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New and Noteworthy Information—June 2017
Can Biomarkers Predict Cognitive Deficits in Parkinson’s Disease?
Biomarkers may predict which patients with Parkinson’s disease will have significant cognitive deficits within the first three years after diagnosis, according to a study published May 17 in PLOS One. Researchers conducted an international, prospective study of 423 newly diagnosed and untreated patients with Parkinson’s disease with no signs of cognitive impairment at the time of enrollment in 2010. Investigators conducted brain scans, genetic tests, and analyses of CSF at baseline and during follow-up. At three years, between 15% and 38% of participants had developed cognitive impairment. Brain scans identified dopamine deficiency and decreased brain volume as predictors of cognitive decline. Low CSF beta-amyloid level and single-nucleotide polymorphisms (SNPs) in COMT and BDNF also predicted cognitive decline. These SNPs previously had been associated with cognitive impairment.
Caspell-Garcia C, Simuni T, Tosun-Turgut D, et al. Multiple modality biomarker prediction of cognitive impairment in prospectively followed de novo Parkinson disease. PLoS One. 2017 May 17;12(5):e0175674.
Service Members With Concussive Blast TBI Have Worsening Outcomes
Military service members with concussive blast traumatic brain injury (TBI) have considerable decline in clinical outcomes over five years, according to a study published online ahead of print May 1 in JAMA Neurology. This prospective longitudinal study enrolled active-duty US military after concussive blast injury in the acute to subacute stage and combat-deployed control individuals in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. Physicians in the United States performed one- and five-year clinical evaluations. Among the 94 participants, global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI, compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the five-year evaluation.
Mac Donald CL, Barber J, Jordan M, et al. Early clinical predictors of 5-year outcome after concussive blast traumatic brain injury. JAMA Neurol. 2017 May 1 [Epub ahead of print].
Biomarker Linked to Increased Risk of Ischemic Stroke in Women
High levels of β2-microglobulin are associated with an increased risk of ischemic stroke among women, according to a study published online ahead of print May 10 in Neurology. Researchers performed a nested case–control study among women enrolled in the Nurses’ Health Study who provided blood samples between 1989 and 1990 and were free of prior stroke and cancer. Investigators measured β2-microglobulin levels in 473 ischemic stroke cases and 473 controls matched on age, race, and other variables. Median levels of β2-microglobulin were 1.86 mg/L in cases and 1.80 mg/L in controls. Women in the highest β2-microglobulin quartile had a multivariable-adjusted increased risk of ischemic stroke, compared with women in the lowest quartile (odds ratio, 1.56). Results were similar when restricted to those without chronic kidney disease.
Rist PM, Jiménez MC, Rexrode KM. Prospective association between β2-microglobulin levels and ischemic stroke risk among women. Neurology. 2017 May 10 [Epub ahead of print].
Female Hormones May Cause Headache in Girls With Migraine
Age and pubertal development could moderate the effect of ovarian hormones on days of headache onset in girls with migraine, according to a study published online ahead of print May 8 in Cephalalgia. The study included 34 girls with migraine grouped into three age strata (ie, prepubertal, pubertal, and postpubertal). Participants collected daily urine samples and recorded the occurrence and severity of headache in a daily diary. Urine samples were assayed for estrone glucuronide and pregnandiol glucuronide, and the daily change in each was calculated. The primary outcome measures were headache onset days and headache severity. Models of headache onset days demonstrated a significant interaction between age and pregnandiol glucuronide. Change in pregnandiol glucuronide was associated with headache severity.
Martin VT, Allen JR, Houle TT, et al. Ovarian hormones, age and pubertal development and their association with days of headache onset in girls with migraine: an observational cohort study. Cephalalgia. 2017 Jan 1 [Epub ahead of print].
PTSD Is Associated With Risk for Dementia Diagnosis
Posttraumatic stress disorder (PTSD) diagnosis is associated with an increased risk for dementia diagnosis that varies with psychotropic medication, according to a study published in the May issue of the Journal of the American Geriatrics Society. Researchers examined information from 417,172 veterans age 56 and older without dementia or mild cognitive impairment. During the study’s nine-year follow-up period, participants had a clinical encounter every two years. PTSD diagnosis significantly increased the risk for dementia diagnosis. The hazard ratio for dementia diagnosis among veterans diagnosed with PTSD who did not use psychotropic medications was 1.55. Among veterans diagnosed with PTSD and prescribed psychotropic medication, the hazard ratio for dementia diagnosis ranged from 1.99 for SSRIs to 4.21 for atypical antipsychotics.
Mawanda F, Wallace RB, McCoy K, Abrams TE. PTSD, psychotropic medication use, and the risk of dementia among US veterans: a retrospective cohort study. J Am Geriatr Soc. 2017;65(5):1043-1050.
Screening for Atrial Fibrillation Recommended
Screening for asymptomatic atrial fibrillation in people age 65 and older and treating it with anticoagulant medications could greatly reduce the risk of stroke and premature death, according to the AF-SCREEN International Collaboration report published May 9 in Circulation. In 2016, 60 members of the collaboration, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare a draft document. They concluded that screen-detected atrial fibrillation found at a single timepoint or by intermittent ECG recordings over two weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. Handheld ECG devices are preferred as screening tools because they provide a verifiable ECG trace that guidelines require for diagnosis, said the authors.
Freedman B, Camm J, Calkins H, et al. Screening for atrial fibrillation: a report of the AF-SCREEN international collaboration. Circulation. 2017;135(19):1851-1867.
Can Music Reduce Depressive Symptoms in Dementia?
Providing people with dementia with at least five sessions of a music-based therapeutic intervention probably reduces depressive symptoms, but has little or no effect on agitation or aggression, according to a study published online ahead of print May 2 in the Cochrane Database of Systematic Reviews. Researchers searched ALOIS on April 14, 2010, using the terms “music therapy,” “music,” “singing,” “sing,” and “auditory stimulation.” Sixteen studies with a total of 620 participants contributed data to meta-analyses. Participants in the studies had dementia of varying severity. The investigators found that music-based therapeutic interventions may have little or no effect on emotional well-being and quality of life, overall behavior problems, and cognition. Study authors also found moderate-quality evidence that these interventions reduce depressive symptoms, but do not decrease agitation or aggression.
van der Steen JT, van Soest-Poortvliet MC, van der Wouden JC, et al. Music-based therapeutic interventions for people with dementia. Cochrane Database Syst Rev. 2017 May 2 [Epub ahead of print].
FDA Approves Radicava for Treatment of ALS
The FDA has approved Radicava (edaravone) as an IV treatment for amyotrophic lateral sclerosis (ALS). A phase III study evaluated the efficacy and safety of Radicava, compared with placebo, in 137 people with ALS. After a 12-week preobservation period, eligible patients were randomized 1:1 to receive 60 mg of Radicava in an IV for 60 minutes or placebo during a six-month double-blind phase. People given Radicava showed significantly less decline in physical function, compared with controls, as measured by the ALS Functional Rating Scale-Revised. The most common adverse reactions that occurred in greater than 10% of patients and greater than placebo were bruising, walking difficulties, and headache. Radicava is administered in 28-day cycles. MT Pharma America, headquartered in Jersey City, New Jersey, markets Radicava.
Can Cooling the Body Reduce Brain Injury?
Cooling the body may reduce brain injury for people in a coma after being revived from cardiac arrest, according to a guideline published online ahead of print May 10 in Neurology. Researchers reviewed evidence from studies of methods to reduce brain injury in people who are comatose after resuscitation from cardiac arrest. The guideline found that for patients who are treated with electric shocks to the heart after out-of-hospital cardiac arrest and who are in a coma, cooling the body to 89.6 to 93.2 °F for 24 hours effectively improves the chance of recovering brain function. The authors also found that keeping the body cooled to 96.8 °F for 24 hours, followed by rewarming to 99.5 °F over eight hours, effectively reduces brain injury after cardiac arrest.
Geocadin RG, Wijdicks E, Armstrong MJ, et al. Practice guideline summary: reducing brain injury following cardiopulmonary resuscitation: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2017 May 10 [Epub ahead of print].
Granger Causality Analysis Can Localize Ictal Networks
Granger causality analysis has the potential to help localize ictal networks from interictal data, according to a study published online ahead of print May 2 in Neurosurgery. For this study, 20-minute interictal baselines were obtained from 25 patients with hard-to-treat epilepsy who previously had had long-term EEG monitoring. The Granger causality maps were quantitatively compared with conventionally constructed surgical plans by using rank order and Cartesian distance statistics. In 16 of 25 participants, the interictal Granger causality rankings of the electrodes in the ictally active electrode set were lower than predicted by chance. The Granger causality maps thus likely correlated with ictal networks. The distance from the highest Granger causality electrode to the ictally active electrode set and to the resection averaged 6 and 4 mm, respectively.
Park EH, Madsen JR. Granger causality analysis of interictal iEEG predicts seizure focus and ultimate resection. Neurosurgery. 2017 May 2 [Epub ahead of print].
Tourette Disorder Risk Genes Identified
Researchers have identified the first risk gene for Tourette disorder and three other probable risk genes, according to a study published May 3 in Neuron. Researchers analyzed genomic data from 311 trios of children with Tourette disorder and their parents. Data were collected by the Tourette International Collaborative Genetics group. The authors found strong evidence that variants of WWC1 can play a significant role in triggering the disorder. Investigators conducted a replication study in 173 trios and found the same results. Extrapolating from the number of de novo variants, investigators estimated that approximately 12% of Tourette disorder cases are likely to involve de novo variants. The genes CELSR3, NIPBL, and FN1 were identified as having at least 70% probability of contributing to Tourette disorder.
Willsey AJ, Fernandez TV, Yu D, et al. De novo coding variants are strongly associated with Tourette disorder. Neuron. 2017;94(3):486-499.
—Kimberly Williams
Can Biomarkers Predict Cognitive Deficits in Parkinson’s Disease?
Biomarkers may predict which patients with Parkinson’s disease will have significant cognitive deficits within the first three years after diagnosis, according to a study published May 17 in PLOS One. Researchers conducted an international, prospective study of 423 newly diagnosed and untreated patients with Parkinson’s disease with no signs of cognitive impairment at the time of enrollment in 2010. Investigators conducted brain scans, genetic tests, and analyses of CSF at baseline and during follow-up. At three years, between 15% and 38% of participants had developed cognitive impairment. Brain scans identified dopamine deficiency and decreased brain volume as predictors of cognitive decline. Low CSF beta-amyloid level and single-nucleotide polymorphisms (SNPs) in COMT and BDNF also predicted cognitive decline. These SNPs previously had been associated with cognitive impairment.
Caspell-Garcia C, Simuni T, Tosun-Turgut D, et al. Multiple modality biomarker prediction of cognitive impairment in prospectively followed de novo Parkinson disease. PLoS One. 2017 May 17;12(5):e0175674.
Service Members With Concussive Blast TBI Have Worsening Outcomes
Military service members with concussive blast traumatic brain injury (TBI) have considerable decline in clinical outcomes over five years, according to a study published online ahead of print May 1 in JAMA Neurology. This prospective longitudinal study enrolled active-duty US military after concussive blast injury in the acute to subacute stage and combat-deployed control individuals in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. Physicians in the United States performed one- and five-year clinical evaluations. Among the 94 participants, global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI, compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the five-year evaluation.
Mac Donald CL, Barber J, Jordan M, et al. Early clinical predictors of 5-year outcome after concussive blast traumatic brain injury. JAMA Neurol. 2017 May 1 [Epub ahead of print].
Biomarker Linked to Increased Risk of Ischemic Stroke in Women
High levels of β2-microglobulin are associated with an increased risk of ischemic stroke among women, according to a study published online ahead of print May 10 in Neurology. Researchers performed a nested case–control study among women enrolled in the Nurses’ Health Study who provided blood samples between 1989 and 1990 and were free of prior stroke and cancer. Investigators measured β2-microglobulin levels in 473 ischemic stroke cases and 473 controls matched on age, race, and other variables. Median levels of β2-microglobulin were 1.86 mg/L in cases and 1.80 mg/L in controls. Women in the highest β2-microglobulin quartile had a multivariable-adjusted increased risk of ischemic stroke, compared with women in the lowest quartile (odds ratio, 1.56). Results were similar when restricted to those without chronic kidney disease.
Rist PM, Jiménez MC, Rexrode KM. Prospective association between β2-microglobulin levels and ischemic stroke risk among women. Neurology. 2017 May 10 [Epub ahead of print].
