminish the distance between those who are speaking and those who are listening will lead to a richer experience for everyone.
 

SAN DIEGO – “Working at the top of your license,” focusing only on those tasks that cannot be performed by anyone else but you, is a key strategy when handling mass casualties, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.

Vidyard Video

In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.

Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
 

SAN DIEGO – “Working at the top of your license,” focusing only on those tasks that cannot be performed by anyone else but you, is a key strategy when handling mass casualties, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.

Vidyard Video

In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.

Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
 

SAN DIEGO – “Working at the top of your license,” focusing only on those tasks that cannot be performed by anyone else but you, is a key strategy when handling mass casualties, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.

Vidyard Video

In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.

Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
 

SAN DIEGO – Point-of-care ultrasound should be the go-to approach for the routine assessment of suspected shoulder dislocations in the ED, based on data from a prospective, multicenter study presented at the annual meeting of the American College of Emergency Physicians.

In the observational study, the average time needed to diagnose shoulder dislocation using ultrasound was 18 seconds, far faster than time from triage to x-ray, according to Michael Secko, MD, director of the emergency ultrasound division at Stony Brook University (NY).

The results from this study, called MUDDS (Musculoskeletal Ultrasound to Diagnose Dislocated Shoulders), support point-of-care ultrasound as a faster and more readily performed alternative to x-ray. Of the 46 adult patients enrolled so far in the ongoing study, ultrasound’s sensitivity has been 96% and its specificity 100% when validated by x-ray findings.

In the study, adults presenting to the ED are evaluated with point-of-care ultrasound from a posterior approach using either a curvilinear or linear transducer in the transverse plane. About half of the patients enrolled so far had injuries caused by falls, and many of the others had a shoulder complaint related to being pulled. Slightly more than one-third had a previous shoulder dislocation.

When evaluated with point-of-care ultrasound and x-ray, 23 of the 42 evaluable patients had a dislocation. The time from triage to ultrasound evaluation averaged 60 minutes, 40 minutes faster than the average of 100 minutes from triage to x-ray. Both tests were ordered at the same time.

Ultrasound performed less well for the diagnosis of a fracture, with a sensitivity of only 53%. Dr. Secko said the anterior approach would not be expected to provide a comprehensive assessment for fracture. He noted, for example, that there was no attempt in this study to evaluate patients for the presence of Bankart lesions. However, in those found to have a fracture on point-of-care ultrasound, the specificity of this imaging tool was 96%.

Ultimately, a major goal of this study was to determine whether a posterior point-of-care ultrasound could provide a quick answer to the question, “is it in or out?” Although patients are still being enrolled, Dr. Secko believed there is already good evidence that ultrasound is fast and effective for diagnosing dislocations.

Others have addressed this same question. Citing a meta-analysis published last year, Dr. Secko reported that all but one of four studies evaluating ultrasound for shoulder dislocations found a sensitivity and specificity of 100% (Gottlieb M et al. West J Emerg Med. 2017 Aug;18[5]:937-942).

Many centers have already switched to ultrasound for the evaluation of shoulder dislocations, according to Andrew S. Liteplo, MD, who moderated the ACEP session in which Dr. Secko presented his data. “If you are not already doing this for suspected shoulder dislocation, start right away because it is easy and awesome,” said Dr. Liteplo, who is chief of the division of ultrasound in emergency medicine at Massachusetts General Hospital, Boston. He also advised that ultrasound can also can be performed after reduction to confirm the efficacy of treatment.

Dr. Secko reported no financial relationships relevant to this study.
 

SAN DIEGO – Point-of-care ultrasound should be the go-to approach for the routine assessment of suspected shoulder dislocations in the ED, based on data from a prospective, multicenter study presented at the annual meeting of the American College of Emergency Physicians.

In the observational study, the average time needed to diagnose shoulder dislocation using ultrasound was 18 seconds, far faster than time from triage to x-ray, according to Michael Secko, MD, director of the emergency ultrasound division at Stony Brook University (NY).

The results from this study, called MUDDS (Musculoskeletal Ultrasound to Diagnose Dislocated Shoulders), support point-of-care ultrasound as a faster and more readily performed alternative to x-ray. Of the 46 adult patients enrolled so far in the ongoing study, ultrasound’s sensitivity has been 96% and its specificity 100% when validated by x-ray findings.

