SAN DIEGO — “It’s very important that we know how to correctly diagnose this disease,” began nurse practitioner, Mary Lou Hayden, RN, MS, FNP-BC, AE-C, referring to the disease of asthma. She explained that correct diagnosis is important partly because the disease is so common, affecting 7.6% of adults and 8.4% of children in the United States, and partly because it is responsible for significant health care utilization, including 6.5% of office visits and 1.6 million emergency department visits.

Correctly and objectively diagnosing asthma is also important, Hayden continued in a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit, because, “We cannot simply rely upon patients’ reports of symptoms. Patients very frequently underreport their symptoms and don’t assume it’s asthma.” She says that while peak flow meters can be helpful, they are not diagnostic. “It’s important that we have objective measures . . . and the most important measure is spirometry.”

“You can buy a small office spirometer for as little as $1000,” Hayden continued at the conference, held by Global Academy for Medical Education, “and as a reimbursable procedure, it pays for itself in a short period of time.” “It actually becomes a revenue center for the practice,” she added.

She explained that she’s seen patients with supposed uncontrolled asthma referred to her practice who don’t, in fact, have asthma at all. “If the [referring] office had had a spirometer, they would have perhaps not needed to refer.”

So important is spirometry to the diagnosis and management of asthma that Hayden offers an annual pre-conference workshop on the test, so that “NPs and PAs can leave the conference having all the tools they need to optimize treatment.”

Selecting therapy
Hayden explained that because the US National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf), commonly known as NAEPP or EPR-3, haven’t been updated since 2007, that it’s important to look to the Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention (GINA) (https://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-prevention/), 2018, which is updated annually, for treatment guidance.

For example, personalized or precision medicine is now heavily influencing the field of asthma. Phenotypes, endotypes, and genotypes are helping to guide treatment of severe asthma with monoclonal antibodies and other therapeutic agents, remarked Hayden.

Continue to: Other aspects important to the selection...

Other aspects important to the selection of appropriate therapies include the severity of disease, the level of asthma control, patient preference, and practical issues such as is the patient able to use a particular device, is the patient likely to adhere to the dosing schedule, and, of course, cost. “Cost overlies everything,” said Hayden, “because if a patient can’t afford to buy [a drug], or their insurance doesn’t cover it, or their deductible is so high that it is unlikely that they are going to use it, then we need to think of an alternative that is on their formulary that they are more likely to use.”

At every visit . . .
“We need to measure for control at every visit,” Hayden emphasized, explaining that we assess control in terms of impairment and risk. Impairment includes aspects such as the number of times the patient has had symptoms or used their reliever medication in the past 2 weeks. It can also include results of lung function tests.

Risk includes questions about occurrence of exacerbations, use of systemic corticosteroids, any unscheduled or acute visits for asthma, significant deterioration in lung function, and adverse effects from the medications that have already been prescribed.

Another event that should occur at every visit is review of inhaler technique, said Hayden. She explained that there’s a wide variety of inhalers available that utilize different techniques. “With inhaled medicine, if you are not using the inhaler correctly, you are not going to get good drug deposition in the airways where its meant to be.”

Hayden summarized, “Even people with mild disease can have severe exacerbations following a viral cold or an unfortunate air pollutant exposure, so primary care [practices] need to feel comfortable managing mild to moderate asthma and need to know when to refer those who are not responding appropriately to recommended treatment plans.”

SAN DIEGO — “It’s very important that we know how to correctly diagnose this disease,” began nurse practitioner, Mary Lou Hayden, RN, MS, FNP-BC, AE-C, referring to the disease of asthma. She explained that correct diagnosis is important partly because the disease is so common, affecting 7.6% of adults and 8.4% of children in the United States, and partly because it is responsible for significant health care utilization, including 6.5% of office visits and 1.6 million emergency department visits.

Correctly and objectively diagnosing asthma is also important, Hayden continued in a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit, because, “We cannot simply rely upon patients’ reports of symptoms. Patients very frequently underreport their symptoms and don’t assume it’s asthma.” She says that while peak flow meters can be helpful, they are not diagnostic. “It’s important that we have objective measures . . . and the most important measure is spirometry.”

“You can buy a small office spirometer for as little as $1000,” Hayden continued at the conference, held by Global Academy for Medical Education, “and as a reimbursable procedure, it pays for itself in a short period of time.” “It actually becomes a revenue center for the practice,” she added.

She explained that she’s seen patients with supposed uncontrolled asthma referred to her practice who don’t, in fact, have asthma at all. “If the [referring] office had had a spirometer, they would have perhaps not needed to refer.”

So important is spirometry to the diagnosis and management of asthma that Hayden offers an annual pre-conference workshop on the test, so that “NPs and PAs can leave the conference having all the tools they need to optimize treatment.”

Selecting therapy
Hayden explained that because the US National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf), commonly known as NAEPP or EPR-3, haven’t been updated since 2007, that it’s important to look to the Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention (GINA) (https://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-prevention/), 2018, which is updated annually, for treatment guidance.

For example, personalized or precision medicine is now heavily influencing the field of asthma. Phenotypes, endotypes, and genotypes are helping to guide treatment of severe asthma with monoclonal antibodies and other therapeutic agents, remarked Hayden.

Continue to: Other aspects important to the selection...

Other aspects important to the selection of appropriate therapies include the severity of disease, the level of asthma control, patient preference, and practical issues such as is the patient able to use a particular device, is the patient likely to adhere to the dosing schedule, and, of course, cost. “Cost overlies everything,” said Hayden, “because if a patient can’t afford to buy [a drug], or their insurance doesn’t cover it, or their deductible is so high that it is unlikely that they are going to use it, then we need to think of an alternative that is on their formulary that they are more likely to use.”

At every visit . . .
“We need to measure for control at every visit,” Hayden emphasized, explaining that we assess control in terms of impairment and risk. Impairment includes aspects such as the number of times the patient has had symptoms or used their reliever medication in the past 2 weeks. It can also include results of lung function tests.

Risk includes questions about occurrence of exacerbations, use of systemic corticosteroids, any unscheduled or acute visits for asthma, significant deterioration in lung function, and adverse effects from the medications that have already been prescribed.

Another event that should occur at every visit is review of inhaler technique, said Hayden. She explained that there’s a wide variety of inhalers available that utilize different techniques. “With inhaled medicine, if you are not using the inhaler correctly, you are not going to get good drug deposition in the airways where its meant to be.”

Hayden summarized, “Even people with mild disease can have severe exacerbations following a viral cold or an unfortunate air pollutant exposure, so primary care [practices] need to feel comfortable managing mild to moderate asthma and need to know when to refer those who are not responding appropriately to recommended treatment plans.”

SAN DIEGO — “It’s very important that we know how to correctly diagnose this disease,” began nurse practitioner, Mary Lou Hayden, RN, MS, FNP-BC, AE-C, referring to the disease of asthma. She explained that correct diagnosis is important partly because the disease is so common, affecting 7.6% of adults and 8.4% of children in the United States, and partly because it is responsible for significant health care utilization, including 6.5% of office visits and 1.6 million emergency department visits.

Correctly and objectively diagnosing asthma is also important, Hayden continued in a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit, because, “We cannot simply rely upon patients’ reports of symptoms. Patients very frequently underreport their symptoms and don’t assume it’s asthma.” She says that while peak flow meters can be helpful, they are not diagnostic. “It’s important that we have objective measures . . . and the most important measure is spirometry.”

“You can buy a small office spirometer for as little as $1000,” Hayden continued at the conference, held by Global Academy for Medical Education, “and as a reimbursable procedure, it pays for itself in a short period of time.” “It actually becomes a revenue center for the practice,” she added.

She explained that she’s seen patients with supposed uncontrolled asthma referred to her practice who don’t, in fact, have asthma at all. “If the [referring] office had had a spirometer, they would have perhaps not needed to refer.”

So important is spirometry to the diagnosis and management of asthma that Hayden offers an annual pre-conference workshop on the test, so that “NPs and PAs can leave the conference having all the tools they need to optimize treatment.”

Selecting therapy
Hayden explained that because the US National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf), commonly known as NAEPP or EPR-3, haven’t been updated since 2007, that it’s important to look to the Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention (GINA) (https://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-prevention/), 2018, which is updated annually, for treatment guidance.

For example, personalized or precision medicine is now heavily influencing the field of asthma. Phenotypes, endotypes, and genotypes are helping to guide treatment of severe asthma with monoclonal antibodies and other therapeutic agents, remarked Hayden.

Continue to: Other aspects important to the selection...

Other aspects important to the selection of appropriate therapies include the severity of disease, the level of asthma control, patient preference, and practical issues such as is the patient able to use a particular device, is the patient likely to adhere to the dosing schedule, and, of course, cost. “Cost overlies everything,” said Hayden, “because if a patient can’t afford to buy [a drug], or their insurance doesn’t cover it, or their deductible is so high that it is unlikely that they are going to use it, then we need to think of an alternative that is on their formulary that they are more likely to use.”

At every visit . . .
“We need to measure for control at every visit,” Hayden emphasized, explaining that we assess control in terms of impairment and risk. Impairment includes aspects such as the number of times the patient has had symptoms or used their reliever medication in the past 2 weeks. It can also include results of lung function tests.

Risk includes questions about occurrence of exacerbations, use of systemic corticosteroids, any unscheduled or acute visits for asthma, significant deterioration in lung function, and adverse effects from the medications that have already been prescribed.