Female Hormones May Cause Headache in Girls With Migraine
Age and pubertal development could moderate the effect of ovarian hormones on days of headache onset in girls with migraine, according to a study published online ahead of print May 8 in Cephalalgia. The study included 34 girls with migraine grouped into three age strata (ie, prepubertal, pubertal, and postpubertal). Participants collected daily urine samples and recorded the occurrence and severity of headache in a daily diary. Urine samples were assayed for estrone glucuronide and pregnandiol glucuronide, and the daily change in each was calculated. The primary outcome measures were headache onset days and headache severity. Models of headache onset days demonstrated a significant interaction between age and pregnandiol glucuronide. Change in pregnandiol glucuronide was associated with headache severity.
Martin VT, Allen JR, Houle TT, et al. Ovarian hormones, age and pubertal development and their association with days of headache onset in girls with migraine: an observational cohort study. Cephalalgia. 2017 Jan 1 [Epub ahead of print].
PTSD Is Associated With Risk for Dementia Diagnosis
Posttraumatic stress disorder (PTSD) diagnosis is associated with an increased risk for dementia diagnosis that varies with psychotropic medication, according to a study published in the May issue of the Journal of the American Geriatrics Society. Researchers examined information from 417,172 veterans age 56 and older without dementia or mild cognitive impairment. During the study’s nine-year follow-up period, participants had a clinical encounter every two years. PTSD diagnosis significantly increased the risk for dementia diagnosis. The hazard ratio for dementia diagnosis among veterans diagnosed with PTSD who did not use psychotropic medications was 1.55. Among veterans diagnosed with PTSD and prescribed psychotropic medication, the hazard ratio for dementia diagnosis ranged from 1.99 for SSRIs to 4.21 for atypical antipsychotics.
Mawanda F, Wallace RB, McCoy K, Abrams TE. PTSD, psychotropic medication use, and the risk of dementia among US veterans: a retrospective cohort study. J Am Geriatr Soc. 2017;65(5):1043-1050.
Screening for Atrial Fibrillation Recommended
Screening for asymptomatic atrial fibrillation in people age 65 and older and treating it with anticoagulant medications could greatly reduce the risk of stroke and premature death, according to the AF-SCREEN International Collaboration report published May 9 in Circulation. In 2016, 60 members of the collaboration, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare a draft document. They concluded that screen-detected atrial fibrillation found at a single timepoint or by intermittent ECG recordings over two weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. Handheld ECG devices are preferred as screening tools because they provide a verifiable ECG trace that guidelines require for diagnosis, said the authors.
Freedman B, Camm J, Calkins H, et al. Screening for atrial fibrillation: a report of the AF-SCREEN international collaboration. Circulation. 2017;135(19):1851-1867.
Can Music Reduce Depressive Symptoms in Dementia?
Providing people with dementia with at least five sessions of a music-based therapeutic intervention probably reduces depressive symptoms, but has little or no effect on agitation or aggression, according to a study published online ahead of print May 2 in the Cochrane Database of Systematic Reviews. Researchers searched ALOIS on April 14, 2010, using the terms “music therapy,” “music,” “singing,” “sing,” and “auditory stimulation.” Sixteen studies with a total of 620 participants contributed data to meta-analyses. Participants in the studies had dementia of varying severity. The investigators found that music-based therapeutic interventions may have little or no effect on emotional well-being and quality of life, overall behavior problems, and cognition. Study authors also found moderate-quality evidence that these interventions reduce depressive symptoms, but do not decrease agitation or aggression.
van der Steen JT, van Soest-Poortvliet MC, van der Wouden JC, et al. Music-based therapeutic interventions for people with dementia. Cochrane Database Syst Rev. 2017 May 2 [Epub ahead of print].
FDA Approves Radicava for Treatment of ALS
The FDA has approved Radicava (edaravone) as an IV treatment for amyotrophic lateral sclerosis (ALS). A phase III study evaluated the efficacy and safety of Radicava, compared with placebo, in 137 people with ALS. After a 12-week preobservation period, eligible patients were randomized 1:1 to receive 60 mg of Radicava in an IV for 60 minutes or placebo during a six-month double-blind phase. People given Radicava showed significantly less decline in physical function, compared with controls, as measured by the ALS Functional Rating Scale-Revised. The most common adverse reactions that occurred in greater than 10% of patients and greater than placebo were bruising, walking difficulties, and headache. Radicava is administered in 28-day cycles. MT Pharma America, headquartered in Jersey City, New Jersey, markets Radicava.
Can Cooling the Body Reduce Brain Injury?
Cooling the body may reduce brain injury for people in a coma after being revived from cardiac arrest, according to a guideline published online ahead of print May 10 in Neurology. Researchers reviewed evidence from studies of methods to reduce brain injury in people who are comatose after resuscitation from cardiac arrest. The guideline found that for patients who are treated with electric shocks to the heart after out-of-hospital cardiac arrest and who are in a coma, cooling the body to 89.6 to 93.2 °F for 24 hours effectively improves the chance of recovering brain function. The authors also found that keeping the body cooled to 96.8 °F for 24 hours, followed by rewarming to 99.5 °F over eight hours, effectively reduces brain injury after cardiac arrest.
Geocadin RG, Wijdicks E, Armstrong MJ, et al. Practice guideline summary: reducing brain injury following cardiopulmonary resuscitation: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2017 May 10 [Epub ahead of print].
Granger Causality Analysis Can Localize Ictal Networks
Granger causality analysis has the potential to help localize ictal networks from interictal data, according to a study published online ahead of print May 2 in Neurosurgery. For this study, 20-minute interictal baselines were obtained from 25 patients with hard-to-treat epilepsy who previously had had long-term EEG monitoring. The Granger causality maps were quantitatively compared with conventionally constructed surgical plans by using rank order and Cartesian distance statistics. In 16 of 25 participants, the interictal Granger causality rankings of the electrodes in the ictally active electrode set were lower than predicted by chance. The Granger causality maps thus likely correlated with ictal networks. The distance from the highest Granger causality electrode to the ictally active electrode set and to the resection averaged 6 and 4 mm, respectively.
Park EH, Madsen JR. Granger causality analysis of interictal iEEG predicts seizure focus and ultimate resection. Neurosurgery. 2017 May 2 [Epub ahead of print].
Tourette Disorder Risk Genes Identified
Researchers have identified the first risk gene for Tourette disorder and three other probable risk genes, according to a study published May 3 in Neuron. Researchers analyzed genomic data from 311 trios of children with Tourette disorder and their parents. Data were collected by the Tourette International Collaborative Genetics group. The authors found strong evidence that variants of WWC1 can play a significant role in triggering the disorder. Investigators conducted a replication study in 173 trios and found the same results. Extrapolating from the number of de novo variants, investigators estimated that approximately 12% of Tourette disorder cases are likely to involve de novo variants. The genes CELSR3, NIPBL, and FN1 were identified as having at least 70% probability of contributing to Tourette disorder.
Willsey AJ, Fernandez TV, Yu D, et al. De novo coding variants are strongly associated with Tourette disorder. Neuron. 2017;94(3):486-499.
—Kimberly Williams
Can Biomarkers Predict Cognitive Deficits in Parkinson’s Disease?
Biomarkers may predict which patients with Parkinson’s disease will have significant cognitive deficits within the first three years after diagnosis, according to a study published May 17 in PLOS One. Researchers conducted an international, prospective study of 423 newly diagnosed and untreated patients with Parkinson’s disease with no signs of cognitive impairment at the time of enrollment in 2010. Investigators conducted brain scans, genetic tests, and analyses of CSF at baseline and during follow-up. At three years, between 15% and 38% of participants had developed cognitive impairment. Brain scans identified dopamine deficiency and decreased brain volume as predictors of cognitive decline. Low CSF beta-amyloid level and single-nucleotide polymorphisms (SNPs) in COMT and BDNF also predicted cognitive decline. These SNPs previously had been associated with cognitive impairment.
Caspell-Garcia C, Simuni T, Tosun-Turgut D, et al. Multiple modality biomarker prediction of cognitive impairment in prospectively followed de novo Parkinson disease. PLoS One. 2017 May 17;12(5):e0175674.
Service Members With Concussive Blast TBI Have Worsening Outcomes
Military service members with concussive blast traumatic brain injury (TBI) have considerable decline in clinical outcomes over five years, according to a study published online ahead of print May 1 in JAMA Neurology. This prospective longitudinal study enrolled active-duty US military after concussive blast injury in the acute to subacute stage and combat-deployed control individuals in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. Physicians in the United States performed one- and five-year clinical evaluations. Among the 94 participants, global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI, compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the five-year evaluation.
Mac Donald CL, Barber J, Jordan M, et al. Early clinical predictors of 5-year outcome after concussive blast traumatic brain injury. JAMA Neurol. 2017 May 1 [Epub ahead of print].
Biomarker Linked to Increased Risk of Ischemic Stroke in Women
High levels of β2-microglobulin are associated with an increased risk of ischemic stroke among women, according to a study published online ahead of print May 10 in Neurology. Researchers performed a nested case–control study among women enrolled in the Nurses’ Health Study who provided blood samples between 1989 and 1990 and were free of prior stroke and cancer. Investigators measured β2-microglobulin levels in 473 ischemic stroke cases and 473 controls matched on age, race, and other variables. Median levels of β2-microglobulin were 1.86 mg/L in cases and 1.80 mg/L in controls. Women in the highest β2-microglobulin quartile had a multivariable-adjusted increased risk of ischemic stroke, compared with women in the lowest quartile (odds ratio, 1.56). Results were similar when restricted to those without chronic kidney disease.
Rist PM, Jiménez MC, Rexrode KM. Prospective association between β2-microglobulin levels and ischemic stroke risk among women. Neurology. 2017 May 10 [Epub ahead of print].
Female Hormones May Cause Headache in Girls With Migraine
Age and pubertal development could moderate the effect of ovarian hormones on days of headache onset in girls with migraine, according to a study published online ahead of print May 8 in Cephalalgia. The study included 34 girls with migraine grouped into three age strata (ie, prepubertal, pubertal, and postpubertal). Participants collected daily urine samples and recorded the occurrence and severity of headache in a daily diary. Urine samples were assayed for estrone glucuronide and pregnandiol glucuronide, and the daily change in each was calculated. The primary outcome measures were headache onset days and headache severity. Models of headache onset days demonstrated a significant interaction between age and pregnandiol glucuronide. Change in pregnandiol glucuronide was associated with headache severity.
Martin VT, Allen JR, Houle TT, et al. Ovarian hormones, age and pubertal development and their association with days of headache onset in girls with migraine: an observational cohort study. Cephalalgia. 2017 Jan 1 [Epub ahead of print].
PTSD Is Associated With Risk for Dementia Diagnosis
Posttraumatic stress disorder (PTSD) diagnosis is associated with an increased risk for dementia diagnosis that varies with psychotropic medication, according to a study published in the May issue of the Journal of the American Geriatrics Society. Researchers examined information from 417,172 veterans age 56 and older without dementia or mild cognitive impairment. During the study’s nine-year follow-up period, participants had a clinical encounter every two years. PTSD diagnosis significantly increased the risk for dementia diagnosis. The hazard ratio for dementia diagnosis among veterans diagnosed with PTSD who did not use psychotropic medications was 1.55. Among veterans diagnosed with PTSD and prescribed psychotropic medication, the hazard ratio for dementia diagnosis ranged from 1.99 for SSRIs to 4.21 for atypical antipsychotics.
Mawanda F, Wallace RB, McCoy K, Abrams TE. PTSD, psychotropic medication use, and the risk of dementia among US veterans: a retrospective cohort study. J Am Geriatr Soc. 2017;65(5):1043-1050.
Screening for Atrial Fibrillation Recommended
Screening for asymptomatic atrial fibrillation in people age 65 and older and treating it with anticoagulant medications could greatly reduce the risk of stroke and premature death, according to the AF-SCREEN International Collaboration report published May 9 in Circulation. In 2016, 60 members of the collaboration, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare a draft document. They concluded that screen-detected atrial fibrillation found at a single timepoint or by intermittent ECG recordings over two weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. Handheld ECG devices are preferred as screening tools because they provide a verifiable ECG trace that guidelines require for diagnosis, said the authors.
Freedman B, Camm J, Calkins H, et al. Screening for atrial fibrillation: a report of the AF-SCREEN international collaboration. Circulation. 2017;135(19):1851-1867.
Can Music Reduce Depressive Symptoms in Dementia?
