WASHINGTON, DC—Smartphone videos may help to support the clinical diagnosis of psychogenic nonepileptic seizures (PNES), according to research presented at the 71st Annual Meeting of the American Epilepsy Society. However, smartphone videos do not replace the need for video-EEG monitoring, researchers noted. “Smartphone videos are a complementary addition to medical history and physical examinations in the outpatient epilepsy clinic and can help triage hospital admission for video EEG-monitoring,” said William O. Tatum, DO, Professor of Neurology at the Mayo Clinic College of Medicine in Jacksonville, Florida, and colleagues. “Most patients bringing smart videos to the clinic are ultimately diagnosed with PNES and nearly 70% are women.”

Video-EEG monitoring is the standard technique for a definitive diagnosis in patients with suspected seizures. Approximately 20% to 30% of patients admitted to the video-EEG monitoring unit are misdiagnosed with epilepsy, however. In addition, expertise availability, cost, and resource utilization of video-EEG monitoring is limited. Patient-generated videos can potentially address these limitations.

A Multicenter Blinded Trial

Dr. Tatum and colleagues conducted a prospective, multicenter, blinded trial to determine the usefulness of outpatient smartphone videos in epilepsy evaluation. Investigators evaluated 41 consecutive patients with uncontrolled seizures (13 participants were male; mean age was 43.7). Patients were excluded if they were younger than 18, had an incomplete medical history and physical examination, had an atypical event, had an inadequate smartphone video, had an unconfirmed video-EEG monitoring diagnosis, or if they did not consent.

Medical history and physical examinations, smartphone videos, and video-EEG monitoring were performed from July 2014 to November 2017. Treating physicians reached a final clinical diagnosis of epilepsy, PNES, or physiologic non-epileptic events using a degree of certainty (scale: 0–10). Ten epileptologists and eight general neurology residents without a special interest in epilepsy were surveyed for a blinded smartphone video diagnosis.

Researchers shared data via HIPPA-protected data transfer utilizing web-based software. The history and physical exams, smartphone videos, and video-EEG monitoring results were obtained using survey forms and were then compared. Finally, sensitivity, specificity, and positive and negative predictive values were analyzed.

Most Smartphone Videos Showed Nonconvulsive Seizures

Epileptologists performed 310 smartphone video reads and residents performed 230 smartphone video reads. Smartphone videos were reviewed in 2.15 minutes compared with 60 minutes for medical history and physicals and 2.54 days for video-EEG monitoring. Most semiology was convulsive and most epilepsy was nonconvulsive. Physicians made a final diagnosis of PNES in 26 patients, epilepsy in 11 patients, physiologic non-epileptic events in three patients, and a PNES with physiologic non-epileptic events in one patient. Medical history and physical examination predicted a definitive diagnosis by video-EEG monitoring in 31 patients.

The median correct response for a smart phone video was 71.4% for epileptologists and 66.7% for residents. The level of confidence was similar between experts and residents, but those who made a correct diagnosis were slightly more confident. Using a level of confidence of at least five, 78% of epileptologists provided correct identification versus 68% of residents. “This suggests that a gap exists in training relative to viewing semiology for diagnostic implications and supports the ongoing need for education in patients with ’events‘”, said Dr. Tatum and colleagues.

The overall quality of smartphone videos was considered adequate for interpretation in 78% of patients. Inter-subject differences were present mainly based upon technical limitations as opposed to video quality. The primary technical limitation was lack of focus on the area of the interest. Researchers concluded that the “secure uploading, exchange, and analysis of smartphone video data in patients with paroxysmal neurological events is feasible.” No safety concerns or complications of taking smartphone videos were reported.

—Erica Tricarico

WASHINGTON, DC—Smartphone videos may help to support the clinical diagnosis of psychogenic nonepileptic seizures (PNES), according to research presented at the 71st Annual Meeting of the American Epilepsy Society. However, smartphone videos do not replace the need for video-EEG monitoring, researchers noted. “Smartphone videos are a complementary addition to medical history and physical examinations in the outpatient epilepsy clinic and can help triage hospital admission for video EEG-monitoring,” said William O. Tatum, DO, Professor of Neurology at the Mayo Clinic College of Medicine in Jacksonville, Florida, and colleagues. “Most patients bringing smart videos to the clinic are ultimately diagnosed with PNES and nearly 70% are women.”

Video-EEG monitoring is the standard technique for a definitive diagnosis in patients with suspected seizures. Approximately 20% to 30% of patients admitted to the video-EEG monitoring unit are misdiagnosed with epilepsy, however. In addition, expertise availability, cost, and resource utilization of video-EEG monitoring is limited. Patient-generated videos can potentially address these limitations.

A Multicenter Blinded Trial

Dr. Tatum and colleagues conducted a prospective, multicenter, blinded trial to determine the usefulness of outpatient smartphone videos in epilepsy evaluation. Investigators evaluated 41 consecutive patients with uncontrolled seizures (13 participants were male; mean age was 43.7). Patients were excluded if they were younger than 18, had an incomplete medical history and physical examination, had an atypical event, had an inadequate smartphone video, had an unconfirmed video-EEG monitoring diagnosis, or if they did not consent.

Medical history and physical examinations, smartphone videos, and video-EEG monitoring were performed from July 2014 to November 2017. Treating physicians reached a final clinical diagnosis of epilepsy, PNES, or physiologic non-epileptic events using a degree of certainty (scale: 0–10). Ten epileptologists and eight general neurology residents without a special interest in epilepsy were surveyed for a blinded smartphone video diagnosis.

Researchers shared data via HIPPA-protected data transfer utilizing web-based software. The history and physical exams, smartphone videos, and video-EEG monitoring results were obtained using survey forms and were then compared. Finally, sensitivity, specificity, and positive and negative predictive values were analyzed.

Most Smartphone Videos Showed Nonconvulsive Seizures

Epileptologists performed 310 smartphone video reads and residents performed 230 smartphone video reads. Smartphone videos were reviewed in 2.15 minutes compared with 60 minutes for medical history and physicals and 2.54 days for video-EEG monitoring. Most semiology was convulsive and most epilepsy was nonconvulsive. Physicians made a final diagnosis of PNES in 26 patients, epilepsy in 11 patients, physiologic non-epileptic events in three patients, and a PNES with physiologic non-epileptic events in one patient. Medical history and physical examination predicted a definitive diagnosis by video-EEG monitoring in 31 patients.

The median correct response for a smart phone video was 71.4% for epileptologists and 66.7% for residents. The level of confidence was similar between experts and residents, but those who made a correct diagnosis were slightly more confident. Using a level of confidence of at least five, 78% of epileptologists provided correct identification versus 68% of residents. “This suggests that a gap exists in training relative to viewing semiology for diagnostic implications and supports the ongoing need for education in patients with ’events‘”, said Dr. Tatum and colleagues.