In the study, adults presenting to the ED are evaluated with point-of-care ultrasound from a posterior approach using either a curvilinear or linear transducer in the transverse plane. About half of the patients enrolled so far had injuries caused by falls, and many of the others had a shoulder complaint related to being pulled. Slightly more than one-third had a previous shoulder dislocation.

When evaluated with point-of-care ultrasound and x-ray, 23 of the 42 evaluable patients had a dislocation. The time from triage to ultrasound evaluation averaged 60 minutes, 40 minutes faster than the average of 100 minutes from triage to x-ray. Both tests were ordered at the same time.

Ultrasound performed less well for the diagnosis of a fracture, with a sensitivity of only 53%. Dr. Secko said the anterior approach would not be expected to provide a comprehensive assessment for fracture. He noted, for example, that there was no attempt in this study to evaluate patients for the presence of Bankart lesions. However, in those found to have a fracture on point-of-care ultrasound, the specificity of this imaging tool was 96%.

Ultimately, a major goal of this study was to determine whether a posterior point-of-care ultrasound could provide a quick answer to the question, “is it in or out?” Although patients are still being enrolled, Dr. Secko believed there is already good evidence that ultrasound is fast and effective for diagnosing dislocations.

Others have addressed this same question. Citing a meta-analysis published last year, Dr. Secko reported that all but one of four studies evaluating ultrasound for shoulder dislocations found a sensitivity and specificity of 100% (Gottlieb M et al. West J Emerg Med. 2017 Aug;18[5]:937-942).

Many centers have already switched to ultrasound for the evaluation of shoulder dislocations, according to Andrew S. Liteplo, MD, who moderated the ACEP session in which Dr. Secko presented his data. “If you are not already doing this for suspected shoulder dislocation, start right away because it is easy and awesome,” said Dr. Liteplo, who is chief of the division of ultrasound in emergency medicine at Massachusetts General Hospital, Boston. He also advised that ultrasound can also can be performed after reduction to confirm the efficacy of treatment.

Dr. Secko reported no financial relationships relevant to this study.
 

SAN DIEGO – Point-of-care ultrasound should be the go-to approach for the routine assessment of suspected shoulder dislocations in the ED, based on data from a prospective, multicenter study presented at the annual meeting of the American College of Emergency Physicians.

In the observational study, the average time needed to diagnose shoulder dislocation using ultrasound was 18 seconds, far faster than time from triage to x-ray, according to Michael Secko, MD, director of the emergency ultrasound division at Stony Brook University (NY).

The results from this study, called MUDDS (Musculoskeletal Ultrasound to Diagnose Dislocated Shoulders), support point-of-care ultrasound as a faster and more readily performed alternative to x-ray. Of the 46 adult patients enrolled so far in the ongoing study, ultrasound’s sensitivity has been 96% and its specificity 100% when validated by x-ray findings.

In the study, adults presenting to the ED are evaluated with point-of-care ultrasound from a posterior approach using either a curvilinear or linear transducer in the transverse plane. About half of the patients enrolled so far had injuries caused by falls, and many of the others had a shoulder complaint related to being pulled. Slightly more than one-third had a previous shoulder dislocation.

When evaluated with point-of-care ultrasound and x-ray, 23 of the 42 evaluable patients had a dislocation. The time from triage to ultrasound evaluation averaged 60 minutes, 40 minutes faster than the average of 100 minutes from triage to x-ray. Both tests were ordered at the same time.

Ultrasound performed less well for the diagnosis of a fracture, with a sensitivity of only 53%. Dr. Secko said the anterior approach would not be expected to provide a comprehensive assessment for fracture. He noted, for example, that there was no attempt in this study to evaluate patients for the presence of Bankart lesions. However, in those found to have a fracture on point-of-care ultrasound, the specificity of this imaging tool was 96%.

Ultimately, a major goal of this study was to determine whether a posterior point-of-care ultrasound could provide a quick answer to the question, “is it in or out?” Although patients are still being enrolled, Dr. Secko believed there is already good evidence that ultrasound is fast and effective for diagnosing dislocations.

Others have addressed this same question. Citing a meta-analysis published last year, Dr. Secko reported that all but one of four studies evaluating ultrasound for shoulder dislocations found a sensitivity and specificity of 100% (Gottlieb M et al. West J Emerg Med. 2017 Aug;18[5]:937-942).