Providing people with dementia with at least five sessions of a music-based therapeutic intervention probably reduces depressive symptoms, but has little or no effect on agitation or aggression, according to a study published online ahead of print May 2 in the Cochrane Database of Systematic Reviews. Researchers searched ALOIS on April 14, 2010, using the terms “music therapy,” “music,” “singing,” “sing,” and “auditory stimulation.” Sixteen studies with a total of 620 participants contributed data to meta-analyses. Participants in the studies had dementia of varying severity. The investigators found that music-based therapeutic interventions may have little or no effect on emotional well-being and quality of life, overall behavior problems, and cognition. Study authors also found moderate-quality evidence that these interventions reduce depressive symptoms, but do not decrease agitation or aggression.
van der Steen JT, van Soest-Poortvliet MC, van der Wouden JC, et al. Music-based therapeutic interventions for people with dementia. Cochrane Database Syst Rev. 2017 May 2 [Epub ahead of print].
FDA Approves Radicava for Treatment of ALS
The FDA has approved Radicava (edaravone) as an IV treatment for amyotrophic lateral sclerosis (ALS). A phase III study evaluated the efficacy and safety of Radicava, compared with placebo, in 137 people with ALS. After a 12-week preobservation period, eligible patients were randomized 1:1 to receive 60 mg of Radicava in an IV for 60 minutes or placebo during a six-month double-blind phase. People given Radicava showed significantly less decline in physical function, compared with controls, as measured by the ALS Functional Rating Scale-Revised. The most common adverse reactions that occurred in greater than 10% of patients and greater than placebo were bruising, walking difficulties, and headache. Radicava is administered in 28-day cycles. MT Pharma America, headquartered in Jersey City, New Jersey, markets Radicava.
Can Cooling the Body Reduce Brain Injury?
Cooling the body may reduce brain injury for people in a coma after being revived from cardiac arrest, according to a guideline published online ahead of print May 10 in Neurology. Researchers reviewed evidence from studies of methods to reduce brain injury in people who are comatose after resuscitation from cardiac arrest. The guideline found that for patients who are treated with electric shocks to the heart after out-of-hospital cardiac arrest and who are in a coma, cooling the body to 89.6 to 93.2 °F for 24 hours effectively improves the chance of recovering brain function. The authors also found that keeping the body cooled to 96.8 °F for 24 hours, followed by rewarming to 99.5 °F over eight hours, effectively reduces brain injury after cardiac arrest.
Geocadin RG, Wijdicks E, Armstrong MJ, et al. Practice guideline summary: reducing brain injury following cardiopulmonary resuscitation: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2017 May 10 [Epub ahead of print].
Granger Causality Analysis Can Localize Ictal Networks
Granger causality analysis has the potential to help localize ictal networks from interictal data, according to a study published online ahead of print May 2 in Neurosurgery. For this study, 20-minute interictal baselines were obtained from 25 patients with hard-to-treat epilepsy who previously had had long-term EEG monitoring. The Granger causality maps were quantitatively compared with conventionally constructed surgical plans by using rank order and Cartesian distance statistics. In 16 of 25 participants, the interictal Granger causality rankings of the electrodes in the ictally active electrode set were lower than predicted by chance. The Granger causality maps thus likely correlated with ictal networks. The distance from the highest Granger causality electrode to the ictally active electrode set and to the resection averaged 6 and 4 mm, respectively.
Park EH, Madsen JR. Granger causality analysis of interictal iEEG predicts seizure focus and ultimate resection. Neurosurgery. 2017 May 2 [Epub ahead of print].
Tourette Disorder Risk Genes Identified
Researchers have identified the first risk gene for Tourette disorder and three other probable risk genes, according to a study published May 3 in Neuron. Researchers analyzed genomic data from 311 trios of children with Tourette disorder and their parents. Data were collected by the Tourette International Collaborative Genetics group. The authors found strong evidence that variants of WWC1 can play a significant role in triggering the disorder. Investigators conducted a replication study in 173 trios and found the same results. Extrapolating from the number of de novo variants, investigators estimated that approximately 12% of Tourette disorder cases are likely to involve de novo variants. The genes CELSR3, NIPBL, and FN1 were identified as having at least 70% probability of contributing to Tourette disorder.
Willsey AJ, Fernandez TV, Yu D, et al. De novo coding variants are strongly associated with Tourette disorder. Neuron. 2017;94(3):486-499.
—Kimberly Williams
Conference News Roundup—Heart Rhythm Society
Experts Release Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation
The Heart Rhythm Society, in joint partnership with heart societies from around the world, issued an international consensus statement that provides a state-of-the-art review of the indications, techniques, and outcomes of catheter and surgical ablation of atrial fibrillation (AF). This document is a complete and comprehensive revision of the 2012 statement.
“The rate of advancement in the tools, techniques, and outcomes of AF ablation continues to increase at a rapid pace. Our writing group worked together to revise the current recommendations to address the medical advancements that have really evolved over the last five years,” said Hugh Calkins, MD, Nicholas J. Fortuin, MD, Professor of Cardiology and Director of the Electrophysiology Laboratory and Arrhythmia Service at the Johns Hopkins Hospital in Baltimore. “It is our hope that this document can help improve patient care by providing a foundation for everyone involved in the care of AF patients, including clinicians who perform catheter or surgical ablations.”
For the first time, the writing group, comprising 60 experts from international organizations, addressed the issue of catheter ablation of AF in select asymptomatic patients. The group also addressed the issues of AF ablation as first-line therapy, the role of AF ablation in patients with heart failure, anticoagulation recommendations for patients undergoing ablation therapy, and the role of AF ablation in subgroups of patients not well represented in clinical trials. Recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including relevant definitions, were also offered.
The final decision regarding care of a patient should be made by health care providers and their patients in light of all the circumstances presented by the patient, according to the authors. The document was published in the online edition of HeartRhythm, the official journal of the Heart Rhythm Society.
Long-Term Use of Aspirin Does Not Lower Risk of Stroke in Some Patients With Atrial Fibrillation
Using long-term aspirin therapy to prevent strokes among patients who are considered to be at low risk for stroke may not be effective as previously thought.
Patients with atrial fibrillation (AF) who received a catheter ablation and were at low risk of stroke did not benefit from long-term aspirin therapy, but were at risk of higher rates of bleeding, compared with patients who received no therapy at all.
“When AF patients are considered low risk for stroke, physicians often treat them with aspirin rather than stronger anticoagulants to further lower that risk,” said Jared Bunch, MD, Director of Heart Rhythm Research at the Intermountain Medical Center Heart Institute in Salt Lake City. “What was unknown was if aspirin was a safe and effective stroke prevention treatment after an ablation in lower-risk AF patients. Traditionally, lower-risk AF patients have been treated with aspirin without significant supportive data.”
Dr. Bunch and his team investigated the impact of long-term use of aspirin in 4,124 low-risk patients with AF who underwent catheter ablation. During a three-year period, those who were on aspirin had a significantly higher risk for gastrointestinal bleeding and genitourinary bleeding, compared with those on warfarin or those who were untreated.
“In both the general and medical communities, aspirin therapy is perceived to reduce risks,” said Dr. Bunch. “It is easy to prescribe, and it is available worldwide over the counter. There has always been little evidence to support its use for stroke prevention in AF patients. This study continues to show that aspirin has little to no benefit for stroke prevention in AF patients, and when used in low-risk patients, it significantly increases a patient’s bleeding risk.”
Artificial Intelligence Automatically Detects Atrial Fibrillation
The Apple Watch’s heart rate sensor, when paired with an artificial intelligence-based algorithm, can detect atrial fibrillation (AF). The research uses a deep neural network (DNN) based on photoplethysmographic (PPG) sensors commonly found in smart watches.
The study enrolled 6,158 users of Cardiogram for Apple Watch into the University of California, San Francisco (UCSF) Health eHeart Study. Data from those participants—including 139 million heart rate measurements and 6,338 mobile ECGs—were used to train a DNN to automatically distinguish AF from normal heart rhythm.
The DNN was validated against a cohort of 51 patients scheduled to undergo cardioversion. Each patient wore an Apple Watch for 20 minutes before and after cardioversion. With a 12-lead ECG as a reference standard, the DNN correctly detected AF with an accuracy of 97%, a sensitivity of 98.04%, and a specificity of 90.20%, which were higher than those of previously validated algorithms for the detection of AF.
“Our results show that common wearable trackers like smartwatches present a novel opportunity to monitor, capture, and prompt medical therapy for AF without any active effort from patients,” said senior author Gregory M. Marcus, MD, Endowed Professor of AF Research and Director of Clinical Research for the Division of Cardiology at UCSF. “While mobile technology screening will not replace more conventional monitoring methods, it has the potential to successfully screen those at an increased risk and lower the number of undiagnosed cases of AF.”
Delayed Use of Blood Thinners for Atrial Fibrillation Increases Risk of Dementia
Dementia rates increase when anticoagulation treatment is delayed for patients with atrial fibrillation. A large-scale study included more than 76,000 patients with atrial fibrillation with no prior history of dementia who were treated with an antiplatelet or warfarin.
Researchers studied patients from the time of their atrial fibrillation diagnosis to actual start of an antiplatelet agent or anticoagulation therapy. Patients were then grouped into two categories: those who received immediate treatment (started less than 30 days after diagnosis) and those who received delayed treatment (started after one year).
Using the CHADS2 VASc score to predict stroke risks and identify those at highest risk of cognitive decline with a delay in therapy, researchers found that the risk of dementia in low-risk patients was 30% higher for those who received delayed treatment, and a significant 136% higher for high-risk patients.
Researchers also found that when the time period of delays was analyzed as a spectrum including less than 30 days, 31 days to one year, one to three years, and longer than three years, the risk of dementia increased as the delays in warfarin initiation increased.
“Our results reinforce the importance of starting anticoagulation treatment as early as possible after a patient is diagnosed with atrial fibrillation,” said Jared Bunch, MD, Director of Heart Rhythm Research at the Intermountain Medical Center Heart Institute in Salt Lake City.
Experts Release Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation
The Heart Rhythm Society, in joint partnership with heart societies from around the world, issued an international consensus statement that provides a state-of-the-art review of the indications, techniques, and outcomes of catheter and surgical ablation of atrial fibrillation (AF). This document is a complete and comprehensive revision of the 2012 statement.
“The rate of advancement in the tools, techniques, and outcomes of AF ablation continues to increase at a rapid pace. Our writing group worked together to revise the current recommendations to address the medical advancements that have really evolved over the last five years,” said Hugh Calkins, MD, Nicholas J. Fortuin, MD, Professor of Cardiology and Director of the Electrophysiology Laboratory and Arrhythmia Service at the Johns Hopkins Hospital in Baltimore. “It is our hope that this document can help improve patient care by providing a foundation for everyone involved in the care of AF patients, including clinicians who perform catheter or surgical ablations.”
For the first time, the writing group, comprising 60 experts from international organizations, addressed the issue of catheter ablation of AF in select asymptomatic patients. The group also addressed the issues of AF ablation as first-line therapy, the role of AF ablation in patients with heart failure, anticoagulation recommendations for patients undergoing ablation therapy, and the role of AF ablation in subgroups of patients not well represented in clinical trials. Recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including relevant definitions, were also offered.
The final decision regarding care of a patient should be made by health care providers and their patients in light of all the circumstances presented by the patient, according to the authors. The document was published in the online edition of HeartRhythm, the official journal of the Heart Rhythm Society.
Long-Term Use of Aspirin Does Not Lower Risk of Stroke in Some Patients With Atrial Fibrillation
Using long-term aspirin therapy to prevent strokes among patients who are considered to be at low risk for stroke may not be effective as previously thought.
Patients with atrial fibrillation (AF) who received a catheter ablation and were at low risk of stroke did not benefit from long-term aspirin therapy, but were at risk of higher rates of bleeding, compared with patients who received no therapy at all.
“When AF patients are considered low risk for stroke, physicians often treat them with aspirin rather than stronger anticoagulants to further lower that risk,” said Jared Bunch, MD, Director of Heart Rhythm Research at the Intermountain Medical Center Heart Institute in Salt Lake City. “What was unknown was if aspirin was a safe and effective stroke prevention treatment after an ablation in lower-risk AF patients. Traditionally, lower-risk AF patients have been treated with aspirin without significant supportive data.”
Dr. Bunch and his team investigated the impact of long-term use of aspirin in 4,124 low-risk patients with AF who underwent catheter ablation. During a three-year period, those who were on aspirin had a significantly higher risk for gastrointestinal bleeding and genitourinary bleeding, compared with those on warfarin or those who were untreated.
“In both the general and medical communities, aspirin therapy is perceived to reduce risks,” said Dr. Bunch. “It is easy to prescribe, and it is available worldwide over the counter. There has always been little evidence to support its use for stroke prevention in AF patients. This study continues to show that aspirin has little to no benefit for stroke prevention in AF patients, and when used in low-risk patients, it significantly increases a patient’s bleeding risk.”