The overall quality of smartphone videos was considered adequate for interpretation in 78% of patients. Inter-subject differences were present mainly based upon technical limitations as opposed to video quality. The primary technical limitation was lack of focus on the area of the interest. Researchers concluded that the “secure uploading, exchange, and analysis of smartphone video data in patients with paroxysmal neurological events is feasible.” No safety concerns or complications of taking smartphone videos were reported.

—Erica Tricarico

WASHINGTON, DC—Smartphone videos may help to support the clinical diagnosis of psychogenic nonepileptic seizures (PNES), according to research presented at the 71st Annual Meeting of the American Epilepsy Society. However, smartphone videos do not replace the need for video-EEG monitoring, researchers noted. “Smartphone videos are a complementary addition to medical history and physical examinations in the outpatient epilepsy clinic and can help triage hospital admission for video EEG-monitoring,” said William O. Tatum, DO, Professor of Neurology at the Mayo Clinic College of Medicine in Jacksonville, Florida, and colleagues. “Most patients bringing smart videos to the clinic are ultimately diagnosed with PNES and nearly 70% are women.”

Video-EEG monitoring is the standard technique for a definitive diagnosis in patients with suspected seizures. Approximately 20% to 30% of patients admitted to the video-EEG monitoring unit are misdiagnosed with epilepsy, however. In addition, expertise availability, cost, and resource utilization of video-EEG monitoring is limited. Patient-generated videos can potentially address these limitations.

A Multicenter Blinded Trial

Dr. Tatum and colleagues conducted a prospective, multicenter, blinded trial to determine the usefulness of outpatient smartphone videos in epilepsy evaluation. Investigators evaluated 41 consecutive patients with uncontrolled seizures (13 participants were male; mean age was 43.7). Patients were excluded if they were younger than 18, had an incomplete medical history and physical examination, had an atypical event, had an inadequate smartphone video, had an unconfirmed video-EEG monitoring diagnosis, or if they did not consent.

Medical history and physical examinations, smartphone videos, and video-EEG monitoring were performed from July 2014 to November 2017. Treating physicians reached a final clinical diagnosis of epilepsy, PNES, or physiologic non-epileptic events using a degree of certainty (scale: 0–10). Ten epileptologists and eight general neurology residents without a special interest in epilepsy were surveyed for a blinded smartphone video diagnosis.

Researchers shared data via HIPPA-protected data transfer utilizing web-based software. The history and physical exams, smartphone videos, and video-EEG monitoring results were obtained using survey forms and were then compared. Finally, sensitivity, specificity, and positive and negative predictive values were analyzed.

Most Smartphone Videos Showed Nonconvulsive Seizures

Epileptologists performed 310 smartphone video reads and residents performed 230 smartphone video reads. Smartphone videos were reviewed in 2.15 minutes compared with 60 minutes for medical history and physicals and 2.54 days for video-EEG monitoring. Most semiology was convulsive and most epilepsy was nonconvulsive. Physicians made a final diagnosis of PNES in 26 patients, epilepsy in 11 patients, physiologic non-epileptic events in three patients, and a PNES with physiologic non-epileptic events in one patient. Medical history and physical examination predicted a definitive diagnosis by video-EEG monitoring in 31 patients.

The median correct response for a smart phone video was 71.4% for epileptologists and 66.7% for residents. The level of confidence was similar between experts and residents, but those who made a correct diagnosis were slightly more confident. Using a level of confidence of at least five, 78% of epileptologists provided correct identification versus 68% of residents. “This suggests that a gap exists in training relative to viewing semiology for diagnostic implications and supports the ongoing need for education in patients with ’events‘”, said Dr. Tatum and colleagues.

The overall quality of smartphone videos was considered adequate for interpretation in 78% of patients. Inter-subject differences were present mainly based upon technical limitations as opposed to video quality. The primary technical limitation was lack of focus on the area of the interest. Researchers concluded that the “secure uploading, exchange, and analysis of smartphone video data in patients with paroxysmal neurological events is feasible.” No safety concerns or complications of taking smartphone videos were reported.

—Erica Tricarico

Clinical trials that evaluate experimental treatment for patients with epilepsy often produce large placebo effects, but a recent database analysis suggests that what appears like a placebo effect may in fact result from the natural variability in patients’ response to treatment.

• Researchers conducted clinical trial simulations using data from sources including a large patient-managed seizure tracking diary database called SeizureTracker.com, a clinical trial that looked at transcranial magnetic stimulation, and a seizure diary dataset called NeuroVista, which tracks longitudinal intracranial monitoring.
• The analysis measured 50% responder rates and median percentage change.
• The clinical trial simulations were performed in 2 directions; it measured outcomes with time running forward and in reverse, ie, moving backwards from baseline through titration, to treatment.
• The analysis found that temporal reversal didn’t prevent large 50% responder rates, suggesting that what appears to be a placebo effect in clinical trials is in fact normal variability in the way patients respond to active treatment.

A multi-dataset time-reversal approach to clinical trial placebo response and the relationship to natural variability in epilepsy. Seizure. 2017; 53:31-36. DOI: http://dx.doi.org/10.1016/j.seizure.2017.10.016.

Clinical trials that evaluate experimental treatment for patients with epilepsy often produce large placebo effects, but a recent database analysis suggests that what appears like a placebo effect may in fact result from the natural variability in patients’ response to treatment.

• Researchers conducted clinical trial simulations using data from sources including a large patient-managed seizure tracking diary database called SeizureTracker.com, a clinical trial that looked at transcranial magnetic stimulation, and a seizure diary dataset called NeuroVista, which tracks longitudinal intracranial monitoring.
• The analysis measured 50% responder rates and median percentage change.
• The clinical trial simulations were performed in 2 directions; it measured outcomes with time running forward and in reverse, ie, moving backwards from baseline through titration, to treatment.
• The analysis found that temporal reversal didn’t prevent large 50% responder rates, suggesting that what appears to be a placebo effect in clinical trials is in fact normal variability in the way patients respond to active treatment.

A multi-dataset time-reversal approach to clinical trial placebo response and the relationship to natural variability in epilepsy. Seizure. 2017; 53:31-36. DOI: http://dx.doi.org/10.1016/j.seizure.2017.10.016.

Clinical trials that evaluate experimental treatment for patients with epilepsy often produce large placebo effects, but a recent database analysis suggests that what appears like a placebo effect may in fact result from the natural variability in patients’ response to treatment.