Many centers have already switched to ultrasound for the evaluation of shoulder dislocations, according to Andrew S. Liteplo, MD, who moderated the ACEP session in which Dr. Secko presented his data. “If you are not already doing this for suspected shoulder dislocation, start right away because it is easy and awesome,” said Dr. Liteplo, who is chief of the division of ultrasound in emergency medicine at Massachusetts General Hospital, Boston. He also advised that ultrasound can also can be performed after reduction to confirm the efficacy of treatment.

Dr. Secko reported no financial relationships relevant to this study.
 

SAN DIEGO – Symptoms alone are usually not sufficient for either patients or staff to determine whether an ED visit is warranted, based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.

The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.

“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”

Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.

In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).

Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.

From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.

“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.

Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.

New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.

Dr. Chou reported no financial relationships relevant to this study.

SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.

SAN DIEGO – Symptoms alone are usually not sufficient for either patients or staff to determine whether an ED visit is warranted, based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.

The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.

“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”

Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.

In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).

Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.

From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.

“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.

Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.

New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.

Dr. Chou reported no financial relationships relevant to this study.

SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.

SAN DIEGO – Symptoms alone are usually not sufficient for either patients or staff to determine whether an ED visit is warranted, based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.

The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.

“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”

Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.

In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).

Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.

From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.

“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.

Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.

New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.

Dr. Chou reported no financial relationships relevant to this study.

SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.

Appendectomy has been associated with a reduced risk of Parkinson’s disease (PD), which supports the potential for a reservoir of aggregated alpha-synuclein in the appendix to affect risk of the condition, according to new epidemiologic and translational evidence from two data sets that promotes a new and emerging theory for PD etiology.

decade3d/Thinkstock

When placed into the context of other recent studies, these epidemiologic data “point to the appendix as a site of origin for Parkinson’s and provide a path forward for devising new treatment strategies,” reported senior author Viviane Labrie, PhD, of the Van Andel Research Institute (VARI) in Grand Rapids, Mich.

The epidemiologic data was the most recent step in a series of findings summarized in a newly published paper in Science Translational Medicine. As the researchers explained, it is relevant to a separate body of evidence that alpha-synuclein, a protein that serves as the hallmark of PD when it appears in Lewy bodies, can be isolated in the nerve fibers and nerve cells of the appendix.

“We have shown that alpha-synuclein proteins, including the truncated forms observed in Lewy bodies, are abundant in the appendix,” reported first author Bryan A. Killinger, PhD, also at VARI, in a press teleconference. He said this finding is likely to explain the reduced risk of PD from appendectomy.

In the largest of the epidemiologic studies, the effect of appendectomy on subsequent risk of PD was evaluated through the health records from more than 1.6 million individuals in Sweden. The incidence of PD was found to be 19.3% lower among 551,647 patients who had an appendectomy, compared with controls.

In addition, the data showed that when PD did occur after appendectomy, it was delayed on average by 3.6 years. It is notable that appendectomy was not associated with protection from PD in patients with a familial link to PD, a group they said comprises less than 10% of cases.

In patients with PD, nonmotor symptoms often include GI tract dysfunction, which can, in some cases, be part of a prodromal presentation that precedes the onset of classical PD symptoms by several years, the authors reported. However, the new research upends previous conceptions of disease. The demonstration of abundant alpha-synuclein in the appendix coupled with the protective effect of appendectomy, suggests that PD may originate in the GI tract and then spread to the central nervous system (CNS) rather than the other way around.

“The vermiform appendix was once considered to be an unnecessary organ. Although there is now good evidence that the appendix plays a major role in the regulation of the immune system, including the regulation of gut bacteria, our work suggests it is also mediates risk of Parkinson’s,” Dr. Labrie said in the teleconference.

In the paper, numerous pieces of the puzzle are brought together to suggest that alpha-synuclein in the appendix is linked to alpha-synuclein in the CNS. Many of the findings along this investigative pathway were described as surprising. For example, immunohistochemistry studies revealed high amounts of alpha-synuclein in nearly every sample of appendiceal tissue examined, including normal and inflamed tissue, tissue from individuals with PD and those without, and tissues from young and old individuals.