Another event that should occur at every visit is review of inhaler technique, said Hayden. She explained that there’s a wide variety of inhalers available that utilize different techniques. “With inhaled medicine, if you are not using the inhaler correctly, you are not going to get good drug deposition in the airways where its meant to be.”

Hayden summarized, “Even people with mild disease can have severe exacerbations following a viral cold or an unfortunate air pollutant exposure, so primary care [practices] need to feel comfortable managing mild to moderate asthma and need to know when to refer those who are not responding appropriately to recommended treatment plans.”

SEATTLE – Movement disorders should be a factor in screening children receiving pharmacotherapy, Jagan K. Chilakamarri, MD, said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. 

“I started seeing a very, very complex group of pediatric patients in my office,” said Dr. Chilakamarri, medical director at the Atlanta Psychiatric Institute, and codirector of the Movement Disorders Program at Emory University, Atlanta. “I decided I needed to coordinate with a neurologist and sort out what was happening.”

Dr. Chilakamarri suspects that the advent of new drug therapies and polytherapy is leading to a range of movement effects, especially in young patients prescribed multiple agents.

Many psychiatrists may not be comfortable with screening or diagnosing movement disorders, preferring instead to refer a patient to a neurologist. That’s understandable, but the neurologist may not have the psychotropic drug history in mind when assessing a patient. If a drug or drug combination is responsible for a movement disorder, it befits the psychiatrist to address it, he said.

“I want psychiatrists to be more familiar with how to do a basic movement disorder assessment, and how to understand these movements in the context of the patient, whether they’re drug induced or related to their own disorder, or something comorbid that we are not able to understand – how to measure them, how to understand them, and when to send them to the appropriate referral so that these patients are being well addressed. Some may not be addressed by a neurologist; maybe the patient should go to an endocrinologist because of a thyroid problem,” said Dr. Chilakamarri.

The best way to gain that understanding and familiarity, aside from reviewing the potential side effects of psychotropic medications, is to partner with a neurologist who can impart a better understanding of how movement disorders present.

“Whenever we see these odd or strange movements, we basically see if we can send the patient to a neurologist. I have no problem with that, but what I’m trying to say is, if we can be a little bit more aware, a little bit more understanding of these things, we can reduce some of those events,” said Dr. Chilakamarri.

He disclosed no conflicts of interest.

SOURCE: Commonly occurring movement disorders in children, AACAP 2018.

SEATTLE – Movement disorders should be a factor in screening children receiving pharmacotherapy, Jagan K. Chilakamarri, MD, said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. 

“I started seeing a very, very complex group of pediatric patients in my office,” said Dr. Chilakamarri, medical director at the Atlanta Psychiatric Institute, and codirector of the Movement Disorders Program at Emory University, Atlanta. “I decided I needed to coordinate with a neurologist and sort out what was happening.”

Dr. Chilakamarri suspects that the advent of new drug therapies and polytherapy is leading to a range of movement effects, especially in young patients prescribed multiple agents.

Many psychiatrists may not be comfortable with screening or diagnosing movement disorders, preferring instead to refer a patient to a neurologist. That’s understandable, but the neurologist may not have the psychotropic drug history in mind when assessing a patient. If a drug or drug combination is responsible for a movement disorder, it befits the psychiatrist to address it, he said.

“I want psychiatrists to be more familiar with how to do a basic movement disorder assessment, and how to understand these movements in the context of the patient, whether they’re drug induced or related to their own disorder, or something comorbid that we are not able to understand – how to measure them, how to understand them, and when to send them to the appropriate referral so that these patients are being well addressed. Some may not be addressed by a neurologist; maybe the patient should go to an endocrinologist because of a thyroid problem,” said Dr. Chilakamarri.

The best way to gain that understanding and familiarity, aside from reviewing the potential side effects of psychotropic medications, is to partner with a neurologist who can impart a better understanding of how movement disorders present.

“Whenever we see these odd or strange movements, we basically see if we can send the patient to a neurologist. I have no problem with that, but what I’m trying to say is, if we can be a little bit more aware, a little bit more understanding of these things, we can reduce some of those events,” said Dr. Chilakamarri.

He disclosed no conflicts of interest.

SOURCE: Commonly occurring movement disorders in children, AACAP 2018.

SEATTLE – Movement disorders should be a factor in screening children receiving pharmacotherapy, Jagan K. Chilakamarri, MD, said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. 

“I started seeing a very, very complex group of pediatric patients in my office,” said Dr. Chilakamarri, medical director at the Atlanta Psychiatric Institute, and codirector of the Movement Disorders Program at Emory University, Atlanta. “I decided I needed to coordinate with a neurologist and sort out what was happening.”

Dr. Chilakamarri suspects that the advent of new drug therapies and polytherapy is leading to a range of movement effects, especially in young patients prescribed multiple agents.

Many psychiatrists may not be comfortable with screening or diagnosing movement disorders, preferring instead to refer a patient to a neurologist. That’s understandable, but the neurologist may not have the psychotropic drug history in mind when assessing a patient. If a drug or drug combination is responsible for a movement disorder, it befits the psychiatrist to address it, he said.

“I want psychiatrists to be more familiar with how to do a basic movement disorder assessment, and how to understand these movements in the context of the patient, whether they’re drug induced or related to their own disorder, or something comorbid that we are not able to understand – how to measure them, how to understand them, and when to send them to the appropriate referral so that these patients are being well addressed. Some may not be addressed by a neurologist; maybe the patient should go to an endocrinologist because of a thyroid problem,” said Dr. Chilakamarri.

The best way to gain that understanding and familiarity, aside from reviewing the potential side effects of psychotropic medications, is to partner with a neurologist who can impart a better understanding of how movement disorders present.

“Whenever we see these odd or strange movements, we basically see if we can send the patient to a neurologist. I have no problem with that, but what I’m trying to say is, if we can be a little bit more aware, a little bit more understanding of these things, we can reduce some of those events,” said Dr. Chilakamarri.

He disclosed no conflicts of interest.

SOURCE: Commonly occurring movement disorders in children, AACAP 2018.

SAN DIEGO—The first practice changer is with the diagnosis of hypertension, began Leslie L. Davis, PhD, RN, ANP-BC, FAANP, FPCNA, FAHA. “The 2017 American Heart Association/American College of Cardiology guidelines¹ show us that Stage 1 hypertension is now 130 to 139 mm Hg systolic, and that has always been traditionally 140 mm Hg and above, so this dramatically changes how we diagnose and treat hypertension.”

“That means that another 14% or so of Americans will now fall under the category of Stage 1 hypertension. It doesn’t mean that all of these people will be on medication; however, when we reclassify, that’s a big chunk of the population. We go from about 32% prevalence to about 46% of adults in the United States having hypertension,” Davis said during a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit.

According to the guidelines, normal blood pressure (BP) is now <120 mm Hg systolic and <80 mm Hg diastolic. Elevated BP is 120 to 129 mm Hg systolic and <80 mm Hg diastolic. And Stage 2 hypertension is ≥140 mm Hg systolic and ≥90 mm Hg diastolic.

“This means we need to be a little more vigilant about screening and about getting patients in the system a little sooner . . . and  potentially about making some critical lifestyle changes because we know that blood pressure over time in men and women will gradually go up,” Davis said at the conference, held by Global Academy for Medical Education. “Systolic and diastolic blood pressure increases every year of life on average, and by the fifth decade of life, diastolic will start going down, but systolic will continue to increase. If we can catch folks sooner, we can prevent the poor outcomes associated with having hypertension,” she stated.

Numbers matter
The new guidelines, Davis continued, mean that “more than ever, accuracy in blood pressure measurement really matters.” She said, "It’s essential to take accurate blood pressures,” and to pay attention to things like having patients in a sitting position, at rest, with both feet planted on a flat surface, with back supported, and with arm at heart level for at least 5 minutes when taking BP measurements; to remove constrictive clothing and not just push it up; to make sure the patient hasn’t used caffeine or tobacco for at least 30 minutes prior to the measurement; to use the correct size sphygmomanometer cuff; to have the patient not talk during the measurement; and to consider out-of-office BP measurements in the overall assessment.

"We might have been late in the game in my opinion in the United States of really pushing this issue of using blood pressures from other settings—not just using in-office blood pressure readings,” Davis said making the point that the European and Canadian guidelines incorporated BP readings from other settings in the recommendations for diagnosing hypertension about 5 years ago.

“We need more than just the blood pressure readings we’re getting in the office,” she said, to identify things like white coat hypertension and masked hypertension, which is the opposite of white coat hypertension, meaning a patient’s BP is within normal limits in the office or clinic, but elevated when he/she is away from a medical setting. 

Continue to: When to start meds

When to start meds
Another practice changer, according to Davis, is when to start medications based on the new guidelines. “We are now looking at 10-year atherosclerotic risk, and that hasn’t been part of the management guidelines in the past for hypertension.” Similarly, “Treatment goals now have lower targets,” she said.

She explained that for patients who require secondary prevention of recurrent CVD (or if they have clinical CVD), then 10-year risk is irrelevant, and practitioners should start medication when systolic blood pressure (SBP) is ≥130 mm Hg or diastolic blood pressure (DBP) is ≥80 mm Hg. If the patient requires primary prevention (ie, no history of CVD or additional markers of increased risk of CVD) and their atherosclerotic 10-year risk is ≥10%, then medication is also warranted when SPB is ≥130 mm Hg or DBP is ≥80 mm Hg. Davis explained, “Some people might say [10% is] not much of a risk, but that’s considered as high a risk as someone who’s had a heart attack or stroke.”