• Researchers conducted clinical trial simulations using data from sources including a large patient-managed seizure tracking diary database called SeizureTracker.com, a clinical trial that looked at transcranial magnetic stimulation, and a seizure diary dataset called NeuroVista, which tracks longitudinal intracranial monitoring.
• The analysis measured 50% responder rates and median percentage change.
• The clinical trial simulations were performed in 2 directions; it measured outcomes with time running forward and in reverse, ie, moving backwards from baseline through titration, to treatment.
• The analysis found that temporal reversal didn’t prevent large 50% responder rates, suggesting that what appears to be a placebo effect in clinical trials is in fact normal variability in the way patients respond to active treatment.

A multi-dataset time-reversal approach to clinical trial placebo response and the relationship to natural variability in epilepsy. Seizure. 2017; 53:31-36. DOI: http://dx.doi.org/10.1016/j.seizure.2017.10.016.

There are four factors at baseline in adults with moderately active rheumatoid arthritis that predict those who are most likely to achieve remission with full-dose combo etanercept-methotrexate (ETN-MTX) induction treatment, said Josef S. Smolen, MD, of the University of Vienna, and his associates.

The original PRESERVE study found that after 604 adults with moderately active rheumatoid arthritis achieved low disease activity after 36 weeks of full-dose etanercept (50 mg once weekly) plus methotrexate, subsequent full-dose or reduced-dose (25 mg once weekly) ETN-MTX combos were better at maintaining remission than was methotrexate alone. At the time of the original study, a Disease Activity Score in 28 joints (DAS28) less than 2.6 was considered to denote remission in practice and clinical trials; now that the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean definition of remission has been published, a DAS28 less than 2.6 no longer indicates remission according to ACR/EULAR criteria, but rather indicates minimal disease activity, the investigators explained.

This study aimed to determine predictors of remission, the researchers said in their article published in Arthritis Research & Therapy.

Those predictors at baseline are young age; body mass index less than 30 kg/m^2; lower Health Assessment Questionnaire scores; and lower disease activity – as measured by DAS28, Simplified Disease Activity Index, and Clinical Disease Activity Index.

If the predictors are favorable and the patients have an “early, strong, and durable response to induction therapy, they are most likely to experience a sustained response after biologic tapering or withdrawal,” Dr. Smolen and his associates said.

In other words, the investigators found that, the lower the residual disease activity, the greater the chance of an enduring response.

“Our findings suggest that patients who did not achieve sustained remission in the open-label period and had higher DAS28 at week 36 were more likely to lose remission with maintenance therapy in the double-blind period. Not surprisingly, patients who achieved remission at only week 36, those who sustained remission at only weeks 28 and 36, and those who sustained remission at only weeks 20, 28, and 36, were at higher risk for loss of remission than patients who sustained remission from week 12 to week 36, indicating that depth of disease control is an important predictor of remission loss,” noted Dr. Smolen and his colleagues.

This study was sponsored by Pfizer. Dr. Smolen has received research grants and consulting fees from AbbVie, Pfizer, Roche, and other biopharmaceutical companies. Several of the investigators are employees of Pfizer and hold Pfizer stock. Another author is an employee of inVentiv Health and was contracted by Pfizer to provide statistical support.

SOURCE: Smolen JS et al. Arthritis Res Ther. doi: 10.1186/s13075-017-1484-9.

There are four factors at baseline in adults with moderately active rheumatoid arthritis that predict those who are most likely to achieve remission with full-dose combo etanercept-methotrexate (ETN-MTX) induction treatment, said Josef S. Smolen, MD, of the University of Vienna, and his associates.

The original PRESERVE study found that after 604 adults with moderately active rheumatoid arthritis achieved low disease activity after 36 weeks of full-dose etanercept (50 mg once weekly) plus methotrexate, subsequent full-dose or reduced-dose (25 mg once weekly) ETN-MTX combos were better at maintaining remission than was methotrexate alone. At the time of the original study, a Disease Activity Score in 28 joints (DAS28) less than 2.6 was considered to denote remission in practice and clinical trials; now that the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean definition of remission has been published, a DAS28 less than 2.6 no longer indicates remission according to ACR/EULAR criteria, but rather indicates minimal disease activity, the investigators explained.

This study aimed to determine predictors of remission, the researchers said in their article published in Arthritis Research & Therapy.

Those predictors at baseline are young age; body mass index less than 30 kg/m^2; lower Health Assessment Questionnaire scores; and lower disease activity – as measured by DAS28, Simplified Disease Activity Index, and Clinical Disease Activity Index.

If the predictors are favorable and the patients have an “early, strong, and durable response to induction therapy, they are most likely to experience a sustained response after biologic tapering or withdrawal,” Dr. Smolen and his associates said.

In other words, the investigators found that, the lower the residual disease activity, the greater the chance of an enduring response.

“Our findings suggest that patients who did not achieve sustained remission in the open-label period and had higher DAS28 at week 36 were more likely to lose remission with maintenance therapy in the double-blind period. Not surprisingly, patients who achieved remission at only week 36, those who sustained remission at only weeks 28 and 36, and those who sustained remission at only weeks 20, 28, and 36, were at higher risk for loss of remission than patients who sustained remission from week 12 to week 36, indicating that depth of disease control is an important predictor of remission loss,” noted Dr. Smolen and his colleagues.

This study was sponsored by Pfizer. Dr. Smolen has received research grants and consulting fees from AbbVie, Pfizer, Roche, and other biopharmaceutical companies. Several of the investigators are employees of Pfizer and hold Pfizer stock. Another author is an employee of inVentiv Health and was contracted by Pfizer to provide statistical support.

SOURCE: Smolen JS et al. Arthritis Res Ther. doi: 10.1186/s13075-017-1484-9.

There are four factors at baseline in adults with moderately active rheumatoid arthritis that predict those who are most likely to achieve remission with full-dose combo etanercept-methotrexate (ETN-MTX) induction treatment, said Josef S. Smolen, MD, of the University of Vienna, and his associates.

The original PRESERVE study found that after 604 adults with moderately active rheumatoid arthritis achieved low disease activity after 36 weeks of full-dose etanercept (50 mg once weekly) plus methotrexate, subsequent full-dose or reduced-dose (25 mg once weekly) ETN-MTX combos were better at maintaining remission than was methotrexate alone. At the time of the original study, a Disease Activity Score in 28 joints (DAS28) less than 2.6 was considered to denote remission in practice and clinical trials; now that the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean definition of remission has been published, a DAS28 less than 2.6 no longer indicates remission according to ACR/EULAR criteria, but rather indicates minimal disease activity, the investigators explained.

This study aimed to determine predictors of remission, the researchers said in their article published in Arthritis Research & Therapy.

Those predictors at baseline are young age; body mass index less than 30 kg/m^2; lower Health Assessment Questionnaire scores; and lower disease activity – as measured by DAS28, Simplified Disease Activity Index, and Clinical Disease Activity Index.