B.A. Killinger et al., Science Translational Medicine (2018)

“The normal tissue, as well as appendiceal tissue from PD patients, contained high levels of alpha-synuclein in the truncated forms analogous to those seen in Lewy body pathology,” Dr. Killinger said. Based on these and other findings, he believes that alpha-synuclein in the appendix forms a reservoir for seeding the aggregates involved in the pathology of PD, although he acknowledged that it is not yet clear how the proteins in the appendix find their way to the brain.

From these data, it appears that most individuals with an intact appendix have alpha-synuclein in the nerve fibers, but Dr. Labrie pointed out that the only about 1% of the population develops PD. She speculated that there is “some confluence of events,” such as an environmental trigger altering the GI microbiome, that mediates ultimate risk of PD, but she noted that these events may take place decades before signs and symptoms of PD develop. The data appear to be a substantial reorientation in understanding PD.

“We have shown that the appendix is a hub for the accumulation of clumped forms of alpha-synuclein proteins, which are implicated in Parkinson’s,” Dr. Killinger said. “This knowledge will be invaluable as we explore new prevention and treatment strategies.”

The research was funded by a variety of governmental and private grants to individual authors. Dr. Killinger and Dr. Labrie report no financial relationships relevant to this study.

SOURCE: Killinger BA et al. Sci Transl Med. 2018;10:eaar5380.

Appendectomy has been associated with a reduced risk of Parkinson’s disease (PD), which supports the potential for a reservoir of aggregated alpha-synuclein in the appendix to affect risk of the condition, according to new epidemiologic and translational evidence from two data sets that promotes a new and emerging theory for PD etiology.

decade3d/Thinkstock

When placed into the context of other recent studies, these epidemiologic data “point to the appendix as a site of origin for Parkinson’s and provide a path forward for devising new treatment strategies,” reported senior author Viviane Labrie, PhD, of the Van Andel Research Institute (VARI) in Grand Rapids, Mich.

The epidemiologic data was the most recent step in a series of findings summarized in a newly published paper in Science Translational Medicine. As the researchers explained, it is relevant to a separate body of evidence that alpha-synuclein, a protein that serves as the hallmark of PD when it appears in Lewy bodies, can be isolated in the nerve fibers and nerve cells of the appendix.

“We have shown that alpha-synuclein proteins, including the truncated forms observed in Lewy bodies, are abundant in the appendix,” reported first author Bryan A. Killinger, PhD, also at VARI, in a press teleconference. He said this finding is likely to explain the reduced risk of PD from appendectomy.

In the largest of the epidemiologic studies, the effect of appendectomy on subsequent risk of PD was evaluated through the health records from more than 1.6 million individuals in Sweden. The incidence of PD was found to be 19.3% lower among 551,647 patients who had an appendectomy, compared with controls.

In addition, the data showed that when PD did occur after appendectomy, it was delayed on average by 3.6 years. It is notable that appendectomy was not associated with protection from PD in patients with a familial link to PD, a group they said comprises less than 10% of cases.

In patients with PD, nonmotor symptoms often include GI tract dysfunction, which can, in some cases, be part of a prodromal presentation that precedes the onset of classical PD symptoms by several years, the authors reported. However, the new research upends previous conceptions of disease. The demonstration of abundant alpha-synuclein in the appendix coupled with the protective effect of appendectomy, suggests that PD may originate in the GI tract and then spread to the central nervous system (CNS) rather than the other way around.

“The vermiform appendix was once considered to be an unnecessary organ. Although there is now good evidence that the appendix plays a major role in the regulation of the immune system, including the regulation of gut bacteria, our work suggests it is also mediates risk of Parkinson’s,” Dr. Labrie said in the teleconference.

In the paper, numerous pieces of the puzzle are brought together to suggest that alpha-synuclein in the appendix is linked to alpha-synuclein in the CNS. Many of the findings along this investigative pathway were described as surprising. For example, immunohistochemistry studies revealed high amounts of alpha-synuclein in nearly every sample of appendiceal tissue examined, including normal and inflamed tissue, tissue from individuals with PD and those without, and tissues from young and old individuals.

B.A. Killinger et al., Science Translational Medicine (2018)

“The normal tissue, as well as appendiceal tissue from PD patients, contained high levels of alpha-synuclein in the truncated forms analogous to those seen in Lewy body pathology,” Dr. Killinger said. Based on these and other findings, he believes that alpha-synuclein in the appendix forms a reservoir for seeding the aggregates involved in the pathology of PD, although he acknowledged that it is not yet clear how the proteins in the appendix find their way to the brain.