If a patient requires primary prevention (ie, no history of CVD) and they have a 10-year atherosclerotic risk <10%, then health care providers should start medication when the patient’s SBP is ≥140 mm Hg or DBP is ≥90 mm Hg. Yet, Davis added, as with any patient with any elevation of BP, these patients should adopt lifestyle changes to reduce their BP.

In the end, Davis reminded that these are simply evidence-based guidelines, and that practitioners still need to have discussions with patients about when to start pharmacotherapy.

Continue to: Follow-up and nonpharmacologic care

Follow-up and nonpharmacologic care
“If patients have low atherosclerotic risk and an SBP that is 120 to 129 mm Hg, you can repeat the BP measurement after up to 6 months of lifestyle changes,” said Davis. “These guidelines don’t add anything magical about lifestyle changes,” Davis explained. “It’s stuff we’ve known” and been doing for a long time, such as the DASH diet and weight loss, which “are as good as low-dose medication at reducing BP in many cases.”

She cautioned, however, that with patients who are Stage 1 and Stage 2, “Don’t wait too long to bring them back; bring them back within a month.” She said that most patients with Stage 1 hypertension are managed with a combination of lifestyle changes and a medication, while those with Stage 2 hypertension are often started on 2 medications at once, along with lifestyle changes.

Lastly, Davis explained that older adults are defined as those ≥65 years of age, and that this population can range widely from those who are ambulatory and well to those who have many comorbid conditions. As a result, practitioners really need to talk to these patients and perhaps their families to determine through shared decision-making what treatment is necessary.

SAN DIEGO—The first practice changer is with the diagnosis of hypertension, began Leslie L. Davis, PhD, RN, ANP-BC, FAANP, FPCNA, FAHA. “The 2017 American Heart Association/American College of Cardiology guidelines¹ show us that Stage 1 hypertension is now 130 to 139 mm Hg systolic, and that has always been traditionally 140 mm Hg and above, so this dramatically changes how we diagnose and treat hypertension.”

“That means that another 14% or so of Americans will now fall under the category of Stage 1 hypertension. It doesn’t mean that all of these people will be on medication; however, when we reclassify, that’s a big chunk of the population. We go from about 32% prevalence to about 46% of adults in the United States having hypertension,” Davis said during a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit.

According to the guidelines, normal blood pressure (BP) is now <120 mm Hg systolic and <80 mm Hg diastolic. Elevated BP is 120 to 129 mm Hg systolic and <80 mm Hg diastolic. And Stage 2 hypertension is ≥140 mm Hg systolic and ≥90 mm Hg diastolic.

“This means we need to be a little more vigilant about screening and about getting patients in the system a little sooner . . . and  potentially about making some critical lifestyle changes because we know that blood pressure over time in men and women will gradually go up,” Davis said at the conference, held by Global Academy for Medical Education. “Systolic and diastolic blood pressure increases every year of life on average, and by the fifth decade of life, diastolic will start going down, but systolic will continue to increase. If we can catch folks sooner, we can prevent the poor outcomes associated with having hypertension,” she stated.

Numbers matter
The new guidelines, Davis continued, mean that “more than ever, accuracy in blood pressure measurement really matters.” She said, "It’s essential to take accurate blood pressures,” and to pay attention to things like having patients in a sitting position, at rest, with both feet planted on a flat surface, with back supported, and with arm at heart level for at least 5 minutes when taking BP measurements; to remove constrictive clothing and not just push it up; to make sure the patient hasn’t used caffeine or tobacco for at least 30 minutes prior to the measurement; to use the correct size sphygmomanometer cuff; to have the patient not talk during the measurement; and to consider out-of-office BP measurements in the overall assessment.

"We might have been late in the game in my opinion in the United States of really pushing this issue of using blood pressures from other settings—not just using in-office blood pressure readings,” Davis said making the point that the European and Canadian guidelines incorporated BP readings from other settings in the recommendations for diagnosing hypertension about 5 years ago.

“We need more than just the blood pressure readings we’re getting in the office,” she said, to identify things like white coat hypertension and masked hypertension, which is the opposite of white coat hypertension, meaning a patient’s BP is within normal limits in the office or clinic, but elevated when he/she is away from a medical setting. 

Continue to: When to start meds

When to start meds
Another practice changer, according to Davis, is when to start medications based on the new guidelines. “We are now looking at 10-year atherosclerotic risk, and that hasn’t been part of the management guidelines in the past for hypertension.” Similarly, “Treatment goals now have lower targets,” she said.

She explained that for patients who require secondary prevention of recurrent CVD (or if they have clinical CVD), then 10-year risk is irrelevant, and practitioners should start medication when systolic blood pressure (SBP) is ≥130 mm Hg or diastolic blood pressure (DBP) is ≥80 mm Hg. If the patient requires primary prevention (ie, no history of CVD or additional markers of increased risk of CVD) and their atherosclerotic 10-year risk is ≥10%, then medication is also warranted when SPB is ≥130 mm Hg or DBP is ≥80 mm Hg. Davis explained, “Some people might say [10% is] not much of a risk, but that’s considered as high a risk as someone who’s had a heart attack or stroke.”

If a patient requires primary prevention (ie, no history of CVD) and they have a 10-year atherosclerotic risk <10%, then health care providers should start medication when the patient’s SBP is ≥140 mm Hg or DBP is ≥90 mm Hg. Yet, Davis added, as with any patient with any elevation of BP, these patients should adopt lifestyle changes to reduce their BP.

In the end, Davis reminded that these are simply evidence-based guidelines, and that practitioners still need to have discussions with patients about when to start pharmacotherapy.

Continue to: Follow-up and nonpharmacologic care

Follow-up and nonpharmacologic care
“If patients have low atherosclerotic risk and an SBP that is 120 to 129 mm Hg, you can repeat the BP measurement after up to 6 months of lifestyle changes,” said Davis. “These guidelines don’t add anything magical about lifestyle changes,” Davis explained. “It’s stuff we’ve known” and been doing for a long time, such as the DASH diet and weight loss, which “are as good as low-dose medication at reducing BP in many cases.”

She cautioned, however, that with patients who are Stage 1 and Stage 2, “Don’t wait too long to bring them back; bring them back within a month.” She said that most patients with Stage 1 hypertension are managed with a combination of lifestyle changes and a medication, while those with Stage 2 hypertension are often started on 2 medications at once, along with lifestyle changes.

Lastly, Davis explained that older adults are defined as those ≥65 years of age, and that this population can range widely from those who are ambulatory and well to those who have many comorbid conditions. As a result, practitioners really need to talk to these patients and perhaps their families to determine through shared decision-making what treatment is necessary.

SAN DIEGO—The first practice changer is with the diagnosis of hypertension, began Leslie L. Davis, PhD, RN, ANP-BC, FAANP, FPCNA, FAHA. “The 2017 American Heart Association/American College of Cardiology guidelines¹ show us that Stage 1 hypertension is now 130 to 139 mm Hg systolic, and that has always been traditionally 140 mm Hg and above, so this dramatically changes how we diagnose and treat hypertension.”

“That means that another 14% or so of Americans will now fall under the category of Stage 1 hypertension. It doesn’t mean that all of these people will be on medication; however, when we reclassify, that’s a big chunk of the population. We go from about 32% prevalence to about 46% of adults in the United States having hypertension,” Davis said during a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit.

According to the guidelines, normal blood pressure (BP) is now <120 mm Hg systolic and <80 mm Hg diastolic. Elevated BP is 120 to 129 mm Hg systolic and <80 mm Hg diastolic. And Stage 2 hypertension is ≥140 mm Hg systolic and ≥90 mm Hg diastolic.

“This means we need to be a little more vigilant about screening and about getting patients in the system a little sooner . . . and  potentially about making some critical lifestyle changes because we know that blood pressure over time in men and women will gradually go up,” Davis said at the conference, held by Global Academy for Medical Education. “Systolic and diastolic blood pressure increases every year of life on average, and by the fifth decade of life, diastolic will start going down, but systolic will continue to increase. If we can catch folks sooner, we can prevent the poor outcomes associated with having hypertension,” she stated.

Numbers matter
The new guidelines, Davis continued, mean that “more than ever, accuracy in blood pressure measurement really matters.” She said, "It’s essential to take accurate blood pressures,” and to pay attention to things like having patients in a sitting position, at rest, with both feet planted on a flat surface, with back supported, and with arm at heart level for at least 5 minutes when taking BP measurements; to remove constrictive clothing and not just push it up; to make sure the patient hasn’t used caffeine or tobacco for at least 30 minutes prior to the measurement; to use the correct size sphygmomanometer cuff; to have the patient not talk during the measurement; and to consider out-of-office BP measurements in the overall assessment.

"We might have been late in the game in my opinion in the United States of really pushing this issue of using blood pressures from other settings—not just using in-office blood pressure readings,” Davis said making the point that the European and Canadian guidelines incorporated BP readings from other settings in the recommendations for diagnosing hypertension about 5 years ago.

“We need more than just the blood pressure readings we’re getting in the office,” she said, to identify things like white coat hypertension and masked hypertension, which is the opposite of white coat hypertension, meaning a patient’s BP is within normal limits in the office or clinic, but elevated when he/she is away from a medical setting. 

Continue to: When to start meds

When to start meds
Another practice changer, according to Davis, is when to start medications based on the new guidelines. “We are now looking at 10-year atherosclerotic risk, and that hasn’t been part of the management guidelines in the past for hypertension.” Similarly, “Treatment goals now have lower targets,” she said.