If the predictors are favorable and the patients have an “early, strong, and durable response to induction therapy, they are most likely to experience a sustained response after biologic tapering or withdrawal,” Dr. Smolen and his associates said.

In other words, the investigators found that, the lower the residual disease activity, the greater the chance of an enduring response.

“Our findings suggest that patients who did not achieve sustained remission in the open-label period and had higher DAS28 at week 36 were more likely to lose remission with maintenance therapy in the double-blind period. Not surprisingly, patients who achieved remission at only week 36, those who sustained remission at only weeks 28 and 36, and those who sustained remission at only weeks 20, 28, and 36, were at higher risk for loss of remission than patients who sustained remission from week 12 to week 36, indicating that depth of disease control is an important predictor of remission loss,” noted Dr. Smolen and his colleagues.

This study was sponsored by Pfizer. Dr. Smolen has received research grants and consulting fees from AbbVie, Pfizer, Roche, and other biopharmaceutical companies. Several of the investigators are employees of Pfizer and hold Pfizer stock. Another author is an employee of inVentiv Health and was contracted by Pfizer to provide statistical support.

SOURCE: Smolen JS et al. Arthritis Res Ther. doi: 10.1186/s13075-017-1484-9.

Ictal electroencephalography (EEG) does not appear to help determine the best approach to surgery in pediatric patients if magnetic resonance imaging (MRI) findings and other presurgical data have pinpointed the epileptogenic focus, according to retrospective analysis that included 115 children.

• Investigators looked at children with epilepsy who had surgical resection based on a lesion that was identified by MRI and corroborated by other presurgical findings.
• Ictal video EEG findings were divided into 2 groups; ictal EEG findings were labeled “positive” if the identified location of the lesion agreed with the location indicated by the MRI, or “negative” if results were discordant with the MRI findings.
• The analysis found no differences in seizure-free outcomes when negative and positive EEGs were compared.
• A positive ictal EEG was not linked with better clinical outcomes regardless of the surgical site or the pathology of the lesion.
• EEGs had limited predictive value, which prompted researchers to question whether they are worth doing if MRI findings and related presurgical data confirm the location of the epileptogenic site.

MRI supersedes ictal EEG when other presurgical data are concordant. Seizure. 2017; 53:18-22. DOI: http://dx.doi.org/10.1016/j.seizure.2017.10.013.

Ictal electroencephalography (EEG) does not appear to help determine the best approach to surgery in pediatric patients if magnetic resonance imaging (MRI) findings and other presurgical data have pinpointed the epileptogenic focus, according to retrospective analysis that included 115 children.

• Investigators looked at children with epilepsy who had surgical resection based on a lesion that was identified by MRI and corroborated by other presurgical findings.
• Ictal video EEG findings were divided into 2 groups; ictal EEG findings were labeled “positive” if the identified location of the lesion agreed with the location indicated by the MRI, or “negative” if results were discordant with the MRI findings.
• The analysis found no differences in seizure-free outcomes when negative and positive EEGs were compared.
• A positive ictal EEG was not linked with better clinical outcomes regardless of the surgical site or the pathology of the lesion.
• EEGs had limited predictive value, which prompted researchers to question whether they are worth doing if MRI findings and related presurgical data confirm the location of the epileptogenic site.

MRI supersedes ictal EEG when other presurgical data are concordant. Seizure. 2017; 53:18-22. DOI: http://dx.doi.org/10.1016/j.seizure.2017.10.013.

Ictal electroencephalography (EEG) does not appear to help determine the best approach to surgery in pediatric patients if magnetic resonance imaging (MRI) findings and other presurgical data have pinpointed the epileptogenic focus, according to retrospective analysis that included 115 children.

• Investigators looked at children with epilepsy who had surgical resection based on a lesion that was identified by MRI and corroborated by other presurgical findings.
• Ictal video EEG findings were divided into 2 groups; ictal EEG findings were labeled “positive” if the identified location of the lesion agreed with the location indicated by the MRI, or “negative” if results were discordant with the MRI findings.
• The analysis found no differences in seizure-free outcomes when negative and positive EEGs were compared.
• A positive ictal EEG was not linked with better clinical outcomes regardless of the surgical site or the pathology of the lesion.
• EEGs had limited predictive value, which prompted researchers to question whether they are worth doing if MRI findings and related presurgical data confirm the location of the epileptogenic site.

MRI supersedes ictal EEG when other presurgical data are concordant. Seizure. 2017; 53:18-22. DOI: http://dx.doi.org/10.1016/j.seizure.2017.10.013.

Telling the difference between epilepsy and psychogenic non-epileptic seizures (PNES) has always been a challenge, especially in low-resource clinical settings in which video-electroencephalography (EEG) monitoring is not available. Patient questionnaires may help differentiate the 2 conditions, suggests a recent study.

• Investigators gave adult patients and eyewitnesses questionnaires that discussed subjective experiences and vulnerabilities, including signs, symptoms, and risk factors.
• They also calculated specificity and sensitivity for each measured variable, comparing the responses of patients and eyewitnesses to the final diagnosis.
• The study generated 28 useful patient questionnaires, including 17 from patients who had PNES and 11 who had epileptic seizures.
• The analysis uncovered 7 variables that had both high sensitivity and specificity scores, and 5 of these markers were found to be statistically significant diagnostic predictors.
• The most indicative items on the questionnaires included head injury, physical abuse, chronic fatigue, heart racing, and tingling or numbness.
• The analysis also yielded 16 useful eyewitness questionnaires, which found side-to-side head movements and closed eyes as statistically significant markers.

​Patients’ and caregivers’ contributions for differentiating epileptic from psychogenic nonepileptic seizures. Value and limitations of self-reporting questionnaires: A pilot study. Seizure. 2017;53:66-71. DOI: http://dx.doi.org/10.1016/j.seizure.2017.11.001.

Telling the difference between epilepsy and psychogenic non-epileptic seizures (PNES) has always been a challenge, especially in low-resource clinical settings in which video-electroencephalography (EEG) monitoring is not available. Patient questionnaires may help differentiate the 2 conditions, suggests a recent study.

• Investigators gave adult patients and eyewitnesses questionnaires that discussed subjective experiences and vulnerabilities, including signs, symptoms, and risk factors.
• They also calculated specificity and sensitivity for each measured variable, comparing the responses of patients and eyewitnesses to the final diagnosis.
• The study generated 28 useful patient questionnaires, including 17 from patients who had PNES and 11 who had epileptic seizures.
• The analysis uncovered 7 variables that had both high sensitivity and specificity scores, and 5 of these markers were found to be statistically significant diagnostic predictors.
• The most indicative items on the questionnaires included head injury, physical abuse, chronic fatigue, heart racing, and tingling or numbness.
• The analysis also yielded 16 useful eyewitness questionnaires, which found side-to-side head movements and closed eyes as statistically significant markers.