Artificial Intelligence Automatically Detects Atrial Fibrillation
The Apple Watch’s heart rate sensor, when paired with an artificial intelligence-based algorithm, can detect atrial fibrillation (AF). The research uses a deep neural network (DNN) based on photoplethysmographic (PPG) sensors commonly found in smart watches.
The study enrolled 6,158 users of Cardiogram for Apple Watch into the University of California, San Francisco (UCSF) Health eHeart Study. Data from those participants—including 139 million heart rate measurements and 6,338 mobile ECGs—were used to train a DNN to automatically distinguish AF from normal heart rhythm.
The DNN was validated against a cohort of 51 patients scheduled to undergo cardioversion. Each patient wore an Apple Watch for 20 minutes before and after cardioversion. With a 12-lead ECG as a reference standard, the DNN correctly detected AF with an accuracy of 97%, a sensitivity of 98.04%, and a specificity of 90.20%, which were higher than those of previously validated algorithms for the detection of AF.
“Our results show that common wearable trackers like smartwatches present a novel opportunity to monitor, capture, and prompt medical therapy for AF without any active effort from patients,” said senior author Gregory M. Marcus, MD, Endowed Professor of AF Research and Director of Clinical Research for the Division of Cardiology at UCSF. “While mobile technology screening will not replace more conventional monitoring methods, it has the potential to successfully screen those at an increased risk and lower the number of undiagnosed cases of AF.”
Delayed Use of Blood Thinners for Atrial Fibrillation Increases Risk of Dementia
Dementia rates increase when anticoagulation treatment is delayed for patients with atrial fibrillation. A large-scale study included more than 76,000 patients with atrial fibrillation with no prior history of dementia who were treated with an antiplatelet or warfarin.
Researchers studied patients from the time of their atrial fibrillation diagnosis to actual start of an antiplatelet agent or anticoagulation therapy. Patients were then grouped into two categories: those who received immediate treatment (started less than 30 days after diagnosis) and those who received delayed treatment (started after one year).
Using the CHADS2 VASc score to predict stroke risks and identify those at highest risk of cognitive decline with a delay in therapy, researchers found that the risk of dementia in low-risk patients was 30% higher for those who received delayed treatment, and a significant 136% higher for high-risk patients.
Researchers also found that when the time period of delays was analyzed as a spectrum including less than 30 days, 31 days to one year, one to three years, and longer than three years, the risk of dementia increased as the delays in warfarin initiation increased.
“Our results reinforce the importance of starting anticoagulation treatment as early as possible after a patient is diagnosed with atrial fibrillation,” said Jared Bunch, MD, Director of Heart Rhythm Research at the Intermountain Medical Center Heart Institute in Salt Lake City.
Experts Release Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation
The Heart Rhythm Society, in joint partnership with heart societies from around the world, issued an international consensus statement that provides a state-of-the-art review of the indications, techniques, and outcomes of catheter and surgical ablation of atrial fibrillation (AF). This document is a complete and comprehensive revision of the 2012 statement.
“The rate of advancement in the tools, techniques, and outcomes of AF ablation continues to increase at a rapid pace. Our writing group worked together to revise the current recommendations to address the medical advancements that have really evolved over the last five years,” said Hugh Calkins, MD, Nicholas J. Fortuin, MD, Professor of Cardiology and Director of the Electrophysiology Laboratory and Arrhythmia Service at the Johns Hopkins Hospital in Baltimore. “It is our hope that this document can help improve patient care by providing a foundation for everyone involved in the care of AF patients, including clinicians who perform catheter or surgical ablations.”
For the first time, the writing group, comprising 60 experts from international organizations, addressed the issue of catheter ablation of AF in select asymptomatic patients. The group also addressed the issues of AF ablation as first-line therapy, the role of AF ablation in patients with heart failure, anticoagulation recommendations for patients undergoing ablation therapy, and the role of AF ablation in subgroups of patients not well represented in clinical trials. Recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including relevant definitions, were also offered.
The final decision regarding care of a patient should be made by health care providers and their patients in light of all the circumstances presented by the patient, according to the authors. The document was published in the online edition of HeartRhythm, the official journal of the Heart Rhythm Society.
Long-Term Use of Aspirin Does Not Lower Risk of Stroke in Some Patients With Atrial Fibrillation
Using long-term aspirin therapy to prevent strokes among patients who are considered to be at low risk for stroke may not be effective as previously thought.
Patients with atrial fibrillation (AF) who received a catheter ablation and were at low risk of stroke did not benefit from long-term aspirin therapy, but were at risk of higher rates of bleeding, compared with patients who received no therapy at all.
“When AF patients are considered low risk for stroke, physicians often treat them with aspirin rather than stronger anticoagulants to further lower that risk,” said Jared Bunch, MD, Director of Heart Rhythm Research at the Intermountain Medical Center Heart Institute in Salt Lake City. “What was unknown was if aspirin was a safe and effective stroke prevention treatment after an ablation in lower-risk AF patients. Traditionally, lower-risk AF patients have been treated with aspirin without significant supportive data.”
Dr. Bunch and his team investigated the impact of long-term use of aspirin in 4,124 low-risk patients with AF who underwent catheter ablation. During a three-year period, those who were on aspirin had a significantly higher risk for gastrointestinal bleeding and genitourinary bleeding, compared with those on warfarin or those who were untreated.
“In both the general and medical communities, aspirin therapy is perceived to reduce risks,” said Dr. Bunch. “It is easy to prescribe, and it is available worldwide over the counter. There has always been little evidence to support its use for stroke prevention in AF patients. This study continues to show that aspirin has little to no benefit for stroke prevention in AF patients, and when used in low-risk patients, it significantly increases a patient’s bleeding risk.”
Artificial Intelligence Automatically Detects Atrial Fibrillation
The Apple Watch’s heart rate sensor, when paired with an artificial intelligence-based algorithm, can detect atrial fibrillation (AF). The research uses a deep neural network (DNN) based on photoplethysmographic (PPG) sensors commonly found in smart watches.
The study enrolled 6,158 users of Cardiogram for Apple Watch into the University of California, San Francisco (UCSF) Health eHeart Study. Data from those participants—including 139 million heart rate measurements and 6,338 mobile ECGs—were used to train a DNN to automatically distinguish AF from normal heart rhythm.
The DNN was validated against a cohort of 51 patients scheduled to undergo cardioversion. Each patient wore an Apple Watch for 20 minutes before and after cardioversion. With a 12-lead ECG as a reference standard, the DNN correctly detected AF with an accuracy of 97%, a sensitivity of 98.04%, and a specificity of 90.20%, which were higher than those of previously validated algorithms for the detection of AF.
“Our results show that common wearable trackers like smartwatches present a novel opportunity to monitor, capture, and prompt medical therapy for AF without any active effort from patients,” said senior author Gregory M. Marcus, MD, Endowed Professor of AF Research and Director of Clinical Research for the Division of Cardiology at UCSF. “While mobile technology screening will not replace more conventional monitoring methods, it has the potential to successfully screen those at an increased risk and lower the number of undiagnosed cases of AF.”
Delayed Use of Blood Thinners for Atrial Fibrillation Increases Risk of Dementia
Dementia rates increase when anticoagulation treatment is delayed for patients with atrial fibrillation. A large-scale study included more than 76,000 patients with atrial fibrillation with no prior history of dementia who were treated with an antiplatelet or warfarin.
Researchers studied patients from the time of their atrial fibrillation diagnosis to actual start of an antiplatelet agent or anticoagulation therapy. Patients were then grouped into two categories: those who received immediate treatment (started less than 30 days after diagnosis) and those who received delayed treatment (started after one year).
Using the CHADS2 VASc score to predict stroke risks and identify those at highest risk of cognitive decline with a delay in therapy, researchers found that the risk of dementia in low-risk patients was 30% higher for those who received delayed treatment, and a significant 136% higher for high-risk patients.
Researchers also found that when the time period of delays was analyzed as a spectrum including less than 30 days, 31 days to one year, one to three years, and longer than three years, the risk of dementia increased as the delays in warfarin initiation increased.
“Our results reinforce the importance of starting anticoagulation treatment as early as possible after a patient is diagnosed with atrial fibrillation,” said Jared Bunch, MD, Director of Heart Rhythm Research at the Intermountain Medical Center Heart Institute in Salt Lake City.
How to Diagnose and Treat Rare Movement Disorders
MIAMI—When evaluating a patient with a movement disorder that seems to be rare, neurologists should employ their clinical expertise and consider a broad range of possible causes, said Anthony E. Lang, MD, Professor and Director of Neurology at the University of Toronto. 
“Not everything is going to be diagnosed with whole exome sequencing,” Dr. Lang said at the First Pan American Parkinson’s Disease and Movement Disorders Congress. “Think much more broadly than that, or you are going to miss some important diagnoses and, in some cases, miss quite treatable diagnoses.”
A patient’s history, the physical and neurologic exam, and laboratory and genetic testing are important tools in developing a differential diagnosis. Once a diagnosis has been made, certain disorders may entail a risk of long-term complications that require preventive measures and surveillance.
Dr. Lang cochairs an annual session at the International Congress of Parkinson’s Disease and Movement Disorders that features video presentations of unusual cases. “The more you are aware of and the more you have seen, the more you may have an impact on helping the patient,” he said.
Think Broadly
Approximately 80% of rare diseases are genetic, and modern molecular genetic tests increasingly allow neurologists to make accurate diagnoses. Other causes of rare movement disorders include autoimmune disease, infection, neoplasms, environmental exposures, degenerative disorders, and deficiency states.
Camilo Toro, MD, a neurologist with the NIH Undiagnosed Diseases Program, advises that the classical phenotypes of rare diseases often represent the worst-case scenario, Dr. Lang said. Neurologists increasingly are recognizing broader phenotypic variability and milder forms of rare genetic diseases. In addition, the boundaries between pediatric and adult genetic disorders are blurred, and a patient with more than one genetic disorder may have a blended phenotype. It is also possible that a patient has a rare presentation of a common disorder.
Patient and Family History
Neurologists should consider how a movement disorder began (eg, triggers or precipitants) and whether a patient has other neurologic or general medical illnesses. A patient’s old images, videos, and laboratory tests may offer insights. Genetic counselors can be a valuable resource for neurologists who are interested in learning how to take a careful family history.
Possible sources of confusion about the inheritance of genetic disorders include de novo mutations, missed family history of a disorder (eg, if a relative has a mild manifestation), incomplete penetrance of dominant disorders, incorrect attribution of paternity, and the possibility of pseudodominance in inbred families with recessive disorders. Other types of inheritance include maternal inheritance, maternal imprinting (eg, in myoclonus dystonia), and uniparental disomy.
General and Neurologic Examinations
A patient’s habitus, stature, and facial dysmorphism may be informative. After seeing a patient with Woodhouse-Sakati syndrome in a case that had been presented at a conference, Dr. Lang recognized that he had a patient with the same facial characteristics. “Sure enough, the patient has Woodhouse-Sakati syndrome,” he said.
Patients with 22q11.2 deletion syndrome may have variable craniofacial features, and Dr. Lang’s clinic is following a number of patients with parkinsonism or other movement disorders as a consequence of this disorder.
Skin and related features, including telangiectasia, pigmentation, and nails, may suggest a diagnosis (eg, blue lunula in Wilson’s disease), as can the heart and other organs.
In addition to movements, other information can be gleaned from the eye during an examination, such as the presence of a sunflower cataract (which may suggest Wilson’s disease), a cherry-red spot on the retina (sialidosis), or choreoretinitis with maculopathy and optic atrophy (eg, subacute sclerosing panencephalitis).
During the neurologic examination, neurologists can assess behavior, language, cranial nerves, upper and lower motor neuron signs, eye movement disorders (eg, opsoclonus, oculogyric crisis, oculomotor apraxia, and supranuclear gaze palsies), and the phenomenology, distribution, and timing of movement disorders. In addition, a sensory exam may be useful. Parkinsonism with pure dorsal column sensory abnormalities, for example, is characteristic of POLG1 mutations.
Laboratory Tests
Many laboratory tests are available, and neurologists should use them selectively. As a visiting professor, Dr. Lang sees many patients who have undergone unnecessary tests. “Do not use a shotgun approach,” Dr. Lang said. “Be focused. Use them intelligently.”
Various metabolic pathways can be altered in patients with inborn errors of metabolism, thus creating risk of decompensation. Tests for patients suspected of having an inborn error of metabolism may include blood gases, anion gap, ammonia, glucose, lactate, uric acid, creatine kinase, amino acids, insulin, urine organic acids, ketones, and reducing substances.