She explained that for patients who require secondary prevention of recurrent CVD (or if they have clinical CVD), then 10-year risk is irrelevant, and practitioners should start medication when systolic blood pressure (SBP) is ≥130 mm Hg or diastolic blood pressure (DBP) is ≥80 mm Hg. If the patient requires primary prevention (ie, no history of CVD or additional markers of increased risk of CVD) and their atherosclerotic 10-year risk is ≥10%, then medication is also warranted when SPB is ≥130 mm Hg or DBP is ≥80 mm Hg. Davis explained, “Some people might say [10% is] not much of a risk, but that’s considered as high a risk as someone who’s had a heart attack or stroke.”

If a patient requires primary prevention (ie, no history of CVD) and they have a 10-year atherosclerotic risk <10%, then health care providers should start medication when the patient’s SBP is ≥140 mm Hg or DBP is ≥90 mm Hg. Yet, Davis added, as with any patient with any elevation of BP, these patients should adopt lifestyle changes to reduce their BP.

In the end, Davis reminded that these are simply evidence-based guidelines, and that practitioners still need to have discussions with patients about when to start pharmacotherapy.

Continue to: Follow-up and nonpharmacologic care

Follow-up and nonpharmacologic care
“If patients have low atherosclerotic risk and an SBP that is 120 to 129 mm Hg, you can repeat the BP measurement after up to 6 months of lifestyle changes,” said Davis. “These guidelines don’t add anything magical about lifestyle changes,” Davis explained. “It’s stuff we’ve known” and been doing for a long time, such as the DASH diet and weight loss, which “are as good as low-dose medication at reducing BP in many cases.”

She cautioned, however, that with patients who are Stage 1 and Stage 2, “Don’t wait too long to bring them back; bring them back within a month.” She said that most patients with Stage 1 hypertension are managed with a combination of lifestyle changes and a medication, while those with Stage 2 hypertension are often started on 2 medications at once, along with lifestyle changes.

Lastly, Davis explained that older adults are defined as those ≥65 years of age, and that this population can range widely from those who are ambulatory and well to those who have many comorbid conditions. As a result, practitioners really need to talk to these patients and perhaps their families to determine through shared decision-making what treatment is necessary.

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.

BOSTON – For women undergoing nipple-sparing mastectomy, advanced age and neoadjuvant chemotherapy are not associated with increased postoperative complications, results of recent studies suggest.

Andrew D. Bowser/MDedge News

The procedure was “surgically safe” in older patients, with complication rates comparable to those seen in younger patients, Solange E. Cox, MD, of MedStar Georgetown University Hospital, Washington, said in a presentation of one those two retrospective analyses at the annual clinical congress of the American College of Surgeons.

“From this, we think that eligible older patients should be offered a nipple-sparing mastectomy as a surgical option for breast cancer, and age alone should not be used as criteria to exclude these patients from the option,” she said.

The second retrospective study showed that patients undergoing neoadjuvant chemotherapy had a rate of surgical complications and unintended reoperations comparable to what was seen in women undergoing primary surgery.

“Our big-picture takeaway from this study is that receipt of neoadjuvant chemotherapy is not a contraindication for nipple-sparing mastectomy,” said investigator Alex J. Bartholomew, MS, also of Medstar Georgetown University Hospital.

Mr. Bartholomew’s conclusion was based on an analysis of the nipple-sparing mastectomy registry of the American Society of Breast Surgeons that included a total of 3,125 breasts. Neoadjuvant chemotherapy was used in 528, or 16.9%, while primary surgery was performed in 2,597, or 83.1%.

The overall rate of complications was 11%, with nonsignificant differences between the neoadjuvant chemotherapy and primary surgery groups at 12.7% and 10.7%, respectively.

Andrew D. Bowser/MDedge News

SOURCES: Cox S et al. SF310 abstract; Bartholomew AJ et al. SF310 abstract ACS Clinical Congress 2018

BOSTON – For women undergoing nipple-sparing mastectomy, advanced age and neoadjuvant chemotherapy are not associated with increased postoperative complications, results of recent studies suggest.

Andrew D. Bowser/MDedge News

The procedure was “surgically safe” in older patients, with complication rates comparable to those seen in younger patients, Solange E. Cox, MD, of MedStar Georgetown University Hospital, Washington, said in a presentation of one those two retrospective analyses at the annual clinical congress of the American College of Surgeons.

“From this, we think that eligible older patients should be offered a nipple-sparing mastectomy as a surgical option for breast cancer, and age alone should not be used as criteria to exclude these patients from the option,” she said.

The second retrospective study showed that patients undergoing neoadjuvant chemotherapy had a rate of surgical complications and unintended reoperations comparable to what was seen in women undergoing primary surgery.

“Our big-picture takeaway from this study is that receipt of neoadjuvant chemotherapy is not a contraindication for nipple-sparing mastectomy,” said investigator Alex J. Bartholomew, MS, also of Medstar Georgetown University Hospital.

Mr. Bartholomew’s conclusion was based on an analysis of the nipple-sparing mastectomy registry of the American Society of Breast Surgeons that included a total of 3,125 breasts. Neoadjuvant chemotherapy was used in 528, or 16.9%, while primary surgery was performed in 2,597, or 83.1%.

The overall rate of complications was 11%, with nonsignificant differences between the neoadjuvant chemotherapy and primary surgery groups at 12.7% and 10.7%, respectively.

Andrew D. Bowser/MDedge News

SOURCES: Cox S et al. SF310 abstract; Bartholomew AJ et al. SF310 abstract ACS Clinical Congress 2018

BOSTON – For women undergoing nipple-sparing mastectomy, advanced age and neoadjuvant chemotherapy are not associated with increased postoperative complications, results of recent studies suggest.

Andrew D. Bowser/MDedge News

The procedure was “surgically safe” in older patients, with complication rates comparable to those seen in younger patients, Solange E. Cox, MD, of MedStar Georgetown University Hospital, Washington, said in a presentation of one those two retrospective analyses at the annual clinical congress of the American College of Surgeons.

“From this, we think that eligible older patients should be offered a nipple-sparing mastectomy as a surgical option for breast cancer, and age alone should not be used as criteria to exclude these patients from the option,” she said.

The second retrospective study showed that patients undergoing neoadjuvant chemotherapy had a rate of surgical complications and unintended reoperations comparable to what was seen in women undergoing primary surgery.

“Our big-picture takeaway from this study is that receipt of neoadjuvant chemotherapy is not a contraindication for nipple-sparing mastectomy,” said investigator Alex J. Bartholomew, MS, also of Medstar Georgetown University Hospital.

Mr. Bartholomew’s conclusion was based on an analysis of the nipple-sparing mastectomy registry of the American Society of Breast Surgeons that included a total of 3,125 breasts. Neoadjuvant chemotherapy was used in 528, or 16.9%, while primary surgery was performed in 2,597, or 83.1%.

The overall rate of complications was 11%, with nonsignificant differences between the neoadjuvant chemotherapy and primary surgery groups at 12.7% and 10.7%, respectively.

Andrew D. Bowser/MDedge News

SOURCES: Cox S et al. SF310 abstract; Bartholomew AJ et al. SF310 abstract ACS Clinical Congress 2018

In a southwestern U.S. population having renal cell carcinoma (RCC), patient and disease characteristics differ by race/ethnicity in ways that may have implications for prevention, diagnosis, prognosis, and treatment, finds a single-center cohort study.

Investigators led by Ken Batai, PhD, of University of Arizona, Tucson, retrospectively reviewed the medical records of 294 patients with RCC as their first cancer who underwent partial or radical nephrectomy: 151 European Americans, 95 Hispanic Americans, 22 Native Americans, 9 African Americans, and 17 other race/ethnicity. About 12% overall had metastases at presentation.

On average, compared with European Americans, Hispanic Americans were about 5 years younger at diagnosis (55.8 vs. 60.5) and had higher odds of diagnosis before the age of 50 (odds ratio, 2.77), according to results published in Clinical Genitourinary Cancer.

Native Americans were even younger (49.7) and had dramatically elevated odds of diagnosis before that age (odds ratio, 6.23).

Relative to their European American counterparts, Hispanic Americans less commonly smoked (30.5% vs 48.6%) and African Americans more commonly had chronic kidney disease (37.5% vs. 5.8%). Both groups had higher prevalence of diabetes (45.6% and 54.5% vs. 21.7%). In addition, Native Americans had higher body mass index (35.2 vs. 30.7).

Clear cell histology was seen in 78.8% of European Americans, but in 92.6% of Hispanic Americans (odds ratio, 2.79) and 86.4% of Native Americans. African Americans more commonly had stage III or IV disease at diagnosis (77.8% vs. 35.3%; odds ratio, 6.51), but the racial/ethnic groups did not differ significantly on grade, tumor size, or presence of necrosis.

Among the Hispanic American patients undergoing radical nephrectomy, disease was more commonly of stage III or IV at diagnosis in those who were aged 65 or older (odds ratio, 10.48) and those who spoke Spanish as their primary language (odds ratios, 4.61).

The reasons for the observed racial/ethnic disparities remain unclear, according to Dr. Batai and his coinvestigators. Nonetheless, “it is necessary to better understand the clinical characteristics of these underserved Hispanic American and Native American populations with high kidney cancer burden,” they wrote.

“Our findings can direct future research toward elucidating the difference in tumor behavior among the different ethnic groups and health care issues causing poor outcomes,” they concluded. The findings also “bring ... awareness to practitioners treating patients from these racial/ethnic minority groups regarding the clinical characteristics and underlying issues in these patient populations.”