​Patients’ and caregivers’ contributions for differentiating epileptic from psychogenic nonepileptic seizures. Value and limitations of self-reporting questionnaires: A pilot study. Seizure. 2017;53:66-71. DOI: http://dx.doi.org/10.1016/j.seizure.2017.11.001.

Telling the difference between epilepsy and psychogenic non-epileptic seizures (PNES) has always been a challenge, especially in low-resource clinical settings in which video-electroencephalography (EEG) monitoring is not available. Patient questionnaires may help differentiate the 2 conditions, suggests a recent study.

• Investigators gave adult patients and eyewitnesses questionnaires that discussed subjective experiences and vulnerabilities, including signs, symptoms, and risk factors.
• They also calculated specificity and sensitivity for each measured variable, comparing the responses of patients and eyewitnesses to the final diagnosis.
• The study generated 28 useful patient questionnaires, including 17 from patients who had PNES and 11 who had epileptic seizures.
• The analysis uncovered 7 variables that had both high sensitivity and specificity scores, and 5 of these markers were found to be statistically significant diagnostic predictors.
• The most indicative items on the questionnaires included head injury, physical abuse, chronic fatigue, heart racing, and tingling or numbness.
• The analysis also yielded 16 useful eyewitness questionnaires, which found side-to-side head movements and closed eyes as statistically significant markers.

​Patients’ and caregivers’ contributions for differentiating epileptic from psychogenic nonepileptic seizures. Value and limitations of self-reporting questionnaires: A pilot study. Seizure. 2017;53:66-71. DOI: http://dx.doi.org/10.1016/j.seizure.2017.11.001.

The prevalent reason offered for increased mortality rates during weekend hours are shortages in staffing and services. The “weekend effect,” elucidated by Pauls et al.¹ in their recent meta-analysis, and the accompanying editorial by Quinn and Bell,² highlight these and other potential causes for this anomaly.

Pauls et al.¹ also cite patient selection bias as a possible explanation for the uptick in deaths during this span (off-hour admissions may be sicker). It is due to the latter that we wish to highlight additional studies published after mid-2013 when the authors concluded their search.

Recent disputes within the UK’s National Health Service³ concerning health system funding spurred timely papers in BMJ⁴ and Lancet⁵ on the uncertainty. They both discovered a stronger signal from patient characteristics admitted during this time rather than on-hand resources and workforce. These new investigations strengthen the support for patient acuity as a determinant in explaining worse outcomes.

We highlight these manuscripts so investigators will continue their attempts to understand the weekend phenomena as suggested by both Pauls et al.¹ and the editorialists.² To allow for the delivery of correct interventions, we must understand its root causes. In this case, it may be the unique features of patients presenting on Saturdays and Sundays and, hence, would require a different set of process changes.

Disclosure: The authors declare no conflict of interest.

The prevalent reason offered for increased mortality rates during weekend hours are shortages in staffing and services. The “weekend effect,” elucidated by Pauls et al.¹ in their recent meta-analysis, and the accompanying editorial by Quinn and Bell,² highlight these and other potential causes for this anomaly.

Pauls et al.¹ also cite patient selection bias as a possible explanation for the uptick in deaths during this span (off-hour admissions may be sicker). It is due to the latter that we wish to highlight additional studies published after mid-2013 when the authors concluded their search.

Recent disputes within the UK’s National Health Service³ concerning health system funding spurred timely papers in BMJ⁴ and Lancet⁵ on the uncertainty. They both discovered a stronger signal from patient characteristics admitted during this time rather than on-hand resources and workforce. These new investigations strengthen the support for patient acuity as a determinant in explaining worse outcomes.

We highlight these manuscripts so investigators will continue their attempts to understand the weekend phenomena as suggested by both Pauls et al.¹ and the editorialists.² To allow for the delivery of correct interventions, we must understand its root causes. In this case, it may be the unique features of patients presenting on Saturdays and Sundays and, hence, would require a different set of process changes.

Disclosure: The authors declare no conflict of interest.

The prevalent reason offered for increased mortality rates during weekend hours are shortages in staffing and services. The “weekend effect,” elucidated by Pauls et al.¹ in their recent meta-analysis, and the accompanying editorial by Quinn and Bell,² highlight these and other potential causes for this anomaly.

Pauls et al.¹ also cite patient selection bias as a possible explanation for the uptick in deaths during this span (off-hour admissions may be sicker). It is due to the latter that we wish to highlight additional studies published after mid-2013 when the authors concluded their search.

Recent disputes within the UK’s National Health Service³ concerning health system funding spurred timely papers in BMJ⁴ and Lancet⁵ on the uncertainty. They both discovered a stronger signal from patient characteristics admitted during this time rather than on-hand resources and workforce. These new investigations strengthen the support for patient acuity as a determinant in explaining worse outcomes.

We highlight these manuscripts so investigators will continue their attempts to understand the weekend phenomena as suggested by both Pauls et al.¹ and the editorialists.² To allow for the delivery of correct interventions, we must understand its root causes. In this case, it may be the unique features of patients presenting on Saturdays and Sundays and, hence, would require a different set of process changes.

Disclosure: The authors declare no conflict of interest.

Treating rheumatoid arthritis patients with lower doses of rituximab for long-term maintenance reduced the risk of serious infections and saved money, based on data from approximately 1,200 patients in a French registry.

In a study published in Rheumatology, Julien Henry, MD, of Institut pour la Sante et la Recherche Medicale, Paris, and colleagues reviewed data from 1,278 patients; 1,093 (85.5%) received a standard dose of rituximab, and 185 (14.5%) received a reduced dose for maintenance therapy. A standard dose was 1,000 mg per infusion given in two infusions 2 weeks apart), and a reduced dose was 500 mg per infusion given in two infusions 2 weeks apart.

After 5 years, maintenance was 55.5% in the standard group and 53.8% in the reduced group; with no significant difference (hazard ratio, 1.03). However, the cumulative dose for retreatment was 39% less in the reduced group (1.4 g per year vs. 2.3 g per year), “which is greatly cost effective,” the researchers wrote.

In addition, the rate of serious infections was significantly lower in the reduced-dose group, compared with the standard-dose group (2.2 per 100 patient-years vs. 4.1 per 100 patient-years; adjusted hazard ratio = 0.50).

“Of note, factors associated with risk of serious infection, such as baseline low gamma globulin or IgG levels, chronic lung or cardiac disease, and extra-articular involvement, did not differ between groups,” the researchers said.

The study findings were limited by several factors including the observational design and lack of data on certain RA outcome measures such as radiographic progression and function, the researchers noted. However, the results support data from similar studies and suggest that a lower dose of rituximab for retreatment of RA “did not alter the maintenance of the treatment at 5 years and is associated with a significant lower rate of serious infections,” they said.