From these data, it appears that most individuals with an intact appendix have alpha-synuclein in the nerve fibers, but Dr. Labrie pointed out that the only about 1% of the population develops PD. She speculated that there is “some confluence of events,” such as an environmental trigger altering the GI microbiome, that mediates ultimate risk of PD, but she noted that these events may take place decades before signs and symptoms of PD develop. The data appear to be a substantial reorientation in understanding PD.

“We have shown that the appendix is a hub for the accumulation of clumped forms of alpha-synuclein proteins, which are implicated in Parkinson’s,” Dr. Killinger said. “This knowledge will be invaluable as we explore new prevention and treatment strategies.”

The research was funded by a variety of governmental and private grants to individual authors. Dr. Killinger and Dr. Labrie report no financial relationships relevant to this study.

SOURCE: Killinger BA et al. Sci Transl Med. 2018;10:eaar5380.

Appendectomy has been associated with a reduced risk of Parkinson’s disease (PD), which supports the potential for a reservoir of aggregated alpha-synuclein in the appendix to affect risk of the condition, according to new epidemiologic and translational evidence from two data sets that promotes a new and emerging theory for PD etiology.

decade3d/Thinkstock

When placed into the context of other recent studies, these epidemiologic data “point to the appendix as a site of origin for Parkinson’s and provide a path forward for devising new treatment strategies,” reported senior author Viviane Labrie, PhD, of the Van Andel Research Institute (VARI) in Grand Rapids, Mich.

The epidemiologic data was the most recent step in a series of findings summarized in a newly published paper in Science Translational Medicine. As the researchers explained, it is relevant to a separate body of evidence that alpha-synuclein, a protein that serves as the hallmark of PD when it appears in Lewy bodies, can be isolated in the nerve fibers and nerve cells of the appendix.

“We have shown that alpha-synuclein proteins, including the truncated forms observed in Lewy bodies, are abundant in the appendix,” reported first author Bryan A. Killinger, PhD, also at VARI, in a press teleconference. He said this finding is likely to explain the reduced risk of PD from appendectomy.

In the largest of the epidemiologic studies, the effect of appendectomy on subsequent risk of PD was evaluated through the health records from more than 1.6 million individuals in Sweden. The incidence of PD was found to be 19.3% lower among 551,647 patients who had an appendectomy, compared with controls.

In addition, the data showed that when PD did occur after appendectomy, it was delayed on average by 3.6 years. It is notable that appendectomy was not associated with protection from PD in patients with a familial link to PD, a group they said comprises less than 10% of cases.

In patients with PD, nonmotor symptoms often include GI tract dysfunction, which can, in some cases, be part of a prodromal presentation that precedes the onset of classical PD symptoms by several years, the authors reported. However, the new research upends previous conceptions of disease. The demonstration of abundant alpha-synuclein in the appendix coupled with the protective effect of appendectomy, suggests that PD may originate in the GI tract and then spread to the central nervous system (CNS) rather than the other way around.

“The vermiform appendix was once considered to be an unnecessary organ. Although there is now good evidence that the appendix plays a major role in the regulation of the immune system, including the regulation of gut bacteria, our work suggests it is also mediates risk of Parkinson’s,” Dr. Labrie said in the teleconference.

In the paper, numerous pieces of the puzzle are brought together to suggest that alpha-synuclein in the appendix is linked to alpha-synuclein in the CNS. Many of the findings along this investigative pathway were described as surprising. For example, immunohistochemistry studies revealed high amounts of alpha-synuclein in nearly every sample of appendiceal tissue examined, including normal and inflamed tissue, tissue from individuals with PD and those without, and tissues from young and old individuals.

B.A. Killinger et al., Science Translational Medicine (2018)

“The normal tissue, as well as appendiceal tissue from PD patients, contained high levels of alpha-synuclein in the truncated forms analogous to those seen in Lewy body pathology,” Dr. Killinger said. Based on these and other findings, he believes that alpha-synuclein in the appendix forms a reservoir for seeding the aggregates involved in the pathology of PD, although he acknowledged that it is not yet clear how the proteins in the appendix find their way to the brain.