The study was supported by the American Cancer Society and the Partnership for Native American Cancer Prevention.

SOURCE: Batai K et al. Clin Genitourin Cancer. 2018 Oct 26. doi: 10.1016/j.clgc.2018.10.012.

In a southwestern U.S. population having renal cell carcinoma (RCC), patient and disease characteristics differ by race/ethnicity in ways that may have implications for prevention, diagnosis, prognosis, and treatment, finds a single-center cohort study.

Investigators led by Ken Batai, PhD, of University of Arizona, Tucson, retrospectively reviewed the medical records of 294 patients with RCC as their first cancer who underwent partial or radical nephrectomy: 151 European Americans, 95 Hispanic Americans, 22 Native Americans, 9 African Americans, and 17 other race/ethnicity. About 12% overall had metastases at presentation.

On average, compared with European Americans, Hispanic Americans were about 5 years younger at diagnosis (55.8 vs. 60.5) and had higher odds of diagnosis before the age of 50 (odds ratio, 2.77), according to results published in Clinical Genitourinary Cancer.

Native Americans were even younger (49.7) and had dramatically elevated odds of diagnosis before that age (odds ratio, 6.23).

Relative to their European American counterparts, Hispanic Americans less commonly smoked (30.5% vs 48.6%) and African Americans more commonly had chronic kidney disease (37.5% vs. 5.8%). Both groups had higher prevalence of diabetes (45.6% and 54.5% vs. 21.7%). In addition, Native Americans had higher body mass index (35.2 vs. 30.7).

Clear cell histology was seen in 78.8% of European Americans, but in 92.6% of Hispanic Americans (odds ratio, 2.79) and 86.4% of Native Americans. African Americans more commonly had stage III or IV disease at diagnosis (77.8% vs. 35.3%; odds ratio, 6.51), but the racial/ethnic groups did not differ significantly on grade, tumor size, or presence of necrosis.

Among the Hispanic American patients undergoing radical nephrectomy, disease was more commonly of stage III or IV at diagnosis in those who were aged 65 or older (odds ratio, 10.48) and those who spoke Spanish as their primary language (odds ratios, 4.61).

The reasons for the observed racial/ethnic disparities remain unclear, according to Dr. Batai and his coinvestigators. Nonetheless, “it is necessary to better understand the clinical characteristics of these underserved Hispanic American and Native American populations with high kidney cancer burden,” they wrote.

“Our findings can direct future research toward elucidating the difference in tumor behavior among the different ethnic groups and health care issues causing poor outcomes,” they concluded. The findings also “bring ... awareness to practitioners treating patients from these racial/ethnic minority groups regarding the clinical characteristics and underlying issues in these patient populations.”

The study was supported by the American Cancer Society and the Partnership for Native American Cancer Prevention.

SOURCE: Batai K et al. Clin Genitourin Cancer. 2018 Oct 26. doi: 10.1016/j.clgc.2018.10.012.

In a southwestern U.S. population having renal cell carcinoma (RCC), patient and disease characteristics differ by race/ethnicity in ways that may have implications for prevention, diagnosis, prognosis, and treatment, finds a single-center cohort study.

Investigators led by Ken Batai, PhD, of University of Arizona, Tucson, retrospectively reviewed the medical records of 294 patients with RCC as their first cancer who underwent partial or radical nephrectomy: 151 European Americans, 95 Hispanic Americans, 22 Native Americans, 9 African Americans, and 17 other race/ethnicity. About 12% overall had metastases at presentation.

On average, compared with European Americans, Hispanic Americans were about 5 years younger at diagnosis (55.8 vs. 60.5) and had higher odds of diagnosis before the age of 50 (odds ratio, 2.77), according to results published in Clinical Genitourinary Cancer.

Native Americans were even younger (49.7) and had dramatically elevated odds of diagnosis before that age (odds ratio, 6.23).

Relative to their European American counterparts, Hispanic Americans less commonly smoked (30.5% vs 48.6%) and African Americans more commonly had chronic kidney disease (37.5% vs. 5.8%). Both groups had higher prevalence of diabetes (45.6% and 54.5% vs. 21.7%). In addition, Native Americans had higher body mass index (35.2 vs. 30.7).

Clear cell histology was seen in 78.8% of European Americans, but in 92.6% of Hispanic Americans (odds ratio, 2.79) and 86.4% of Native Americans. African Americans more commonly had stage III or IV disease at diagnosis (77.8% vs. 35.3%; odds ratio, 6.51), but the racial/ethnic groups did not differ significantly on grade, tumor size, or presence of necrosis.

Among the Hispanic American patients undergoing radical nephrectomy, disease was more commonly of stage III or IV at diagnosis in those who were aged 65 or older (odds ratio, 10.48) and those who spoke Spanish as their primary language (odds ratios, 4.61).

The reasons for the observed racial/ethnic disparities remain unclear, according to Dr. Batai and his coinvestigators. Nonetheless, “it is necessary to better understand the clinical characteristics of these underserved Hispanic American and Native American populations with high kidney cancer burden,” they wrote.

“Our findings can direct future research toward elucidating the difference in tumor behavior among the different ethnic groups and health care issues causing poor outcomes,” they concluded. The findings also “bring ... awareness to practitioners treating patients from these racial/ethnic minority groups regarding the clinical characteristics and underlying issues in these patient populations.”

The study was supported by the American Cancer Society and the Partnership for Native American Cancer Prevention.

SOURCE: Batai K et al. Clin Genitourin Cancer. 2018 Oct 26. doi: 10.1016/j.clgc.2018.10.012.

NEW YORK – A bee-derived supplement known to have anti-inflammatory properties showed promise in potentiating the effect of levodopa in a rodent model of Parkinson’s disease, with biochemical and behavioral improvements seen that exceeded high-dose levodopa alone.

Levodopa (L-dopa) has long been a keystone in treatment for individuals with Parkinson’s disease (PD). However, its effectiveness wanes with time and long-term use is associated with significant undesirable side effects, including dyskinesias.

A dopamine precursor, L-dopa, once converted to dopamine, replaces the dopamine no longer made by the substantia nigra. Increasingly, neuroinflammation and oxidative stress are felt to play a role in the natural history of PD, said Azza Ali, PhD, who presented the findings at a poster session of the International Conference on Parkinson’s Disease and Movement Disorders. Whether mitigating these effects can alter the disease course for individuals with PD has not been well investigated, she added.

Dr. Ali and her research group at Al-Azhar University, Cairo, Egypt, where she heads the department of pharmacology and toxicology, are investigating several nutritional and supplement strategies to dampen inflammation. Among the substances she and her colleagues are investigating is propolis, a plant-derived product produced by bees and distinct from honey or beeswax.

Propolis has been shown to have antioxidant properties in addition to other reported health benefits.

Dr. Ali and her colleagues used a rodent model for PD: Rats were dosed with rotenone, which is known to induce a histologically verifiable parkinsonian syndrome. The investigators used six groups of rats; one group was the normal control, while the others all had rotenone-induced parkinsonism.

Of the remaining groups, one rotenone-dosed group was given neither L-dopa nor propolis. Two groups were treated with oral L-dopa alone, at 10 or 25 mg/kg per day. Another group was given an oral dose of 300 mg/kg per day of propolis, and the last group received propolis at that dose while also receiving the lower dose of L-dopa.

All groups were subject to behavioral assessments including a swim test, an open field test, a maze test, and other tasks designed to assess motor function and other aspects of behavior. Additionally, Dr. Ali and her collaborators assessed a variety of biochemical parameters that looked at oxidative stress and neuroinflammation in all rodent groups.

For most parameters, the rotenone-dosed rats that showed results most like normal controls were those who received both low-dose L-dopa and propolis. In particular, the rats receiving both L-dopa and propolis outperformed the other rotenone groups in the behavioral open field test and a grid test, where their performance neared the control group.

Levels of interleukin-1 beta fell for all treated rodents, but fell the most for those treated with the combination. Tissue dopamine levels were also lower for the rats who received combination treatment, and acetylcholinesterase and malondialdehyde levels also fell to near normal for rats receiving the combination treatment, but not for the other groups.

“Propolis is efficient in protection from PD development and represents a suitable adjuvant therapy, which can be translated to serious reduction of the long-term therapy side effects of the mainstay drug L-dopa,” wrote Dr. Ali and her coauthors. “Consequently, propolis could be recommended as a disease-modifying therapy of PD as well as a promising adjunct therapy with L-dopa especially when given early in the treatment course.”
 

[email protected]

NEW YORK – A bee-derived supplement known to have anti-inflammatory properties showed promise in potentiating the effect of levodopa in a rodent model of Parkinson’s disease, with biochemical and behavioral improvements seen that exceeded high-dose levodopa alone.

Levodopa (L-dopa) has long been a keystone in treatment for individuals with Parkinson’s disease (PD). However, its effectiveness wanes with time and long-term use is associated with significant undesirable side effects, including dyskinesias.

A dopamine precursor, L-dopa, once converted to dopamine, replaces the dopamine no longer made by the substantia nigra. Increasingly, neuroinflammation and oxidative stress are felt to play a role in the natural history of PD, said Azza Ali, PhD, who presented the findings at a poster session of the International Conference on Parkinson’s Disease and Movement Disorders. Whether mitigating these effects can alter the disease course for individuals with PD has not been well investigated, she added.

Dr. Ali and her research group at Al-Azhar University, Cairo, Egypt, where she heads the department of pharmacology and toxicology, are investigating several nutritional and supplement strategies to dampen inflammation. Among the substances she and her colleagues are investigating is propolis, a plant-derived product produced by bees and distinct from honey or beeswax.