Dr. Henry had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple drug companies, but the study received no specific funding from any of these companies.

[email protected]

SOURCE: Henry J et al. Rheumatology. 2017 Dec 15. doi: 10.1093/rheumatology/kex446.

Treating rheumatoid arthritis patients with lower doses of rituximab for long-term maintenance reduced the risk of serious infections and saved money, based on data from approximately 1,200 patients in a French registry.

In a study published in Rheumatology, Julien Henry, MD, of Institut pour la Sante et la Recherche Medicale, Paris, and colleagues reviewed data from 1,278 patients; 1,093 (85.5%) received a standard dose of rituximab, and 185 (14.5%) received a reduced dose for maintenance therapy. A standard dose was 1,000 mg per infusion given in two infusions 2 weeks apart), and a reduced dose was 500 mg per infusion given in two infusions 2 weeks apart.

After 5 years, maintenance was 55.5% in the standard group and 53.8% in the reduced group; with no significant difference (hazard ratio, 1.03). However, the cumulative dose for retreatment was 39% less in the reduced group (1.4 g per year vs. 2.3 g per year), “which is greatly cost effective,” the researchers wrote.

In addition, the rate of serious infections was significantly lower in the reduced-dose group, compared with the standard-dose group (2.2 per 100 patient-years vs. 4.1 per 100 patient-years; adjusted hazard ratio = 0.50).

“Of note, factors associated with risk of serious infection, such as baseline low gamma globulin or IgG levels, chronic lung or cardiac disease, and extra-articular involvement, did not differ between groups,” the researchers said.

The study findings were limited by several factors including the observational design and lack of data on certain RA outcome measures such as radiographic progression and function, the researchers noted. However, the results support data from similar studies and suggest that a lower dose of rituximab for retreatment of RA “did not alter the maintenance of the treatment at 5 years and is associated with a significant lower rate of serious infections,” they said.

Dr. Henry had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple drug companies, but the study received no specific funding from any of these companies.

[email protected]

SOURCE: Henry J et al. Rheumatology. 2017 Dec 15. doi: 10.1093/rheumatology/kex446.

Treating rheumatoid arthritis patients with lower doses of rituximab for long-term maintenance reduced the risk of serious infections and saved money, based on data from approximately 1,200 patients in a French registry.

In a study published in Rheumatology, Julien Henry, MD, of Institut pour la Sante et la Recherche Medicale, Paris, and colleagues reviewed data from 1,278 patients; 1,093 (85.5%) received a standard dose of rituximab, and 185 (14.5%) received a reduced dose for maintenance therapy. A standard dose was 1,000 mg per infusion given in two infusions 2 weeks apart), and a reduced dose was 500 mg per infusion given in two infusions 2 weeks apart.

After 5 years, maintenance was 55.5% in the standard group and 53.8% in the reduced group; with no significant difference (hazard ratio, 1.03). However, the cumulative dose for retreatment was 39% less in the reduced group (1.4 g per year vs. 2.3 g per year), “which is greatly cost effective,” the researchers wrote.

In addition, the rate of serious infections was significantly lower in the reduced-dose group, compared with the standard-dose group (2.2 per 100 patient-years vs. 4.1 per 100 patient-years; adjusted hazard ratio = 0.50).

“Of note, factors associated with risk of serious infection, such as baseline low gamma globulin or IgG levels, chronic lung or cardiac disease, and extra-articular involvement, did not differ between groups,” the researchers said.

The study findings were limited by several factors including the observational design and lack of data on certain RA outcome measures such as radiographic progression and function, the researchers noted. However, the results support data from similar studies and suggest that a lower dose of rituximab for retreatment of RA “did not alter the maintenance of the treatment at 5 years and is associated with a significant lower rate of serious infections,” they said.

Dr. Henry had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple drug companies, but the study received no specific funding from any of these companies.

[email protected]

SOURCE: Henry J et al. Rheumatology. 2017 Dec 15. doi: 10.1093/rheumatology/kex446.

Synovitis detected by ultrasound in patients with rheumatoid arthritis (RA) in clinical remission has a moderate but significant independent predictive value for the loss of remission, new research shows.

These findings, reported by Swiss investigators at multiple centers and with different sonographers and ultrasound (US) machines, adds to previous research that has shown that patients in clinical remission with US-detected residual synovitis had a tendency to flare more often and have a shorter duration of remission than did patients with sonographic remission.

Bogdanhoda/Thinkstock

The research team observed a loss of remission in 60% of 378 remission phases, with having a 28-joint Disease Activity Score greater than 2.6 deciding the loss of remission status in 66% of cases in both the US+ and the US– groups.

The time from the first US during remission to loss of remission was 2-5 months longer for US– patients than it was for US+ patients.

“After adjusting for potential confounders, [the hazard ratio] of loss of remission for all remission phases using the complete follow-up time was higher for patients with US-detected synovitis at baseline than for those without (combined US score hazard ratio, 1.4; 95% CI, 1.03-2.00 vs. HR, 1.5; 95% CI, 1.1-2.1 for left and right imputation, respectively),” the investigators wrote.

Hazard ratios for the loss of remission also showed a two- to threefold increase when US measurements were taken early in remission (that is, within 3-6 months), a finding that the authors wrote indicated “that the short-term predictive power of US-detected residual synovitis may be more significant than its long-term predictive power.”

The researchers concluded that their study showed that US could be useful in predicting how long patients were likely to remain in remission in “real-life conditions,” but said questions remained over whether it should be used at an individual level.

“According to our results, in particular regarding the moderate HR, a single US done in remission cannot be used as the unique predictor of flare,” they wrote.

Nevertheless, their results may have “some importance in promoting the widespread use of US in real-life conditions for the follow-up of RA, especially when in remission,” they said.

“The next step would be to evaluate whether previous US performed prior to reaching remission and repeated US performed while in remission, particularly after 3-6 months, could provide additional information that is useful to the clinician,” they added.

The Swiss Clinical Quality Management Foundation is supported by the Swiss Society of Rheumatology and nine pharmaceutical companies.

SOURCE: Zufferey P et al. J Rheumatol. 2018 Jan 15. doi: 10.3899/jrheum.161193

Synovitis detected by ultrasound in patients with rheumatoid arthritis (RA) in clinical remission has a moderate but significant independent predictive value for the loss of remission, new research shows.

These findings, reported by Swiss investigators at multiple centers and with different sonographers and ultrasound (US) machines, adds to previous research that has shown that patients in clinical remission with US-detected residual synovitis had a tendency to flare more often and have a shorter duration of remission than did patients with sonographic remission.