Blood can be tested for heavy metals, vitamin deficiencies, and antibodies. CSF testing may be invaluable, including real-time quaking-induced conversion in patients with a suspected prion disorder or, when warranted, evaluation for extremely rare disorders such as testing for folate in patients with suspected cerebral folate deficiency.
Tissue biopsies, EEG, and electroretinogram may reveal useful information, and movement disorders laboratory testing, including assessments for functional movement disorder studies (eg, back-averaging) can help diagnose selected conditions, including psychogenic movement disorders.
Imaging
Neurologists should be comfortable looking at neuroimaging to identify patterns of atrophy, the presence of heavy metals, or the occurrence of calcium, for example. Some rare movement disorders require vascular imaging. “Unexpected normal findings should be a clue as well,” he said. Dr. Lang described a patient who was thought to have cerebral palsy, but the patient’s MRI was normal. The patient ultimately was found to have ADCY5-related dyskinesia.
Basal ganglia lesions and recurrent episodes of encephalopathy may indicate that a patient has biotin-responsive basal ganglia disease. “This is a critical disorder for us to recognize,” Dr. Lang said, because a patient who is treated early enough with biotin and thiamine can make a striking recovery.
Punctate changes throughout the posterior fossa, the cerebellum, and the pons, as well as other regions, are characteristic of a vascular abnormality called chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), which can be treated with prednisone.
Genetic Testing
Genetic testing can help establish a diagnosis, but even in careful studies, whole exome sequencing may fail to provide a diagnosis in more than 40% of cases.
Problems with next-generation sequencing include incidental findings, variants of unknown significance, and the possibility of patients having two or more concomitant diseases or incompletely penetrant pathogenic variants. In addition, clinical exome sequencing does not detect repeat expansion disorders, copy number variations, structural variants, or abnormalities in the noncoding part of the genome.
A recently published case report further highlights the need for clinical expertise amid advances in genetic testing, Dr. Lang said. Zittel et al reported a case of a patient who came to a clinic with genetic test results showing that she had GCH1 and TH mutations. Clinically, however, neurologists determined that she had a functional movement disorder. When they went back to the original genetic testing laboratory, they discovered that the patient had doctored the form with the genetic test results. The authors deemed it a case of Munchausen syndrome by genetics.
Treatment
Neurologists should especially consider the possibility of movement disorders caused by autoimmune disease, infection, deficiency states, toxins, drugs, and treatable inborn errors of metabolism because treatment may alter the natural history of the disease and patient outcomes in these cases, Dr. Lang said.
Treatment of metabolic disorders typically requires a multidisciplinary team and may consist of substrate reduction, removal or enhanced clearance of toxic metabolites, replenishment of depleted metabolites, enzyme therapy, cell or organ replacement, and gene therapy.
Certain patients require long-term screening and follow-up to monitor for and prevent complications.
Avoiding infection, trauma, surgery, and vaccination may be important for patients with defects of small molecules. Patients with McLeod syndrome are at risk of transfusion reactions, and patients with ataxia-telangiectasia mutated gene variants should avoid ionizing radiation because of increased risk of malignancy. “If you are following patients with any of these rare disorders, you need to be aware of the long-term consequences,” Dr. Lang said.
In addition, online resources can provide useful information for neurologists who are evaluating patients with potentially rare movement disorders, including OMIM, GeneReviews, Orphanet, Face2Gene, SimulConsult, and MDSGene, Dr. Lang said.
—Jake Remaly
Suggested Reading
Gupta A, Lang AE. Psychogenic movement disorders. Curr Opin Neurol. 2009;22(4):430-436.
Sethi KD, Lang AE. Will new genetic techniques like exome sequencing obviate the need for clinical expertise? No. Mov Disord Clin Pract. 2017;4(1):39-41.
Ure RJ, Dhanju S, Lang AE, Fasano A. Unusual tremor syndromes: know in order to recognise. J Neurol Neurosurg Psychiatry. 2016;87(11):1191-1203.
Zittel S, Lohmann K, Bauer P, et al. Munchausen syndrome by genetics: Next-generation challenges for clinicians. Neurology. 2017;88(10):1000-1001.
MIAMI—When evaluating a patient with a movement disorder that seems to be rare, neurologists should employ their clinical expertise and consider a broad range of possible causes, said Anthony E. Lang, MD, Professor and Director of Neurology at the University of Toronto.
“Not everything is going to be diagnosed with whole exome sequencing,” Dr. Lang said at the First Pan American Parkinson’s Disease and Movement Disorders Congress. “Think much more broadly than that, or you are going to miss some important diagnoses and, in some cases, miss quite treatable diagnoses.”
A patient’s history, the physical and neurologic exam, and laboratory and genetic testing are important tools in developing a differential diagnosis. Once a diagnosis has been made, certain disorders may entail a risk of long-term complications that require preventive measures and surveillance.
Dr. Lang cochairs an annual session at the International Congress of Parkinson’s Disease and Movement Disorders that features video presentations of unusual cases. “The more you are aware of and the more you have seen, the more you may have an impact on helping the patient,” he said.
Think Broadly
Approximately 80% of rare diseases are genetic, and modern molecular genetic tests increasingly allow neurologists to make accurate diagnoses. Other causes of rare movement disorders include autoimmune disease, infection, neoplasms, environmental exposures, degenerative disorders, and deficiency states.
Camilo Toro, MD, a neurologist with the NIH Undiagnosed Diseases Program, advises that the classical phenotypes of rare diseases often represent the worst-case scenario, Dr. Lang said. Neurologists increasingly are recognizing broader phenotypic variability and milder forms of rare genetic diseases. In addition, the boundaries between pediatric and adult genetic disorders are blurred, and a patient with more than one genetic disorder may have a blended phenotype. It is also possible that a patient has a rare presentation of a common disorder.
Patient and Family History
Neurologists should consider how a movement disorder began (eg, triggers or precipitants) and whether a patient has other neurologic or general medical illnesses. A patient’s old images, videos, and laboratory tests may offer insights. Genetic counselors can be a valuable resource for neurologists who are interested in learning how to take a careful family history.
Possible sources of confusion about the inheritance of genetic disorders include de novo mutations, missed family history of a disorder (eg, if a relative has a mild manifestation), incomplete penetrance of dominant disorders, incorrect attribution of paternity, and the possibility of pseudodominance in inbred families with recessive disorders. Other types of inheritance include maternal inheritance, maternal imprinting (eg, in myoclonus dystonia), and uniparental disomy.
General and Neurologic Examinations
A patient’s habitus, stature, and facial dysmorphism may be informative. After seeing a patient with Woodhouse-Sakati syndrome in a case that had been presented at a conference, Dr. Lang recognized that he had a patient with the same facial characteristics. “Sure enough, the patient has Woodhouse-Sakati syndrome,” he said.
Patients with 22q11.2 deletion syndrome may have variable craniofacial features, and Dr. Lang’s clinic is following a number of patients with parkinsonism or other movement disorders as a consequence of this disorder.
Skin and related features, including telangiectasia, pigmentation, and nails, may suggest a diagnosis (eg, blue lunula in Wilson’s disease), as can the heart and other organs.
In addition to movements, other information can be gleaned from the eye during an examination, such as the presence of a sunflower cataract (which may suggest Wilson’s disease), a cherry-red spot on the retina (sialidosis), or choreoretinitis with maculopathy and optic atrophy (eg, subacute sclerosing panencephalitis).
During the neurologic examination, neurologists can assess behavior, language, cranial nerves, upper and lower motor neuron signs, eye movement disorders (eg, opsoclonus, oculogyric crisis, oculomotor apraxia, and supranuclear gaze palsies), and the phenomenology, distribution, and timing of movement disorders. In addition, a sensory exam may be useful. Parkinsonism with pure dorsal column sensory abnormalities, for example, is characteristic of POLG1 mutations.
Laboratory Tests
Many laboratory tests are available, and neurologists should use them selectively. As a visiting professor, Dr. Lang sees many patients who have undergone unnecessary tests. “Do not use a shotgun approach,” Dr. Lang said. “Be focused. Use them intelligently.”
Various metabolic pathways can be altered in patients with inborn errors of metabolism, thus creating risk of decompensation. Tests for patients suspected of having an inborn error of metabolism may include blood gases, anion gap, ammonia, glucose, lactate, uric acid, creatine kinase, amino acids, insulin, urine organic acids, ketones, and reducing substances.
Blood can be tested for heavy metals, vitamin deficiencies, and antibodies. CSF testing may be invaluable, including real-time quaking-induced conversion in patients with a suspected prion disorder or, when warranted, evaluation for extremely rare disorders such as testing for folate in patients with suspected cerebral folate deficiency.
Tissue biopsies, EEG, and electroretinogram may reveal useful information, and movement disorders laboratory testing, including assessments for functional movement disorder studies (eg, back-averaging) can help diagnose selected conditions, including psychogenic movement disorders.
Imaging
Neurologists should be comfortable looking at neuroimaging to identify patterns of atrophy, the presence of heavy metals, or the occurrence of calcium, for example. Some rare movement disorders require vascular imaging. “Unexpected normal findings should be a clue as well,” he said. Dr. Lang described a patient who was thought to have cerebral palsy, but the patient’s MRI was normal. The patient ultimately was found to have ADCY5-related dyskinesia.
Basal ganglia lesions and recurrent episodes of encephalopathy may indicate that a patient has biotin-responsive basal ganglia disease. “This is a critical disorder for us to recognize,” Dr. Lang said, because a patient who is treated early enough with biotin and thiamine can make a striking recovery.
Punctate changes throughout the posterior fossa, the cerebellum, and the pons, as well as other regions, are characteristic of a vascular abnormality called chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), which can be treated with prednisone.
Genetic Testing
Genetic testing can help establish a diagnosis, but even in careful studies, whole exome sequencing may fail to provide a diagnosis in more than 40% of cases.
Problems with next-generation sequencing include incidental findings, variants of unknown significance, and the possibility of patients having two or more concomitant diseases or incompletely penetrant pathogenic variants. In addition, clinical exome sequencing does not detect repeat expansion disorders, copy number variations, structural variants, or abnormalities in the noncoding part of the genome.
A recently published case report further highlights the need for clinical expertise amid advances in genetic testing, Dr. Lang said. Zittel et al reported a case of a patient who came to a clinic with genetic test results showing that she had GCH1 and TH mutations. Clinically, however, neurologists determined that she had a functional movement disorder. When they went back to the original genetic testing laboratory, they discovered that the patient had doctored the form with the genetic test results. The authors deemed it a case of Munchausen syndrome by genetics.
Treatment
Neurologists should especially consider the possibility of movement disorders caused by autoimmune disease, infection, deficiency states, toxins, drugs, and treatable inborn errors of metabolism because treatment may alter the natural history of the disease and patient outcomes in these cases, Dr. Lang said.
Treatment of metabolic disorders typically requires a multidisciplinary team and may consist of substrate reduction, removal or enhanced clearance of toxic metabolites, replenishment of depleted metabolites, enzyme therapy, cell or organ replacement, and gene therapy.
Certain patients require long-term screening and follow-up to monitor for and prevent complications.
Avoiding infection, trauma, surgery, and vaccination may be important for patients with defects of small molecules. Patients with McLeod syndrome are at risk of transfusion reactions, and patients with ataxia-telangiectasia mutated gene variants should avoid ionizing radiation because of increased risk of malignancy. “If you are following patients with any of these rare disorders, you need to be aware of the long-term consequences,” Dr. Lang said.
In addition, online resources can provide useful information for neurologists who are evaluating patients with potentially rare movement disorders, including OMIM, GeneReviews, Orphanet, Face2Gene, SimulConsult, and MDSGene, Dr. Lang said.
—Jake Remaly
Suggested Reading
Gupta A, Lang AE. Psychogenic movement disorders. Curr Opin Neurol. 2009;22(4):430-436.
Sethi KD, Lang AE. Will new genetic techniques like exome sequencing obviate the need for clinical expertise? No. Mov Disord Clin Pract. 2017;4(1):39-41.
Ure RJ, Dhanju S, Lang AE, Fasano A. Unusual tremor syndromes: know in order to recognise. J Neurol Neurosurg Psychiatry. 2016;87(11):1191-1203.
Zittel S, Lohmann K, Bauer P, et al. Munchausen syndrome by genetics: Next-generation challenges for clinicians. Neurology. 2017;88(10):1000-1001.
MIAMI—When evaluating a patient with a movement disorder that seems to be rare, neurologists should employ their clinical expertise and consider a broad range of possible causes, said Anthony E. Lang, MD, Professor and Director of Neurology at the University of Toronto.