Propolis has been shown to have antioxidant properties in addition to other reported health benefits.

Dr. Ali and her colleagues used a rodent model for PD: Rats were dosed with rotenone, which is known to induce a histologically verifiable parkinsonian syndrome. The investigators used six groups of rats; one group was the normal control, while the others all had rotenone-induced parkinsonism.

Of the remaining groups, one rotenone-dosed group was given neither L-dopa nor propolis. Two groups were treated with oral L-dopa alone, at 10 or 25 mg/kg per day. Another group was given an oral dose of 300 mg/kg per day of propolis, and the last group received propolis at that dose while also receiving the lower dose of L-dopa.

All groups were subject to behavioral assessments including a swim test, an open field test, a maze test, and other tasks designed to assess motor function and other aspects of behavior. Additionally, Dr. Ali and her collaborators assessed a variety of biochemical parameters that looked at oxidative stress and neuroinflammation in all rodent groups.

For most parameters, the rotenone-dosed rats that showed results most like normal controls were those who received both low-dose L-dopa and propolis. In particular, the rats receiving both L-dopa and propolis outperformed the other rotenone groups in the behavioral open field test and a grid test, where their performance neared the control group.

Levels of interleukin-1 beta fell for all treated rodents, but fell the most for those treated with the combination. Tissue dopamine levels were also lower for the rats who received combination treatment, and acetylcholinesterase and malondialdehyde levels also fell to near normal for rats receiving the combination treatment, but not for the other groups.

“Propolis is efficient in protection from PD development and represents a suitable adjuvant therapy, which can be translated to serious reduction of the long-term therapy side effects of the mainstay drug L-dopa,” wrote Dr. Ali and her coauthors. “Consequently, propolis could be recommended as a disease-modifying therapy of PD as well as a promising adjunct therapy with L-dopa especially when given early in the treatment course.”
 

[email protected]

NEW YORK – A bee-derived supplement known to have anti-inflammatory properties showed promise in potentiating the effect of levodopa in a rodent model of Parkinson’s disease, with biochemical and behavioral improvements seen that exceeded high-dose levodopa alone.

Levodopa (L-dopa) has long been a keystone in treatment for individuals with Parkinson’s disease (PD). However, its effectiveness wanes with time and long-term use is associated with significant undesirable side effects, including dyskinesias.

A dopamine precursor, L-dopa, once converted to dopamine, replaces the dopamine no longer made by the substantia nigra. Increasingly, neuroinflammation and oxidative stress are felt to play a role in the natural history of PD, said Azza Ali, PhD, who presented the findings at a poster session of the International Conference on Parkinson’s Disease and Movement Disorders. Whether mitigating these effects can alter the disease course for individuals with PD has not been well investigated, she added.

Dr. Ali and her research group at Al-Azhar University, Cairo, Egypt, where she heads the department of pharmacology and toxicology, are investigating several nutritional and supplement strategies to dampen inflammation. Among the substances she and her colleagues are investigating is propolis, a plant-derived product produced by bees and distinct from honey or beeswax.

Propolis has been shown to have antioxidant properties in addition to other reported health benefits.

Dr. Ali and her colleagues used a rodent model for PD: Rats were dosed with rotenone, which is known to induce a histologically verifiable parkinsonian syndrome. The investigators used six groups of rats; one group was the normal control, while the others all had rotenone-induced parkinsonism.

Of the remaining groups, one rotenone-dosed group was given neither L-dopa nor propolis. Two groups were treated with oral L-dopa alone, at 10 or 25 mg/kg per day. Another group was given an oral dose of 300 mg/kg per day of propolis, and the last group received propolis at that dose while also receiving the lower dose of L-dopa.

All groups were subject to behavioral assessments including a swim test, an open field test, a maze test, and other tasks designed to assess motor function and other aspects of behavior. Additionally, Dr. Ali and her collaborators assessed a variety of biochemical parameters that looked at oxidative stress and neuroinflammation in all rodent groups.

For most parameters, the rotenone-dosed rats that showed results most like normal controls were those who received both low-dose L-dopa and propolis. In particular, the rats receiving both L-dopa and propolis outperformed the other rotenone groups in the behavioral open field test and a grid test, where their performance neared the control group.

Levels of interleukin-1 beta fell for all treated rodents, but fell the most for those treated with the combination. Tissue dopamine levels were also lower for the rats who received combination treatment, and acetylcholinesterase and malondialdehyde levels also fell to near normal for rats receiving the combination treatment, but not for the other groups.

“Propolis is efficient in protection from PD development and represents a suitable adjuvant therapy, which can be translated to serious reduction of the long-term therapy side effects of the mainstay drug L-dopa,” wrote Dr. Ali and her coauthors. “Consequently, propolis could be recommended as a disease-modifying therapy of PD as well as a promising adjunct therapy with L-dopa especially when given early in the treatment course.”
 

[email protected]

A new flier on diabetes and vascular disease is now available in English and Spanish as an instant download. This is the second new flier produced by the SVS Foundation as part of its awareness and prevention mission. Please download and share this important information. It’s a good opportunity to remind your patients of the effects of diabetes on their vascular system. We are offering two versions of PDFs on which you can easily type your office contact information. As you share with other physician referrers and your patients, also send them to our Diabetes Information page, where physicians can find the latest vascular and diabetes research, and patients can find useful health information.

A new flier on diabetes and vascular disease is now available in English and Spanish as an instant download. This is the second new flier produced by the SVS Foundation as part of its awareness and prevention mission. Please download and share this important information. It’s a good opportunity to remind your patients of the effects of diabetes on their vascular system. We are offering two versions of PDFs on which you can easily type your office contact information. As you share with other physician referrers and your patients, also send them to our Diabetes Information page, where physicians can find the latest vascular and diabetes research, and patients can find useful health information.

A new flier on diabetes and vascular disease is now available in English and Spanish as an instant download. This is the second new flier produced by the SVS Foundation as part of its awareness and prevention mission. Please download and share this important information. It’s a good opportunity to remind your patients of the effects of diabetes on their vascular system. We are offering two versions of PDFs on which you can easily type your office contact information. As you share with other physician referrers and your patients, also send them to our Diabetes Information page, where physicians can find the latest vascular and diabetes research, and patients can find useful health information.

NEW YORK – Preclinical studies have shown the natural supplements vinpocetine and pomegranate, along with vitamin B complex and vitamin E, may have some effect individually in providing neuroprotection in Parkinson’s disease, but may have a more profound effect when used in combination, a researcher from Egypt reported at the International Conference on Parkinson’s Disease and Movement Disorders.

“We need to carry out a clinical trial to ensure that this multiple direct strategy can provide protection in different stages of neurodegenerative disease – during induction and even during the progression of the disease,” said Azza Ali, PhD, of Al-Azhar University, Cairo. She presented a poster of her research in an unspecified number of rats with manganese-induced Parkinsonian symptoms. The goal of the study was to compare the oral supplements to each other and to evaluate their impact in combinations. Excessive levels of manganese have been associated with movement disorders similar to Parkinson’s disease.

The research involved histologic studies to evaluate the impact of the supplements in the brains, and evaluated biochemical, neuroinflammatory, apoptotic, and oxidative markers. Behavioral tests evaluated cognition, memory, and motor skills.

Histological studies of manganese-induced brains exhibited nuclear pyknosis – clumping of chromosomes, excessive chromatic aberrations, and shrinkage of the nucleus – in the neurons of the cerebral cortex as well as in some areas of the hippocampus, although no alteration was seen in the subiculum, Dr. Ali reported. The stria showed multiple plaque formations with nuclear pyknosis and degeneration in some neurons.

All the studied treatments improved motor, memory, and cognitive decline induced by manganese, with pomegranate and vinpocetine yielding the best results, Dr. Ali said. However, a combination of treatments showed more pronounced improvements in some biochemical markers, as well as the neuroinflammatory, apoptotic, and oxidative markers. “They have a high antioxidant and antiapoptotic effect,” Dr. Ali said. Histopathologic studies confirmed those results, she noted.

Pomegranate (150 mg/kg) had a somewhat positive effect in the subiculum and fascia dentate areas of the hippocampus, although the stria appeared similar to manganese-induced brains. With vinpocetine (20 mg/kg), neurons in the cerebral cortex showed intact histological structure with some degeneration and nuclear pyknosis in the subiculum. There was no alteration in the neurons of the fascia dentate, hilus, and stria of the hippocampus.

Histologic studies of induced brains after treatment with vitamin-B complex (8.5 mg/kg) showed nuclear pyknosis and degeneration in the neurons of the cerebral cortex and hippocampus, including the subiculum. The stria also showed multiple focal eosinophilic plaques with nuclear pyknosis and degeneration in some neurons. Vitamin E (100 mg/kg) resulted in intact neurons in the cerebral cortex but not in the hippocampus.

Histopathologic studies of brains that received combination treatment showed no alteration in the neurons of the cerebral cortex or in the subiculum and fascia dentate of the hippocampus, although a few neurons in the stria showed nuclear pyknosis and degeneration, Dr. Ali said.

She had no financial relationships to disclose.

NEW YORK – Preclinical studies have shown the natural supplements vinpocetine and pomegranate, along with vitamin B complex and vitamin E, may have some effect individually in providing neuroprotection in Parkinson’s disease, but may have a more profound effect when used in combination, a researcher from Egypt reported at the International Conference on Parkinson’s Disease and Movement Disorders.