Bogdanhoda/Thinkstock

The research team observed a loss of remission in 60% of 378 remission phases, with having a 28-joint Disease Activity Score greater than 2.6 deciding the loss of remission status in 66% of cases in both the US+ and the US– groups.

The time from the first US during remission to loss of remission was 2-5 months longer for US– patients than it was for US+ patients.

“After adjusting for potential confounders, [the hazard ratio] of loss of remission for all remission phases using the complete follow-up time was higher for patients with US-detected synovitis at baseline than for those without (combined US score hazard ratio, 1.4; 95% CI, 1.03-2.00 vs. HR, 1.5; 95% CI, 1.1-2.1 for left and right imputation, respectively),” the investigators wrote.

Hazard ratios for the loss of remission also showed a two- to threefold increase when US measurements were taken early in remission (that is, within 3-6 months), a finding that the authors wrote indicated “that the short-term predictive power of US-detected residual synovitis may be more significant than its long-term predictive power.”

The researchers concluded that their study showed that US could be useful in predicting how long patients were likely to remain in remission in “real-life conditions,” but said questions remained over whether it should be used at an individual level.

“According to our results, in particular regarding the moderate HR, a single US done in remission cannot be used as the unique predictor of flare,” they wrote.

Nevertheless, their results may have “some importance in promoting the widespread use of US in real-life conditions for the follow-up of RA, especially when in remission,” they said.

“The next step would be to evaluate whether previous US performed prior to reaching remission and repeated US performed while in remission, particularly after 3-6 months, could provide additional information that is useful to the clinician,” they added.

The Swiss Clinical Quality Management Foundation is supported by the Swiss Society of Rheumatology and nine pharmaceutical companies.

SOURCE: Zufferey P et al. J Rheumatol. 2018 Jan 15. doi: 10.3899/jrheum.161193

Synovitis detected by ultrasound in patients with rheumatoid arthritis (RA) in clinical remission has a moderate but significant independent predictive value for the loss of remission, new research shows.

These findings, reported by Swiss investigators at multiple centers and with different sonographers and ultrasound (US) machines, adds to previous research that has shown that patients in clinical remission with US-detected residual synovitis had a tendency to flare more often and have a shorter duration of remission than did patients with sonographic remission.

Bogdanhoda/Thinkstock

The research team observed a loss of remission in 60% of 378 remission phases, with having a 28-joint Disease Activity Score greater than 2.6 deciding the loss of remission status in 66% of cases in both the US+ and the US– groups.

The time from the first US during remission to loss of remission was 2-5 months longer for US– patients than it was for US+ patients.

“After adjusting for potential confounders, [the hazard ratio] of loss of remission for all remission phases using the complete follow-up time was higher for patients with US-detected synovitis at baseline than for those without (combined US score hazard ratio, 1.4; 95% CI, 1.03-2.00 vs. HR, 1.5; 95% CI, 1.1-2.1 for left and right imputation, respectively),” the investigators wrote.

Hazard ratios for the loss of remission also showed a two- to threefold increase when US measurements were taken early in remission (that is, within 3-6 months), a finding that the authors wrote indicated “that the short-term predictive power of US-detected residual synovitis may be more significant than its long-term predictive power.”

The researchers concluded that their study showed that US could be useful in predicting how long patients were likely to remain in remission in “real-life conditions,” but said questions remained over whether it should be used at an individual level.

“According to our results, in particular regarding the moderate HR, a single US done in remission cannot be used as the unique predictor of flare,” they wrote.

Nevertheless, their results may have “some importance in promoting the widespread use of US in real-life conditions for the follow-up of RA, especially when in remission,” they said.

“The next step would be to evaluate whether previous US performed prior to reaching remission and repeated US performed while in remission, particularly after 3-6 months, could provide additional information that is useful to the clinician,” they added.

The Swiss Clinical Quality Management Foundation is supported by the Swiss Society of Rheumatology and nine pharmaceutical companies.

SOURCE: Zufferey P et al. J Rheumatol. 2018 Jan 15. doi: 10.3899/jrheum.161193

Access ACOG/SMFM algorithm for treatment of pregnant women with flu-like illness

Access ACOG/SMFM algorithm for treatment of pregnant women with flu-like illness

Access ACOG/SMFM algorithm for treatment of pregnant women with flu-like illness

ORLANDO – When the Heart Rhythm Society and several collaborating groups published in October 2017 the first revised consensus statement on atrial fibrillation ablation in 5 years, the document included a novel and perhaps unexpected suggestion: Ablation for asymptomatic atrial fibrillation “may be considered.”

This was “the first time” any group of experts suggested an indication potentially existed for ablating asymptomatic atrial fibrillation (AF), Hugh Calkins, MD, said at the annual International AF Symposium.

“You might say ‘are you out of your mind recommending ablation for asymptomatic AF?’ ” conceded Dr. Calkins, professor of medicine and director of the arrhythmia service at Johns Hopkins Medicine in Baltimore. But Dr. Calkins quickly added that this was a “soft” recommendation by being in the “may be considered” category, and he also noted that it received broad support from about 90% of the members of the statement’s 60-member writing group (Heart Rhythm. 2017 Oct;14[10]:e445-e494).

In addition, he personally believed that an amber light for this strategy made a lot of sense.

Mitchel L. Zoler/Frontline Medical News

The ideal candidate for this approach would be a relatively young patient, say someone in their 50s, who is identified as having AF incidentally, such as someone with an irregular pulse that’s found during a routine examination that leads to an ECG and definitive identification of AF despite the patient’s complete denial of having symptoms.

The next step, Dr. Calkins suggested, would be to treat the patient with an antiarrhythmic drug, such as amiodarone or flecainide, and with cardioversion and see whether this stops the AF and makes the patient feel better. If the patient reports improvement, it suggests the AF really is symptomatic and management could then proceed as with any case of symptomatic AF. But if the patient perceives no change and the AF then recurs in a persistent presentation despite drug treatment, the cardiologist could then discuss with the patient the pros and cons of an ablative procedure.

The pros for immediate ablation are that, when left unablated, the patient will face a substantially increased lifetime risk for stroke, dementia, and new onset heart failure, and after 2-3 years of continued persistent AF the left atrium would remodel and become much less likely to respond to ablation with little prospect for the patient ever returning to a normal sinus rhythm. “It’s either a rhythm control strategy now, or we’ll leave you in AF for the rest of your life,” Dr. Calkins explained. “If I were 50 years old and had asymptomatic AF, there’s no way I’d want to have AF for the rest of my life.” The risks from ablation are that the procedure has about a 68% success rate and about a 1% rate of complications.