“Not everything is going to be diagnosed with whole exome sequencing,” Dr. Lang said at the First Pan American Parkinson’s Disease and Movement Disorders Congress. “Think much more broadly than that, or you are going to miss some important diagnoses and, in some cases, miss quite treatable diagnoses.”
A patient’s history, the physical and neurologic exam, and laboratory and genetic testing are important tools in developing a differential diagnosis. Once a diagnosis has been made, certain disorders may entail a risk of long-term complications that require preventive measures and surveillance.
Dr. Lang cochairs an annual session at the International Congress of Parkinson’s Disease and Movement Disorders that features video presentations of unusual cases. “The more you are aware of and the more you have seen, the more you may have an impact on helping the patient,” he said.
Think Broadly
Approximately 80% of rare diseases are genetic, and modern molecular genetic tests increasingly allow neurologists to make accurate diagnoses. Other causes of rare movement disorders include autoimmune disease, infection, neoplasms, environmental exposures, degenerative disorders, and deficiency states.
Camilo Toro, MD, a neurologist with the NIH Undiagnosed Diseases Program, advises that the classical phenotypes of rare diseases often represent the worst-case scenario, Dr. Lang said. Neurologists increasingly are recognizing broader phenotypic variability and milder forms of rare genetic diseases. In addition, the boundaries between pediatric and adult genetic disorders are blurred, and a patient with more than one genetic disorder may have a blended phenotype. It is also possible that a patient has a rare presentation of a common disorder.
Patient and Family History
Neurologists should consider how a movement disorder began (eg, triggers or precipitants) and whether a patient has other neurologic or general medical illnesses. A patient’s old images, videos, and laboratory tests may offer insights. Genetic counselors can be a valuable resource for neurologists who are interested in learning how to take a careful family history.
Possible sources of confusion about the inheritance of genetic disorders include de novo mutations, missed family history of a disorder (eg, if a relative has a mild manifestation), incomplete penetrance of dominant disorders, incorrect attribution of paternity, and the possibility of pseudodominance in inbred families with recessive disorders. Other types of inheritance include maternal inheritance, maternal imprinting (eg, in myoclonus dystonia), and uniparental disomy.
General and Neurologic Examinations
A patient’s habitus, stature, and facial dysmorphism may be informative. After seeing a patient with Woodhouse-Sakati syndrome in a case that had been presented at a conference, Dr. Lang recognized that he had a patient with the same facial characteristics. “Sure enough, the patient has Woodhouse-Sakati syndrome,” he said.
Patients with 22q11.2 deletion syndrome may have variable craniofacial features, and Dr. Lang’s clinic is following a number of patients with parkinsonism or other movement disorders as a consequence of this disorder.
Skin and related features, including telangiectasia, pigmentation, and nails, may suggest a diagnosis (eg, blue lunula in Wilson’s disease), as can the heart and other organs.
In addition to movements, other information can be gleaned from the eye during an examination, such as the presence of a sunflower cataract (which may suggest Wilson’s disease), a cherry-red spot on the retina (sialidosis), or choreoretinitis with maculopathy and optic atrophy (eg, subacute sclerosing panencephalitis).
During the neurologic examination, neurologists can assess behavior, language, cranial nerves, upper and lower motor neuron signs, eye movement disorders (eg, opsoclonus, oculogyric crisis, oculomotor apraxia, and supranuclear gaze palsies), and the phenomenology, distribution, and timing of movement disorders. In addition, a sensory exam may be useful. Parkinsonism with pure dorsal column sensory abnormalities, for example, is characteristic of POLG1 mutations.
Laboratory Tests
Many laboratory tests are available, and neurologists should use them selectively. As a visiting professor, Dr. Lang sees many patients who have undergone unnecessary tests. “Do not use a shotgun approach,” Dr. Lang said. “Be focused. Use them intelligently.”
Various metabolic pathways can be altered in patients with inborn errors of metabolism, thus creating risk of decompensation. Tests for patients suspected of having an inborn error of metabolism may include blood gases, anion gap, ammonia, glucose, lactate, uric acid, creatine kinase, amino acids, insulin, urine organic acids, ketones, and reducing substances.
Blood can be tested for heavy metals, vitamin deficiencies, and antibodies. CSF testing may be invaluable, including real-time quaking-induced conversion in patients with a suspected prion disorder or, when warranted, evaluation for extremely rare disorders such as testing for folate in patients with suspected cerebral folate deficiency.
Tissue biopsies, EEG, and electroretinogram may reveal useful information, and movement disorders laboratory testing, including assessments for functional movement disorder studies (eg, back-averaging) can help diagnose selected conditions, including psychogenic movement disorders.
Imaging
Neurologists should be comfortable looking at neuroimaging to identify patterns of atrophy, the presence of heavy metals, or the occurrence of calcium, for example. Some rare movement disorders require vascular imaging. “Unexpected normal findings should be a clue as well,” he said. Dr. Lang described a patient who was thought to have cerebral palsy, but the patient’s MRI was normal. The patient ultimately was found to have ADCY5-related dyskinesia.
Basal ganglia lesions and recurrent episodes of encephalopathy may indicate that a patient has biotin-responsive basal ganglia disease. “This is a critical disorder for us to recognize,” Dr. Lang said, because a patient who is treated early enough with biotin and thiamine can make a striking recovery.
Punctate changes throughout the posterior fossa, the cerebellum, and the pons, as well as other regions, are characteristic of a vascular abnormality called chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), which can be treated with prednisone.
Genetic Testing
Genetic testing can help establish a diagnosis, but even in careful studies, whole exome sequencing may fail to provide a diagnosis in more than 40% of cases.
Problems with next-generation sequencing include incidental findings, variants of unknown significance, and the possibility of patients having two or more concomitant diseases or incompletely penetrant pathogenic variants. In addition, clinical exome sequencing does not detect repeat expansion disorders, copy number variations, structural variants, or abnormalities in the noncoding part of the genome.
A recently published case report further highlights the need for clinical expertise amid advances in genetic testing, Dr. Lang said. Zittel et al reported a case of a patient who came to a clinic with genetic test results showing that she had GCH1 and TH mutations. Clinically, however, neurologists determined that she had a functional movement disorder. When they went back to the original genetic testing laboratory, they discovered that the patient had doctored the form with the genetic test results. The authors deemed it a case of Munchausen syndrome by genetics.
Treatment
Neurologists should especially consider the possibility of movement disorders caused by autoimmune disease, infection, deficiency states, toxins, drugs, and treatable inborn errors of metabolism because treatment may alter the natural history of the disease and patient outcomes in these cases, Dr. Lang said.
Treatment of metabolic disorders typically requires a multidisciplinary team and may consist of substrate reduction, removal or enhanced clearance of toxic metabolites, replenishment of depleted metabolites, enzyme therapy, cell or organ replacement, and gene therapy.
Certain patients require long-term screening and follow-up to monitor for and prevent complications.
Avoiding infection, trauma, surgery, and vaccination may be important for patients with defects of small molecules. Patients with McLeod syndrome are at risk of transfusion reactions, and patients with ataxia-telangiectasia mutated gene variants should avoid ionizing radiation because of increased risk of malignancy. “If you are following patients with any of these rare disorders, you need to be aware of the long-term consequences,” Dr. Lang said.
In addition, online resources can provide useful information for neurologists who are evaluating patients with potentially rare movement disorders, including OMIM, GeneReviews, Orphanet, Face2Gene, SimulConsult, and MDSGene, Dr. Lang said.
—Jake Remaly
Suggested Reading
Gupta A, Lang AE. Psychogenic movement disorders. Curr Opin Neurol. 2009;22(4):430-436.
Sethi KD, Lang AE. Will new genetic techniques like exome sequencing obviate the need for clinical expertise? No. Mov Disord Clin Pract. 2017;4(1):39-41.
Ure RJ, Dhanju S, Lang AE, Fasano A. Unusual tremor syndromes: know in order to recognise. J Neurol Neurosurg Psychiatry. 2016;87(11):1191-1203.
Zittel S, Lohmann K, Bauer P, et al. Munchausen syndrome by genetics: Next-generation challenges for clinicians. Neurology. 2017;88(10):1000-1001.
Cord gas analysis can be beneficial but has drawbacks
“HOW AND WHEN UMBILICAL CORD GAS ANALYSIS CAN JUSTIFY YOUR OBSTETRIC MANAGEMENT”
MICHAEL G. ROSS, MD, MPH (MARCH 2017)
Cord gas analysis can be beneficial but has drawbacks
In his article, Dr. Ross makes a few statements I would like to challenge. He gives a list of indications for cord gas analysis, even with a vigorous newborn. I would suggest that doing so is not only unnecessary, but could get the delivering provider in trouble. Normal gases with a vigorous infant are not actionable, and neither are abnormal gases with a vigorous infant. The latter situation could, however, lower the bar for a lawsuit if any neurologic pathology is diagnosed in the child.
At our hospital, blood gas assessments generate charges of $90 for each arterial and venous sample. The author states that gases are helpful for staff education. If that is the purposeof measuring the gases when Apgar scores are normal, then the bill for the gases should be sent to the staff, not the patient or insurance company.
The precise reason for doing cord gases is to prove you are a good doctor. If the Apgar scores are low, a healthy set of gases shows that your interventions were timely and appropriate. Normal gases prevent lawsuits in this situation.
Joe Walsh, MD
Philadelphia, Pennsylvania
Dr. Ross responds
I appreciate the comments of Dr. Walsh, who suggests that we should not obtain cord gases in vigorous infants due, in part, to the hospital charges. There are several reasons for the indications detailed in the article. Although normal Apgar scores would appear to negate the potential for severe metabolic acidosis, Apgar scoring accuracy has been challenged in medical legal cases. Furthermore, there may be newborn complications (eg, pre-existing hypoxic injury, intraventricular bleed) that may not be recognized immediately, yet hypoxemia and acidosis may be alleged to have contributed to the outcome. The actual cost of running a blood gas sample is far less than the $90 hospital charges. Nevertheless, if hospital charge is a concern, I recommend that the physician obtain a cord gas sample immediately following the delivery and determine whether to run the sample after the 5-minute Apgar score is obtained.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“HOW AND WHEN UMBILICAL CORD GAS ANALYSIS CAN JUSTIFY YOUR OBSTETRIC MANAGEMENT”
MICHAEL G. ROSS, MD, MPH (MARCH 2017)
Cord gas analysis can be beneficial but has drawbacks
In his article, Dr. Ross makes a few statements I would like to challenge. He gives a list of indications for cord gas analysis, even with a vigorous newborn. I would suggest that doing so is not only unnecessary, but could get the delivering provider in trouble. Normal gases with a vigorous infant are not actionable, and neither are abnormal gases with a vigorous infant. The latter situation could, however, lower the bar for a lawsuit if any neurologic pathology is diagnosed in the child.
At our hospital, blood gas assessments generate charges of $90 for each arterial and venous sample. The author states that gases are helpful for staff education. If that is the purposeof measuring the gases when Apgar scores are normal, then the bill for the gases should be sent to the staff, not the patient or insurance company.
The precise reason for doing cord gases is to prove you are a good doctor. If the Apgar scores are low, a healthy set of gases shows that your interventions were timely and appropriate. Normal gases prevent lawsuits in this situation.
Joe Walsh, MD
Philadelphia, Pennsylvania
Dr. Ross responds
I appreciate the comments of Dr. Walsh, who suggests that we should not obtain cord gases in vigorous infants due, in part, to the hospital charges. There are several reasons for the indications detailed in the article. Although normal Apgar scores would appear to negate the potential for severe metabolic acidosis, Apgar scoring accuracy has been challenged in medical legal cases. Furthermore, there may be newborn complications (eg, pre-existing hypoxic injury, intraventricular bleed) that may not be recognized immediately, yet hypoxemia and acidosis may be alleged to have contributed to the outcome. The actual cost of running a blood gas sample is far less than the $90 hospital charges. Nevertheless, if hospital charge is a concern, I recommend that the physician obtain a cord gas sample immediately following the delivery and determine whether to run the sample after the 5-minute Apgar score is obtained.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“HOW AND WHEN UMBILICAL CORD GAS ANALYSIS CAN JUSTIFY YOUR OBSTETRIC MANAGEMENT”
MICHAEL G. ROSS, MD, MPH (MARCH 2017)
Cord gas analysis can be beneficial but has drawbacks
In his article, Dr. Ross makes a few statements I would like to challenge. He gives a list of indications for cord gas analysis, even with a vigorous newborn. I would suggest that doing so is not only unnecessary, but could get the delivering provider in trouble. Normal gases with a vigorous infant are not actionable, and neither are abnormal gases with a vigorous infant. The latter situation could, however, lower the bar for a lawsuit if any neurologic pathology is diagnosed in the child.