From these data, it appears that most individuals with an intact appendix have alpha-synuclein in the nerve fibers, but Dr. Labrie pointed out that the only about 1% of the population develops PD. She speculated that there is “some confluence of events,” such as an environmental trigger altering the GI microbiome, that mediates ultimate risk of PD, but she noted that these events may take place decades before signs and symptoms of PD develop. The data appear to be a substantial reorientation in understanding PD.

“We have shown that the appendix is a hub for the accumulation of clumped forms of alpha-synuclein proteins, which are implicated in Parkinson’s,” Dr. Killinger said. “This knowledge will be invaluable as we explore new prevention and treatment strategies.”

The research was funded by a variety of governmental and private grants to individual authors. Dr. Killinger and Dr. Labrie report no financial relationships relevant to this study.

SOURCE: Killinger BA et al. Sci Transl Med. 2018;10:eaar5380.

NEW YORK – As part of a comprehensive support program, a computer program administered to patients with cognitive impairment, including those with Alzheimer’s disease, has been associated with preserved cognitive function.

“Based on this series of cases, we believe that the brain in patients with dementia can maintain cognitive function for up to 8 years when an integrative rehabilitation program is employed,” reported Valentin I. Bragin, MD, PhD, of the Stress and Pain Relief Memory Training Center, New York.

While the integrative program involves other types of supportive care, including physical exercises and pharmacologic treatments, the focus of this case series was on the contribution of a computer program for cognitive training. As described by Dr. Bragin, it consists of tasks aimed at training working memory, selective attention, visual field expansion, and eye-hand coordination.

The computer program is designed to improve or maintain motor speed and reaction time. The aim is a rehabilitation process to activate the brain via sensory motor and other bodily systems to prevent patients with Alzheimer’s disease from decline, according to Dr. Bragin. He explained that the computer program is augmented with pen and paper tasks, such as clock drawing, that also stimulate cognitive function.

“The theory behind this treatment is the notion that increased cerebral blood flow is a highly modifiable factor in the risk of cognitive decline,” Dr. Bragin explained at the International Conference on Parkinson’s Disease and Movement Disorders. This premise is supported by a case series of four patients. The shortest duration of treatment was 4 years, but two patients were treated for 7 years and one for 8 years. In this series, motor speed has remained stable in all four patients throughout follow-up. Reaction time remained stable over the period of study in three of four patients, while working memory remained stable in two of the four. Although there was no control group, this persistence of cognitive function is longer than that expected in patients with progressive dementia, according to Dr. Bragin.

“Previously, we demonstrated an improvement and stabilization of cognitive functions in people with mild dementia and depression for periods of up to 6 years by using pen and paper tests,” Dr. Bragin reported. He explained that the computer program expands on this approach.

“We believe that cerebral blood flow is a highly modifiable factor that is a crucial element for reducing hypoxia, improving energy production, and increasing protein synthesis to prevent dementia,” Dr. Bragin said.

Although Dr. Bragin acknowledged that the findings from this case series are preliminary and need to be replicated in a large and controlled trial, he considers it a reasonable empirical strategy, particularly when employed as part of an integrative rehabilitation program like the one now in place at his center.

“This could be a feasible treatment option for dementia patients to stabilize their cognition and improve their quality of life until newer effective approaches become available,” Dr. Bragin said. He noted in the absence of a clear understanding of the pathology of Alzheimer’s disease and other progressive disorders involving cognitive decline, “the most successful treatment model is integrative care.”

NEW YORK – As part of a comprehensive support program, a computer program administered to patients with cognitive impairment, including those with Alzheimer’s disease, has been associated with preserved cognitive function.

“Based on this series of cases, we believe that the brain in patients with dementia can maintain cognitive function for up to 8 years when an integrative rehabilitation program is employed,” reported Valentin I. Bragin, MD, PhD, of the Stress and Pain Relief Memory Training Center, New York.

While the integrative program involves other types of supportive care, including physical exercises and pharmacologic treatments, the focus of this case series was on the contribution of a computer program for cognitive training. As described by Dr. Bragin, it consists of tasks aimed at training working memory, selective attention, visual field expansion, and eye-hand coordination.

The computer program is designed to improve or maintain motor speed and reaction time. The aim is a rehabilitation process to activate the brain via sensory motor and other bodily systems to prevent patients with Alzheimer’s disease from decline, according to Dr. Bragin. He explained that the computer program is augmented with pen and paper tasks, such as clock drawing, that also stimulate cognitive function.