“A patient with asymptomatic paroxysmal AF doesn’t have much to lose by waiting and seeing whether symptoms develop, but for the patient with persistent AF there is a penalty for allowing continuous AF, because after 2-3 years you won’t be able to successfully ablate it. In the past, we left patients with asymptomatic AF that way for the rest of their life, but now we know that if patients remain in AF over time, they will lose the option to have it ablated, and their risk of stroke, dementia, and heart failure will increase.”Dr. Calkins has been a consultant or adviser to or received honoraria from Abbott, AtriCure, Boehringer Ingelheim, Boston Scientific, iRhythm, Medtronic, Pfizer, St. Jude, and Toray, He has also received research funding from Boston Scientific and Medtronic.

[email protected]

This article was updated 2/9/18.

ORLANDO – When the Heart Rhythm Society and several collaborating groups published in October 2017 the first revised consensus statement on atrial fibrillation ablation in 5 years, the document included a novel and perhaps unexpected suggestion: Ablation for asymptomatic atrial fibrillation “may be considered.”

This was “the first time” any group of experts suggested an indication potentially existed for ablating asymptomatic atrial fibrillation (AF), Hugh Calkins, MD, said at the annual International AF Symposium.

“You might say ‘are you out of your mind recommending ablation for asymptomatic AF?’ ” conceded Dr. Calkins, professor of medicine and director of the arrhythmia service at Johns Hopkins Medicine in Baltimore. But Dr. Calkins quickly added that this was a “soft” recommendation by being in the “may be considered” category, and he also noted that it received broad support from about 90% of the members of the statement’s 60-member writing group (Heart Rhythm. 2017 Oct;14[10]:e445-e494).

In addition, he personally believed that an amber light for this strategy made a lot of sense.

Mitchel L. Zoler/Frontline Medical News

The ideal candidate for this approach would be a relatively young patient, say someone in their 50s, who is identified as having AF incidentally, such as someone with an irregular pulse that’s found during a routine examination that leads to an ECG and definitive identification of AF despite the patient’s complete denial of having symptoms.

The next step, Dr. Calkins suggested, would be to treat the patient with an antiarrhythmic drug, such as amiodarone or flecainide, and with cardioversion and see whether this stops the AF and makes the patient feel better. If the patient reports improvement, it suggests the AF really is symptomatic and management could then proceed as with any case of symptomatic AF. But if the patient perceives no change and the AF then recurs in a persistent presentation despite drug treatment, the cardiologist could then discuss with the patient the pros and cons of an ablative procedure.

The pros for immediate ablation are that, when left unablated, the patient will face a substantially increased lifetime risk for stroke, dementia, and new onset heart failure, and after 2-3 years of continued persistent AF the left atrium would remodel and become much less likely to respond to ablation with little prospect for the patient ever returning to a normal sinus rhythm. “It’s either a rhythm control strategy now, or we’ll leave you in AF for the rest of your life,” Dr. Calkins explained. “If I were 50 years old and had asymptomatic AF, there’s no way I’d want to have AF for the rest of my life.” The risks from ablation are that the procedure has about a 68% success rate and about a 1% rate of complications.

“A patient with asymptomatic paroxysmal AF doesn’t have much to lose by waiting and seeing whether symptoms develop, but for the patient with persistent AF there is a penalty for allowing continuous AF, because after 2-3 years you won’t be able to successfully ablate it. In the past, we left patients with asymptomatic AF that way for the rest of their life, but now we know that if patients remain in AF over time, they will lose the option to have it ablated, and their risk of stroke, dementia, and heart failure will increase.”Dr. Calkins has been a consultant or adviser to or received honoraria from Abbott, AtriCure, Boehringer Ingelheim, Boston Scientific, iRhythm, Medtronic, Pfizer, St. Jude, and Toray, He has also received research funding from Boston Scientific and Medtronic.

[email protected]

This article was updated 2/9/18.

ORLANDO – When the Heart Rhythm Society and several collaborating groups published in October 2017 the first revised consensus statement on atrial fibrillation ablation in 5 years, the document included a novel and perhaps unexpected suggestion: Ablation for asymptomatic atrial fibrillation “may be considered.”

This was “the first time” any group of experts suggested an indication potentially existed for ablating asymptomatic atrial fibrillation (AF), Hugh Calkins, MD, said at the annual International AF Symposium.

“You might say ‘are you out of your mind recommending ablation for asymptomatic AF?’ ” conceded Dr. Calkins, professor of medicine and director of the arrhythmia service at Johns Hopkins Medicine in Baltimore. But Dr. Calkins quickly added that this was a “soft” recommendation by being in the “may be considered” category, and he also noted that it received broad support from about 90% of the members of the statement’s 60-member writing group (Heart Rhythm. 2017 Oct;14[10]:e445-e494).

In addition, he personally believed that an amber light for this strategy made a lot of sense.

Mitchel L. Zoler/Frontline Medical News

The ideal candidate for this approach would be a relatively young patient, say someone in their 50s, who is identified as having AF incidentally, such as someone with an irregular pulse that’s found during a routine examination that leads to an ECG and definitive identification of AF despite the patient’s complete denial of having symptoms.

The next step, Dr. Calkins suggested, would be to treat the patient with an antiarrhythmic drug, such as amiodarone or flecainide, and with cardioversion and see whether this stops the AF and makes the patient feel better. If the patient reports improvement, it suggests the AF really is symptomatic and management could then proceed as with any case of symptomatic AF. But if the patient perceives no change and the AF then recurs in a persistent presentation despite drug treatment, the cardiologist could then discuss with the patient the pros and cons of an ablative procedure.

The pros for immediate ablation are that, when left unablated, the patient will face a substantially increased lifetime risk for stroke, dementia, and new onset heart failure, and after 2-3 years of continued persistent AF the left atrium would remodel and become much less likely to respond to ablation with little prospect for the patient ever returning to a normal sinus rhythm. “It’s either a rhythm control strategy now, or we’ll leave you in AF for the rest of your life,” Dr. Calkins explained. “If I were 50 years old and had asymptomatic AF, there’s no way I’d want to have AF for the rest of my life.” The risks from ablation are that the procedure has about a 68% success rate and about a 1% rate of complications.

“A patient with asymptomatic paroxysmal AF doesn’t have much to lose by waiting and seeing whether symptoms develop, but for the patient with persistent AF there is a penalty for allowing continuous AF, because after 2-3 years you won’t be able to successfully ablate it. In the past, we left patients with asymptomatic AF that way for the rest of their life, but now we know that if patients remain in AF over time, they will lose the option to have it ablated, and their risk of stroke, dementia, and heart failure will increase.”Dr. Calkins has been a consultant or adviser to or received honoraria from Abbott, AtriCure, Boehringer Ingelheim, Boston Scientific, iRhythm, Medtronic, Pfizer, St. Jude, and Toray, He has also received research funding from Boston Scientific and Medtronic.

[email protected]

This article was updated 2/9/18.