At our hospital, blood gas assessments generate charges of $90 for each arterial and venous sample. The author states that gases are helpful for staff education. If that is the purposeof measuring the gases when Apgar scores are normal, then the bill for the gases should be sent to the staff, not the patient or insurance company.
The precise reason for doing cord gases is to prove you are a good doctor. If the Apgar scores are low, a healthy set of gases shows that your interventions were timely and appropriate. Normal gases prevent lawsuits in this situation.
Joe Walsh, MD
Philadelphia, Pennsylvania
Dr. Ross responds
I appreciate the comments of Dr. Walsh, who suggests that we should not obtain cord gases in vigorous infants due, in part, to the hospital charges. There are several reasons for the indications detailed in the article. Although normal Apgar scores would appear to negate the potential for severe metabolic acidosis, Apgar scoring accuracy has been challenged in medical legal cases. Furthermore, there may be newborn complications (eg, pre-existing hypoxic injury, intraventricular bleed) that may not be recognized immediately, yet hypoxemia and acidosis may be alleged to have contributed to the outcome. The actual cost of running a blood gas sample is far less than the $90 hospital charges. Nevertheless, if hospital charge is a concern, I recommend that the physician obtain a cord gas sample immediately following the delivery and determine whether to run the sample after the 5-minute Apgar score is obtained.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Migraineurs Bear Stigma That Influences Health Outcomes
Stigma in Media and Society
Although neurologists and the general public acknowledge the symptoms and disability associated with a disease, they generally discount or fail to recognize its associated stigma, said Dr. Shapiro. Internalized stigma is a person’s sense that he or she is kept at a social distance, and enacted stigma refers to instances of discrimination on the basis of a person’s condition. Consequences of stigma include psychologic distress, low self-esteem, poor social outcomes, and poor health outcomes.
In a 2006 analysis, Caspermeyer et al examined 1,203 newspaper articles about neurologic conditions. They found that, after articles about epilepsy, articles about migraine contained the highest frequency of stigmatizing language (29%). Although migraine was among the most prevalent diseases in the analysis, it was among the least covered topics in newspaper articles.
To determine whether migraine is associated with stigma, Young and colleagues administered the Stigma Scale for Chronic Illness, a questionnaire, to patients with episodic migraine, chronic migraine, or epilepsy. The investigators observed that patients with chronic migraine and patients with epilepsy faced a similar amount of stigma. They further observed that stigma correlated most strongly with inability to work and was greater for chronic migraine than for epilepsy or episodic migraine.
Level of Stigma by Disease
Following these studies, Dr. Shapiro and colleagues investigated externalized stigma, or the rejection of others because of their condition. They polled adult members of the Amazon Mechanical Turk community, a group of approximately 500,000 people who voluntarily respond to surveys for modest monetary compensation. Compared with the US population, the Amazon Mechanical Turk community includes more women, Caucasians, young people, liberals, educated people, secular people, and people with low incomes. The group better represents the US population, however, than general Internet or university convenience samples do.
The investigators presented each respondent with one of four vignettes about people with a disease that does not respond well to treatment and that sometimes results in missed work or family activities. The vignettes were identical except for the condition named. The four conditions were migraine, epilepsy, panic disorder, and asthma. After reviewing the vignette, each respondent completed a validated stigma-assessment instrument using a Likert scale for each item.
In all, 765 people completed the instrument. Respondents’ mean age was 28, and 60% of the sample was female. There was no difference in the level of stigma attributed to migraine, panic disorder, or epilepsy, but respondents attributed less stigma to asthma than to the other three conditions. Noting the similar level of stigma between migraine and epilepsy, Dr. Shapiro said, “Epilepsy historically has been associated with demonic possession. If ever there were a disease that you would assume would have social distance or stigma attached, it certainly would be epilepsy.”
Disease and Productivity Loss
In a second study, Dr. Shapiro and colleagues presented members of the Amazon Mechanical Turk community with one of five vignettes. The vignettes described the following cases:
- A woman with migraine on four days per month who missed no workdays per year
- A woman with migraine on four days per month who missed two workdays per year
- A woman with migraine on 20 days per month who missed 10 workdays per year
- A man with migraine on four days per month who missed two workdays per year
- A woman with seizures on four days per month who missed two workdays per year.
Respondents then completed a social distance scale that included questions about the respondent’s willingness to socialize with, trust, hire, or allow the person in the vignette to marry into his or her family.
The researchers found that the level of externalized stigma was the same for the woman with migraine who missed two workdays per year as it was for the woman with epilepsy who missed two workdays per year. Respondents believed that the person with epilepsy would care more about whether he or she was a burden on others, compared with the migraineur. Respondents also said that the person with epilepsy would try harder and would be less likely to malinger, compared with the migraineur.
The gender of the person in the vignette was not associated with the level of stigma, said Dr. Shapiro. On the other hand, men were much more likely to stigmatize a man or a woman with migraine than women were.
In addition, the researchers found that the woman with chronic migraine who missed 10 workdays per year was much more likely to be stigmatized than migraineurs who missed fewer workdays. People who missed more workdays were less likely to be seen as trying hard, less likely to be interviewed, more likely to be considered malingerers, and less likely to be considered trustworthy.
Fear of Pain and Social Distance
As part of the same study, respondents completed instruments that measured fear of pain and empathy, and also provided demographic information, including migraine status. Overall, fear of pain was similar between migraineurs and nonmigraineurs. Migraineurs feared migraine as much as they feared falling down a flight of stairs or having a car door slammed on the hand. Nonmigraineurs, however, considered migraine to be less severe than migraineurs did. Among nonmigraineurs, greater fear of pain was associated with greater social distance from migraineurs. But in the same group, greater fear of migraine was associated with less social distance from migraineurs.
Furthermore, Dr. Shapiro’s group noted that the more migraine is part of a person’s experience, the less social distance that person maintains from migraineurs. Similarly, they found that as empathy increased, the social distance to migraine decreased.
Other findings included that younger people were more likely to stigmatize migraine than older people, and that non-Caucasians were more likely to stigmatize migraine than Caucasians. The gender of the stigmatizer was a dominant influence on the amount of stigma.
Reasons for Migraine Stigma
Various hypotheses offer potential reasons for stigmatizing migraine. Approximately 75% of migraineurs are women, and migraine changes with hormonal fluctuations. Hence, sexism against women may be one cause of stigma.
Also, migraine has been considered a behavior problem or conversion disorder for decades, said Dr. Shapiro. One illustration of this point is that a monograph published in 1926 identified migraine as a neurosis. In 1894, Freud described migraine as the result of a failure to find release after sexual stimulation.
Migraine is associated with headache, and headache has various connotations. The type of headache with which most people are familiar is tension-type headache, thus the general public may be likely to minimize the severity or importance of migraine. The word “headache” also connotes “concern” or “annoyance,” which may contribute to a minimization of migraine’s severity.
Whatever its origin, the stigma associated with migraine often is overlooked, said Dr. Shapiro. Neurologists should consider the potential effects of stigma on health outcomes as they treat patients with headache, he concluded.
—Erik Greb
Suggested Reading
Caspermeyer JJ, Sylvester EJ, Drazkowski JF, et al. Evaluation of stigmatizing language and medical errors in neurology coverage by US newspapers. Mayo Clin Proc. 2006;81(3):300-306.
Evans RW, Evans RE. A survey of neurologists on the likeability of headaches and other neurological disorders. Headache. 2010;50(7):1126-1129.
Evans RW, Evans RE, Kell HJ. A survey of family doctors on the likeability of migraine and other common diseases and their prevalence of migraine. Cephalalgia. 2010;30(5):620-623.
Young WB, Park JE, Tian IX, Kempner J. The stigma of migraine. PLoS One. 2013;8(1):e54074.
Stigma in Media and Society
Although neurologists and the general public acknowledge the symptoms and disability associated with a disease, they generally discount or fail to recognize its associated stigma, said Dr. Shapiro. Internalized stigma is a person’s sense that he or she is kept at a social distance, and enacted stigma refers to instances of discrimination on the basis of a person’s condition. Consequences of stigma include psychologic distress, low self-esteem, poor social outcomes, and poor health outcomes.
In a 2006 analysis, Caspermeyer et al examined 1,203 newspaper articles about neurologic conditions. They found that, after articles about epilepsy, articles about migraine contained the highest frequency of stigmatizing language (29%). Although migraine was among the most prevalent diseases in the analysis, it was among the least covered topics in newspaper articles.
To determine whether migraine is associated with stigma, Young and colleagues administered the Stigma Scale for Chronic Illness, a questionnaire, to patients with episodic migraine, chronic migraine, or epilepsy. The investigators observed that patients with chronic migraine and patients with epilepsy faced a similar amount of stigma. They further observed that stigma correlated most strongly with inability to work and was greater for chronic migraine than for epilepsy or episodic migraine.
Level of Stigma by Disease
Following these studies, Dr. Shapiro and colleagues investigated externalized stigma, or the rejection of others because of their condition. They polled adult members of the Amazon Mechanical Turk community, a group of approximately 500,000 people who voluntarily respond to surveys for modest monetary compensation. Compared with the US population, the Amazon Mechanical Turk community includes more women, Caucasians, young people, liberals, educated people, secular people, and people with low incomes. The group better represents the US population, however, than general Internet or university convenience samples do.
The investigators presented each respondent with one of four vignettes about people with a disease that does not respond well to treatment and that sometimes results in missed work or family activities. The vignettes were identical except for the condition named. The four conditions were migraine, epilepsy, panic disorder, and asthma. After reviewing the vignette, each respondent completed a validated stigma-assessment instrument using a Likert scale for each item.
In all, 765 people completed the instrument. Respondents’ mean age was 28, and 60% of the sample was female. There was no difference in the level of stigma attributed to migraine, panic disorder, or epilepsy, but respondents attributed less stigma to asthma than to the other three conditions. Noting the similar level of stigma between migraine and epilepsy, Dr. Shapiro said, “Epilepsy historically has been associated with demonic possession. If ever there were a disease that you would assume would have social distance or stigma attached, it certainly would be epilepsy.”
Disease and Productivity Loss
In a second study, Dr. Shapiro and colleagues presented members of the Amazon Mechanical Turk community with one of five vignettes. The vignettes described the following cases:
- A woman with migraine on four days per month who missed no workdays per year
- A woman with migraine on four days per month who missed two workdays per year
- A woman with migraine on 20 days per month who missed 10 workdays per year
- A man with migraine on four days per month who missed two workdays per year
- A woman with seizures on four days per month who missed two workdays per year.
Respondents then completed a social distance scale that included questions about the respondent’s willingness to socialize with, trust, hire, or allow the person in the vignette to marry into his or her family.
The researchers found that the level of externalized stigma was the same for the woman with migraine who missed two workdays per year as it was for the woman with epilepsy who missed two workdays per year. Respondents believed that the person with epilepsy would care more about whether he or she was a burden on others, compared with the migraineur. Respondents also said that the person with epilepsy would try harder and would be less likely to malinger, compared with the migraineur.
The gender of the person in the vignette was not associated with the level of stigma, said Dr. Shapiro. On the other hand, men were much more likely to stigmatize a man or a woman with migraine than women were.
In addition, the researchers found that the woman with chronic migraine who missed 10 workdays per year was much more likely to be stigmatized than migraineurs who missed fewer workdays. People who missed more workdays were less likely to be seen as trying hard, less likely to be interviewed, more likely to be considered malingerers, and less likely to be considered trustworthy.
Fear of Pain and Social Distance
As part of the same study, respondents completed instruments that measured fear of pain and empathy, and also provided demographic information, including migraine status. Overall, fear of pain was similar between migraineurs and nonmigraineurs. Migraineurs feared migraine as much as they feared falling down a flight of stairs or having a car door slammed on the hand. Nonmigraineurs, however, considered migraine to be less severe than migraineurs did. Among nonmigraineurs, greater fear of pain was associated with greater social distance from migraineurs. But in the same group, greater fear of migraine was associated with less social distance from migraineurs.
Furthermore, Dr. Shapiro’s group noted that the more migraine is part of a person’s experience, the less social distance that person maintains from migraineurs. Similarly, they found that as empathy increased, the social distance to migraine decreased.
Other findings included that younger people were more likely to stigmatize migraine than older people, and that non-Caucasians were more likely to stigmatize migraine than Caucasians. The gender of the stigmatizer was a dominant influence on the amount of stigma.
Reasons for Migraine Stigma
Various hypotheses offer potential reasons for stigmatizing migraine. Approximately 75% of migraineurs are women, and migraine changes with hormonal fluctuations. Hence, sexism against women may be one cause of stigma.