“We need to carry out a clinical trial to ensure that this multiple direct strategy can provide protection in different stages of neurodegenerative disease – during induction and even during the progression of the disease,” said Azza Ali, PhD, of Al-Azhar University, Cairo. She presented a poster of her research in an unspecified number of rats with manganese-induced Parkinsonian symptoms. The goal of the study was to compare the oral supplements to each other and to evaluate their impact in combinations. Excessive levels of manganese have been associated with movement disorders similar to Parkinson’s disease.

The research involved histologic studies to evaluate the impact of the supplements in the brains, and evaluated biochemical, neuroinflammatory, apoptotic, and oxidative markers. Behavioral tests evaluated cognition, memory, and motor skills.

Histological studies of manganese-induced brains exhibited nuclear pyknosis – clumping of chromosomes, excessive chromatic aberrations, and shrinkage of the nucleus – in the neurons of the cerebral cortex as well as in some areas of the hippocampus, although no alteration was seen in the subiculum, Dr. Ali reported. The stria showed multiple plaque formations with nuclear pyknosis and degeneration in some neurons.

All the studied treatments improved motor, memory, and cognitive decline induced by manganese, with pomegranate and vinpocetine yielding the best results, Dr. Ali said. However, a combination of treatments showed more pronounced improvements in some biochemical markers, as well as the neuroinflammatory, apoptotic, and oxidative markers. “They have a high antioxidant and antiapoptotic effect,” Dr. Ali said. Histopathologic studies confirmed those results, she noted.

Pomegranate (150 mg/kg) had a somewhat positive effect in the subiculum and fascia dentate areas of the hippocampus, although the stria appeared similar to manganese-induced brains. With vinpocetine (20 mg/kg), neurons in the cerebral cortex showed intact histological structure with some degeneration and nuclear pyknosis in the subiculum. There was no alteration in the neurons of the fascia dentate, hilus, and stria of the hippocampus.

Histologic studies of induced brains after treatment with vitamin-B complex (8.5 mg/kg) showed nuclear pyknosis and degeneration in the neurons of the cerebral cortex and hippocampus, including the subiculum. The stria also showed multiple focal eosinophilic plaques with nuclear pyknosis and degeneration in some neurons. Vitamin E (100 mg/kg) resulted in intact neurons in the cerebral cortex but not in the hippocampus.

Histopathologic studies of brains that received combination treatment showed no alteration in the neurons of the cerebral cortex or in the subiculum and fascia dentate of the hippocampus, although a few neurons in the stria showed nuclear pyknosis and degeneration, Dr. Ali said.

She had no financial relationships to disclose.

NEW YORK – Preclinical studies have shown the natural supplements vinpocetine and pomegranate, along with vitamin B complex and vitamin E, may have some effect individually in providing neuroprotection in Parkinson’s disease, but may have a more profound effect when used in combination, a researcher from Egypt reported at the International Conference on Parkinson’s Disease and Movement Disorders.

“We need to carry out a clinical trial to ensure that this multiple direct strategy can provide protection in different stages of neurodegenerative disease – during induction and even during the progression of the disease,” said Azza Ali, PhD, of Al-Azhar University, Cairo. She presented a poster of her research in an unspecified number of rats with manganese-induced Parkinsonian symptoms. The goal of the study was to compare the oral supplements to each other and to evaluate their impact in combinations. Excessive levels of manganese have been associated with movement disorders similar to Parkinson’s disease.

The research involved histologic studies to evaluate the impact of the supplements in the brains, and evaluated biochemical, neuroinflammatory, apoptotic, and oxidative markers. Behavioral tests evaluated cognition, memory, and motor skills.

Histological studies of manganese-induced brains exhibited nuclear pyknosis – clumping of chromosomes, excessive chromatic aberrations, and shrinkage of the nucleus – in the neurons of the cerebral cortex as well as in some areas of the hippocampus, although no alteration was seen in the subiculum, Dr. Ali reported. The stria showed multiple plaque formations with nuclear pyknosis and degeneration in some neurons.

All the studied treatments improved motor, memory, and cognitive decline induced by manganese, with pomegranate and vinpocetine yielding the best results, Dr. Ali said. However, a combination of treatments showed more pronounced improvements in some biochemical markers, as well as the neuroinflammatory, apoptotic, and oxidative markers. “They have a high antioxidant and antiapoptotic effect,” Dr. Ali said. Histopathologic studies confirmed those results, she noted.

Pomegranate (150 mg/kg) had a somewhat positive effect in the subiculum and fascia dentate areas of the hippocampus, although the stria appeared similar to manganese-induced brains. With vinpocetine (20 mg/kg), neurons in the cerebral cortex showed intact histological structure with some degeneration and nuclear pyknosis in the subiculum. There was no alteration in the neurons of the fascia dentate, hilus, and stria of the hippocampus.

Histologic studies of induced brains after treatment with vitamin-B complex (8.5 mg/kg) showed nuclear pyknosis and degeneration in the neurons of the cerebral cortex and hippocampus, including the subiculum. The stria also showed multiple focal eosinophilic plaques with nuclear pyknosis and degeneration in some neurons. Vitamin E (100 mg/kg) resulted in intact neurons in the cerebral cortex but not in the hippocampus.

Histopathologic studies of brains that received combination treatment showed no alteration in the neurons of the cerebral cortex or in the subiculum and fascia dentate of the hippocampus, although a few neurons in the stria showed nuclear pyknosis and degeneration, Dr. Ali said.

She had no financial relationships to disclose.

SAN ANTONIO – Playing harmonica can improve breathing control and self confidence in people with COPD while also boosting their quality of life, suggest the findings from a small pilot study.

Tara Haelle/MDedge News

Three months of playing the harmonica about a half hour a day most days of the week led to several improved pulmonary outcome measures in participants, Mary Hart, RRT, MS, of Baylor Scott & White Health in Dallas, reported at the annual meeting of the American College of Chest Physicians.

Ms. Hart played a bit of harmonica during her presentation to demonstrate how playing can help with breathing.

“The harder I push with my diaphragm, the louder I was blowing,” she told attendees. “There’s actually a different amount of effort that you have to use to create sounds with using the harmonica notes.”

Hart said her team found a news article from 1999 about the benefits of playing harmonica, and they became interested in exploring whether it might be a helpful adjunct to respiratory therapy.

Though some previous research has explored potential benefits of harmonica playing in patients with lung disease, one study was too short to demonstrate significant improvement and the other looked at multiple different pulmonary conditions, Ms. Hart said.

The cohort study began with 14 former smokers, average age 72 years, who had completed pulmonary rehabilitation at least 6 months prior to joining the “Harmaniacs,” as the group eventually called themselves.

All participants received a harmonica, an instruction booklet with audio and video supplements, and sheet music for a harmonica in the key of C.

They attended a 2-hour group session once a week with a respiratory therapist and music therapist. The classes focused initially on breathing and relaxation techniques, pacing, and basic harmonica instruction, but the amount of actual playing time increased as the 12-week course went on. Participants were expected to practice their playing for at least a half hour 5 days a week at home.

The group began with the songs “Taps” and “Happy Birthday” because these songs were easy to play. Then they added a song each week, such as “America the Beautiful” and “You Are My Sunshine,” then seasonal favorites such as “We Wish You a Merry Christmas” and “Silent Night,” and easy pop tunes.

The researchers measured both respiratory and quality of life outcomes. Assessments included spirometry, the Six Minute Walk Test, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), the COPD Assessment Test, the modified Medical Research Council Dyspnea Scale, the Patient Health Questionnaire for depression, the St. George’s Respiratory Questionnaire for quality of life, perceived exertion using the Borg scale and assessments by the respiratory therapist and music therapist.

The music therapist listened to and documented participants’ “stories about how they felt about life living with COPD,” and Ms. Hart and her colleagues conducted a respiratory assessment that included data on medication management, adherence to medication, previous hospitalizations and length of stay, perceived shortness of breath, and daily living activities.

In addition to those assessments, the researchers collected data on the length of practice sessions, Borg scores before and after playing, the percentage of time taken for participation in class, the participants’ ability to make a sound, their challenges and triumphs, their tiredness and/or soreness after playing, and the number of people who continued playing after training.

Among the 11 participants who completed the training and all evaluations, the MIP increased by an average 15.36 cmH₂0 (P = .0017), and their MEP increased by an average 14.36 cmH₂0 (P = .0061).

Participants increased their distance in the Six Minute Walk Test by an average 60.55 meters (P = .0280), and Ms. Hart reported an improvement in quality of life scores.

In addition to home practice, participants were expected to keep a daily log of how it felt to play and what their biggest challenges and rewards were. The comments they wrote revealed benefits that sometimes surprised even the researchers:

“I can do laundry now.”

“I am more confident.”

“It is relaxing.”

“I want to keep playing forever.”

“It helps me cough up phlegm.”

“I lose track of time and enjoy my playing.”

“I played Happy Birthday at a party for my friend.”

Others express their difficulties as well, such as one person who wrote of being “really frustrated” and another who claimed to “have a hard time playing just one note.”

But the players learned to play as a group as well, even ordering T-shirts for themselves to give concerts. The group now has about 30 songs in its repertoire, Ms. Hart said, and they recently gave a 2-hour concert during which they played all 30 songs twice.

One consistent theme that emerged, Ms. Hart said, was improved control of breathing since playing the harmonica required participants to purse their lips (similar to the way needed for expiratory maneuvers), breathe from their diaphragms, and pace themselves. Playing exercised “the muscles that help pull air in and push air out of the lungs,” Ms. Hart said, and strengthened participants’ abdominal muscles, allowing more effective coughing.