“The theory behind this treatment is the notion that increased cerebral blood flow is a highly modifiable factor in the risk of cognitive decline,” Dr. Bragin explained at the International Conference on Parkinson’s Disease and Movement Disorders. This premise is supported by a case series of four patients. The shortest duration of treatment was 4 years, but two patients were treated for 7 years and one for 8 years. In this series, motor speed has remained stable in all four patients throughout follow-up. Reaction time remained stable over the period of study in three of four patients, while working memory remained stable in two of the four. Although there was no control group, this persistence of cognitive function is longer than that expected in patients with progressive dementia, according to Dr. Bragin.

“Previously, we demonstrated an improvement and stabilization of cognitive functions in people with mild dementia and depression for periods of up to 6 years by using pen and paper tests,” Dr. Bragin reported. He explained that the computer program expands on this approach.

“We believe that cerebral blood flow is a highly modifiable factor that is a crucial element for reducing hypoxia, improving energy production, and increasing protein synthesis to prevent dementia,” Dr. Bragin said.

Although Dr. Bragin acknowledged that the findings from this case series are preliminary and need to be replicated in a large and controlled trial, he considers it a reasonable empirical strategy, particularly when employed as part of an integrative rehabilitation program like the one now in place at his center.

“This could be a feasible treatment option for dementia patients to stabilize their cognition and improve their quality of life until newer effective approaches become available,” Dr. Bragin said. He noted in the absence of a clear understanding of the pathology of Alzheimer’s disease and other progressive disorders involving cognitive decline, “the most successful treatment model is integrative care.”

NEW YORK – As part of a comprehensive support program, a computer program administered to patients with cognitive impairment, including those with Alzheimer’s disease, has been associated with preserved cognitive function.

“Based on this series of cases, we believe that the brain in patients with dementia can maintain cognitive function for up to 8 years when an integrative rehabilitation program is employed,” reported Valentin I. Bragin, MD, PhD, of the Stress and Pain Relief Memory Training Center, New York.

While the integrative program involves other types of supportive care, including physical exercises and pharmacologic treatments, the focus of this case series was on the contribution of a computer program for cognitive training. As described by Dr. Bragin, it consists of tasks aimed at training working memory, selective attention, visual field expansion, and eye-hand coordination.

The computer program is designed to improve or maintain motor speed and reaction time. The aim is a rehabilitation process to activate the brain via sensory motor and other bodily systems to prevent patients with Alzheimer’s disease from decline, according to Dr. Bragin. He explained that the computer program is augmented with pen and paper tasks, such as clock drawing, that also stimulate cognitive function.

“The theory behind this treatment is the notion that increased cerebral blood flow is a highly modifiable factor in the risk of cognitive decline,” Dr. Bragin explained at the International Conference on Parkinson’s Disease and Movement Disorders. This premise is supported by a case series of four patients. The shortest duration of treatment was 4 years, but two patients were treated for 7 years and one for 8 years. In this series, motor speed has remained stable in all four patients throughout follow-up. Reaction time remained stable over the period of study in three of four patients, while working memory remained stable in two of the four. Although there was no control group, this persistence of cognitive function is longer than that expected in patients with progressive dementia, according to Dr. Bragin.

“Previously, we demonstrated an improvement and stabilization of cognitive functions in people with mild dementia and depression for periods of up to 6 years by using pen and paper tests,” Dr. Bragin reported. He explained that the computer program expands on this approach.

“We believe that cerebral blood flow is a highly modifiable factor that is a crucial element for reducing hypoxia, improving energy production, and increasing protein synthesis to prevent dementia,” Dr. Bragin said.

Although Dr. Bragin acknowledged that the findings from this case series are preliminary and need to be replicated in a large and controlled trial, he considers it a reasonable empirical strategy, particularly when employed as part of an integrative rehabilitation program like the one now in place at his center.

“This could be a feasible treatment option for dementia patients to stabilize their cognition and improve their quality of life until newer effective approaches become available,” Dr. Bragin said. He noted in the absence of a clear understanding of the pathology of Alzheimer’s disease and other progressive disorders involving cognitive decline, “the most successful treatment model is integrative care.”