Playing harmonica also increased self-confidence. It provided stress relief for some, and others simply found it fun or enjoyed the socializing opportunities.

The study’s small size and lack of a control group limit the generalizability of its findings.

Baylor Scott & White Central Texas Foundation funded the research. Ms. Hart reported no conflicts of interest.

SOURCE: Hart M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.669.

SAN ANTONIO – Playing harmonica can improve breathing control and self confidence in people with COPD while also boosting their quality of life, suggest the findings from a small pilot study.

Tara Haelle/MDedge News

Three months of playing the harmonica about a half hour a day most days of the week led to several improved pulmonary outcome measures in participants, Mary Hart, RRT, MS, of Baylor Scott & White Health in Dallas, reported at the annual meeting of the American College of Chest Physicians.

Ms. Hart played a bit of harmonica during her presentation to demonstrate how playing can help with breathing.

“The harder I push with my diaphragm, the louder I was blowing,” she told attendees. “There’s actually a different amount of effort that you have to use to create sounds with using the harmonica notes.”

Hart said her team found a news article from 1999 about the benefits of playing harmonica, and they became interested in exploring whether it might be a helpful adjunct to respiratory therapy.

Though some previous research has explored potential benefits of harmonica playing in patients with lung disease, one study was too short to demonstrate significant improvement and the other looked at multiple different pulmonary conditions, Ms. Hart said.

The cohort study began with 14 former smokers, average age 72 years, who had completed pulmonary rehabilitation at least 6 months prior to joining the “Harmaniacs,” as the group eventually called themselves.

All participants received a harmonica, an instruction booklet with audio and video supplements, and sheet music for a harmonica in the key of C.

They attended a 2-hour group session once a week with a respiratory therapist and music therapist. The classes focused initially on breathing and relaxation techniques, pacing, and basic harmonica instruction, but the amount of actual playing time increased as the 12-week course went on. Participants were expected to practice their playing for at least a half hour 5 days a week at home.

The group began with the songs “Taps” and “Happy Birthday” because these songs were easy to play. Then they added a song each week, such as “America the Beautiful” and “You Are My Sunshine,” then seasonal favorites such as “We Wish You a Merry Christmas” and “Silent Night,” and easy pop tunes.

The researchers measured both respiratory and quality of life outcomes. Assessments included spirometry, the Six Minute Walk Test, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), the COPD Assessment Test, the modified Medical Research Council Dyspnea Scale, the Patient Health Questionnaire for depression, the St. George’s Respiratory Questionnaire for quality of life, perceived exertion using the Borg scale and assessments by the respiratory therapist and music therapist.

The music therapist listened to and documented participants’ “stories about how they felt about life living with COPD,” and Ms. Hart and her colleagues conducted a respiratory assessment that included data on medication management, adherence to medication, previous hospitalizations and length of stay, perceived shortness of breath, and daily living activities.

In addition to those assessments, the researchers collected data on the length of practice sessions, Borg scores before and after playing, the percentage of time taken for participation in class, the participants’ ability to make a sound, their challenges and triumphs, their tiredness and/or soreness after playing, and the number of people who continued playing after training.

Among the 11 participants who completed the training and all evaluations, the MIP increased by an average 15.36 cmH₂0 (P = .0017), and their MEP increased by an average 14.36 cmH₂0 (P = .0061).

Participants increased their distance in the Six Minute Walk Test by an average 60.55 meters (P = .0280), and Ms. Hart reported an improvement in quality of life scores.

In addition to home practice, participants were expected to keep a daily log of how it felt to play and what their biggest challenges and rewards were. The comments they wrote revealed benefits that sometimes surprised even the researchers:

“I can do laundry now.”

“I am more confident.”

“It is relaxing.”

“I want to keep playing forever.”

“It helps me cough up phlegm.”

“I lose track of time and enjoy my playing.”

“I played Happy Birthday at a party for my friend.”

Others express their difficulties as well, such as one person who wrote of being “really frustrated” and another who claimed to “have a hard time playing just one note.”

But the players learned to play as a group as well, even ordering T-shirts for themselves to give concerts. The group now has about 30 songs in its repertoire, Ms. Hart said, and they recently gave a 2-hour concert during which they played all 30 songs twice.

One consistent theme that emerged, Ms. Hart said, was improved control of breathing since playing the harmonica required participants to purse their lips (similar to the way needed for expiratory maneuvers), breathe from their diaphragms, and pace themselves. Playing exercised “the muscles that help pull air in and push air out of the lungs,” Ms. Hart said, and strengthened participants’ abdominal muscles, allowing more effective coughing.

Playing harmonica also increased self-confidence. It provided stress relief for some, and others simply found it fun or enjoyed the socializing opportunities.

The study’s small size and lack of a control group limit the generalizability of its findings.

Baylor Scott & White Central Texas Foundation funded the research. Ms. Hart reported no conflicts of interest.

SOURCE: Hart M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.669.

SAN ANTONIO – Playing harmonica can improve breathing control and self confidence in people with COPD while also boosting their quality of life, suggest the findings from a small pilot study.

Tara Haelle/MDedge News

Three months of playing the harmonica about a half hour a day most days of the week led to several improved pulmonary outcome measures in participants, Mary Hart, RRT, MS, of Baylor Scott & White Health in Dallas, reported at the annual meeting of the American College of Chest Physicians.

Ms. Hart played a bit of harmonica during her presentation to demonstrate how playing can help with breathing.

“The harder I push with my diaphragm, the louder I was blowing,” she told attendees. “There’s actually a different amount of effort that you have to use to create sounds with using the harmonica notes.”

Hart said her team found a news article from 1999 about the benefits of playing harmonica, and they became interested in exploring whether it might be a helpful adjunct to respiratory therapy.

Though some previous research has explored potential benefits of harmonica playing in patients with lung disease, one study was too short to demonstrate significant improvement and the other looked at multiple different pulmonary conditions, Ms. Hart said.

The cohort study began with 14 former smokers, average age 72 years, who had completed pulmonary rehabilitation at least 6 months prior to joining the “Harmaniacs,” as the group eventually called themselves.

All participants received a harmonica, an instruction booklet with audio and video supplements, and sheet music for a harmonica in the key of C.

They attended a 2-hour group session once a week with a respiratory therapist and music therapist. The classes focused initially on breathing and relaxation techniques, pacing, and basic harmonica instruction, but the amount of actual playing time increased as the 12-week course went on. Participants were expected to practice their playing for at least a half hour 5 days a week at home.

The group began with the songs “Taps” and “Happy Birthday” because these songs were easy to play. Then they added a song each week, such as “America the Beautiful” and “You Are My Sunshine,” then seasonal favorites such as “We Wish You a Merry Christmas” and “Silent Night,” and easy pop tunes.

The researchers measured both respiratory and quality of life outcomes. Assessments included spirometry, the Six Minute Walk Test, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), the COPD Assessment Test, the modified Medical Research Council Dyspnea Scale, the Patient Health Questionnaire for depression, the St. George’s Respiratory Questionnaire for quality of life, perceived exertion using the Borg scale and assessments by the respiratory therapist and music therapist.

The music therapist listened to and documented participants’ “stories about how they felt about life living with COPD,” and Ms. Hart and her colleagues conducted a respiratory assessment that included data on medication management, adherence to medication, previous hospitalizations and length of stay, perceived shortness of breath, and daily living activities.

In addition to those assessments, the researchers collected data on the length of practice sessions, Borg scores before and after playing, the percentage of time taken for participation in class, the participants’ ability to make a sound, their challenges and triumphs, their tiredness and/or soreness after playing, and the number of people who continued playing after training.

Among the 11 participants who completed the training and all evaluations, the MIP increased by an average 15.36 cmH₂0 (P = .0017), and their MEP increased by an average 14.36 cmH₂0 (P = .0061).

Participants increased their distance in the Six Minute Walk Test by an average 60.55 meters (P = .0280), and Ms. Hart reported an improvement in quality of life scores.

In addition to home practice, participants were expected to keep a daily log of how it felt to play and what their biggest challenges and rewards were. The comments they wrote revealed benefits that sometimes surprised even the researchers:

“I can do laundry now.”

“I am more confident.”

“It is relaxing.”

“I want to keep playing forever.”

“It helps me cough up phlegm.”

“I lose track of time and enjoy my playing.”

“I played Happy Birthday at a party for my friend.”

Others express their difficulties as well, such as one person who wrote of being “really frustrated” and another who claimed to “have a hard time playing just one note.”

But the players learned to play as a group as well, even ordering T-shirts for themselves to give concerts. The group now has about 30 songs in its repertoire, Ms. Hart said, and they recently gave a 2-hour concert during which they played all 30 songs twice.

One consistent theme that emerged, Ms. Hart said, was improved control of breathing since playing the harmonica required participants to purse their lips (similar to the way needed for expiratory maneuvers), breathe from their diaphragms, and pace themselves. Playing exercised “the muscles that help pull air in and push air out of the lungs,” Ms. Hart said, and strengthened participants’ abdominal muscles, allowing more effective coughing.

Playing harmonica also increased self-confidence. It provided stress relief for some, and others simply found it fun or enjoyed the socializing opportunities.

The study’s small size and lack of a control group limit the generalizability of its findings.

Baylor Scott & White Central Texas Foundation funded the research. Ms. Hart reported no conflicts of interest.

SOURCE: Hart M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.669.