Also, migraine has been considered a behavior problem or conversion disorder for decades, said Dr. Shapiro. One illustration of this point is that a monograph published in 1926 identified migraine as a neurosis. In 1894, Freud described migraine as the result of a failure to find release after sexual stimulation.
Migraine is associated with headache, and headache has various connotations. The type of headache with which most people are familiar is tension-type headache, thus the general public may be likely to minimize the severity or importance of migraine. The word “headache” also connotes “concern” or “annoyance,” which may contribute to a minimization of migraine’s severity.
Whatever its origin, the stigma associated with migraine often is overlooked, said Dr. Shapiro. Neurologists should consider the potential effects of stigma on health outcomes as they treat patients with headache, he concluded.
—Erik Greb
Suggested Reading
Caspermeyer JJ, Sylvester EJ, Drazkowski JF, et al. Evaluation of stigmatizing language and medical errors in neurology coverage by US newspapers. Mayo Clin Proc. 2006;81(3):300-306.
Evans RW, Evans RE. A survey of neurologists on the likeability of headaches and other neurological disorders. Headache. 2010;50(7):1126-1129.
Evans RW, Evans RE, Kell HJ. A survey of family doctors on the likeability of migraine and other common diseases and their prevalence of migraine. Cephalalgia. 2010;30(5):620-623.
Young WB, Park JE, Tian IX, Kempner J. The stigma of migraine. PLoS One. 2013;8(1):e54074.
Stigma in Media and Society
Although neurologists and the general public acknowledge the symptoms and disability associated with a disease, they generally discount or fail to recognize its associated stigma, said Dr. Shapiro. Internalized stigma is a person’s sense that he or she is kept at a social distance, and enacted stigma refers to instances of discrimination on the basis of a person’s condition. Consequences of stigma include psychologic distress, low self-esteem, poor social outcomes, and poor health outcomes.
In a 2006 analysis, Caspermeyer et al examined 1,203 newspaper articles about neurologic conditions. They found that, after articles about epilepsy, articles about migraine contained the highest frequency of stigmatizing language (29%). Although migraine was among the most prevalent diseases in the analysis, it was among the least covered topics in newspaper articles.
To determine whether migraine is associated with stigma, Young and colleagues administered the Stigma Scale for Chronic Illness, a questionnaire, to patients with episodic migraine, chronic migraine, or epilepsy. The investigators observed that patients with chronic migraine and patients with epilepsy faced a similar amount of stigma. They further observed that stigma correlated most strongly with inability to work and was greater for chronic migraine than for epilepsy or episodic migraine.
Level of Stigma by Disease
Following these studies, Dr. Shapiro and colleagues investigated externalized stigma, or the rejection of others because of their condition. They polled adult members of the Amazon Mechanical Turk community, a group of approximately 500,000 people who voluntarily respond to surveys for modest monetary compensation. Compared with the US population, the Amazon Mechanical Turk community includes more women, Caucasians, young people, liberals, educated people, secular people, and people with low incomes. The group better represents the US population, however, than general Internet or university convenience samples do.
The investigators presented each respondent with one of four vignettes about people with a disease that does not respond well to treatment and that sometimes results in missed work or family activities. The vignettes were identical except for the condition named. The four conditions were migraine, epilepsy, panic disorder, and asthma. After reviewing the vignette, each respondent completed a validated stigma-assessment instrument using a Likert scale for each item.
In all, 765 people completed the instrument. Respondents’ mean age was 28, and 60% of the sample was female. There was no difference in the level of stigma attributed to migraine, panic disorder, or epilepsy, but respondents attributed less stigma to asthma than to the other three conditions. Noting the similar level of stigma between migraine and epilepsy, Dr. Shapiro said, “Epilepsy historically has been associated with demonic possession. If ever there were a disease that you would assume would have social distance or stigma attached, it certainly would be epilepsy.”
Disease and Productivity Loss
In a second study, Dr. Shapiro and colleagues presented members of the Amazon Mechanical Turk community with one of five vignettes. The vignettes described the following cases:
- A woman with migraine on four days per month who missed no workdays per year
- A woman with migraine on four days per month who missed two workdays per year
- A woman with migraine on 20 days per month who missed 10 workdays per year
- A man with migraine on four days per month who missed two workdays per year
- A woman with seizures on four days per month who missed two workdays per year.
Respondents then completed a social distance scale that included questions about the respondent’s willingness to socialize with, trust, hire, or allow the person in the vignette to marry into his or her family.
The researchers found that the level of externalized stigma was the same for the woman with migraine who missed two workdays per year as it was for the woman with epilepsy who missed two workdays per year. Respondents believed that the person with epilepsy would care more about whether he or she was a burden on others, compared with the migraineur. Respondents also said that the person with epilepsy would try harder and would be less likely to malinger, compared with the migraineur.
The gender of the person in the vignette was not associated with the level of stigma, said Dr. Shapiro. On the other hand, men were much more likely to stigmatize a man or a woman with migraine than women were.
In addition, the researchers found that the woman with chronic migraine who missed 10 workdays per year was much more likely to be stigmatized than migraineurs who missed fewer workdays. People who missed more workdays were less likely to be seen as trying hard, less likely to be interviewed, more likely to be considered malingerers, and less likely to be considered trustworthy.
Fear of Pain and Social Distance
As part of the same study, respondents completed instruments that measured fear of pain and empathy, and also provided demographic information, including migraine status. Overall, fear of pain was similar between migraineurs and nonmigraineurs. Migraineurs feared migraine as much as they feared falling down a flight of stairs or having a car door slammed on the hand. Nonmigraineurs, however, considered migraine to be less severe than migraineurs did. Among nonmigraineurs, greater fear of pain was associated with greater social distance from migraineurs. But in the same group, greater fear of migraine was associated with less social distance from migraineurs.
Furthermore, Dr. Shapiro’s group noted that the more migraine is part of a person’s experience, the less social distance that person maintains from migraineurs. Similarly, they found that as empathy increased, the social distance to migraine decreased.
Other findings included that younger people were more likely to stigmatize migraine than older people, and that non-Caucasians were more likely to stigmatize migraine than Caucasians. The gender of the stigmatizer was a dominant influence on the amount of stigma.
Reasons for Migraine Stigma
Various hypotheses offer potential reasons for stigmatizing migraine. Approximately 75% of migraineurs are women, and migraine changes with hormonal fluctuations. Hence, sexism against women may be one cause of stigma.
Also, migraine has been considered a behavior problem or conversion disorder for decades, said Dr. Shapiro. One illustration of this point is that a monograph published in 1926 identified migraine as a neurosis. In 1894, Freud described migraine as the result of a failure to find release after sexual stimulation.
Migraine is associated with headache, and headache has various connotations. The type of headache with which most people are familiar is tension-type headache, thus the general public may be likely to minimize the severity or importance of migraine. The word “headache” also connotes “concern” or “annoyance,” which may contribute to a minimization of migraine’s severity.
Whatever its origin, the stigma associated with migraine often is overlooked, said Dr. Shapiro. Neurologists should consider the potential effects of stigma on health outcomes as they treat patients with headache, he concluded.
—Erik Greb
Suggested Reading
Caspermeyer JJ, Sylvester EJ, Drazkowski JF, et al. Evaluation of stigmatizing language and medical errors in neurology coverage by US newspapers. Mayo Clin Proc. 2006;81(3):300-306.
Evans RW, Evans RE. A survey of neurologists on the likeability of headaches and other neurological disorders. Headache. 2010;50(7):1126-1129.
Evans RW, Evans RE, Kell HJ. A survey of family doctors on the likeability of migraine and other common diseases and their prevalence of migraine. Cephalalgia. 2010;30(5):620-623.
Young WB, Park JE, Tian IX, Kempner J. The stigma of migraine. PLoS One. 2013;8(1):e54074.
Saturday - On Tap
It’s the final day of the Vascular Annual Meeting – and there is plenty on the agenda to keep you busy.
6:30 to 8:00 a.m. – Three Breakfast Sessions: “Beyond the Basics of Hemodialysis Access,” “The Treatment of Chronic Venous Leg Ulcers,” and “How to Write a Paper and Have it Accepted in the JVS or EJVES.”
8:00 to 10:00 a.m. – Plenary 7 and Plenary 8. With so many high-quality abstracts submitted, two plenary sessions are set for Saturday; Plenary 8 includes late-breaking abstracts and the Vascular Quality Initiative. SDCC, Room 6 A/B
9:00 a.m. to 1:00 p.m. – It’s your last chance to visit the Exhibit Hall to see what’s new and improved. Exhibit Hall B.
10:30 a.m. to 12:00 p.m. – Four concurrent sessions, on the modern VA vascular practice and three joint sessions with an alphabet soup of allied societies, on medical management of vascular disease (SVM), collaboration of vascular surgeons and nurses (SVN), and building and managing a vascular laboratory (SVU).
10:30 a.m. to 12:00 p.m. – Top 10 papers relevant to vascular surgery that were NOT published in the Journal of Vascular Surgery. SDCC, Room 6 A/B.
12:00 p.m. – SVS members, see the passing of the gavel and other business issues, as well as award presentations. SDCC, Room 6 D/E.
1:30 to 3:30 p.m. – Sometimes seeing makes more of an impact than listening. The “How I do it” Video Session will feature 11 video abstracts on a variety of topics. SDCC, Room 6C.
1:30 to 5:00 p.m. – RPVI exam preparation, in collaboration with the Society for Vascular Ultrasound. SDCC, Room 4.
1:30 to 5:15 p.m. – Aortic Summit, with the Society of Thoracic Surgeons. SDCC, Room 3.
3:30 to 4:30 p.m. – Poster Runoff: Championship Round. From 120 posters to just 10, with three winners selected by the audience. SDCC, Room 6C.
It’s the final day of the Vascular Annual Meeting – and there is plenty on the agenda to keep you busy.
6:30 to 8:00 a.m. – Three Breakfast Sessions: “Beyond the Basics of Hemodialysis Access,” “The Treatment of Chronic Venous Leg Ulcers,” and “How to Write a Paper and Have it Accepted in the JVS or EJVES.”
8:00 to 10:00 a.m. – Plenary 7 and Plenary 8. With so many high-quality abstracts submitted, two plenary sessions are set for Saturday; Plenary 8 includes late-breaking abstracts and the Vascular Quality Initiative. SDCC, Room 6 A/B
9:00 a.m. to 1:00 p.m. – It’s your last chance to visit the Exhibit Hall to see what’s new and improved. Exhibit Hall B.
10:30 a.m. to 12:00 p.m. – Four concurrent sessions, on the modern VA vascular practice and three joint sessions with an alphabet soup of allied societies, on medical management of vascular disease (SVM), collaboration of vascular surgeons and nurses (SVN), and building and managing a vascular laboratory (SVU).
10:30 a.m. to 12:00 p.m. – Top 10 papers relevant to vascular surgery that were NOT published in the Journal of Vascular Surgery. SDCC, Room 6 A/B.
12:00 p.m. – SVS members, see the passing of the gavel and other business issues, as well as award presentations. SDCC, Room 6 D/E.
1:30 to 3:30 p.m. – Sometimes seeing makes more of an impact than listening. The “How I do it” Video Session will feature 11 video abstracts on a variety of topics. SDCC, Room 6C.
1:30 to 5:00 p.m. – RPVI exam preparation, in collaboration with the Society for Vascular Ultrasound. SDCC, Room 4.
1:30 to 5:15 p.m. – Aortic Summit, with the Society of Thoracic Surgeons. SDCC, Room 3.
3:30 to 4:30 p.m. – Poster Runoff: Championship Round. From 120 posters to just 10, with three winners selected by the audience. SDCC, Room 6C.
It’s the final day of the Vascular Annual Meeting – and there is plenty on the agenda to keep you busy.
6:30 to 8:00 a.m. – Three Breakfast Sessions: “Beyond the Basics of Hemodialysis Access,” “The Treatment of Chronic Venous Leg Ulcers,” and “How to Write a Paper and Have it Accepted in the JVS or EJVES.”
8:00 to 10:00 a.m. – Plenary 7 and Plenary 8. With so many high-quality abstracts submitted, two plenary sessions are set for Saturday; Plenary 8 includes late-breaking abstracts and the Vascular Quality Initiative. SDCC, Room 6 A/B
9:00 a.m. to 1:00 p.m. – It’s your last chance to visit the Exhibit Hall to see what’s new and improved. Exhibit Hall B.
10:30 a.m. to 12:00 p.m. – Four concurrent sessions, on the modern VA vascular practice and three joint sessions with an alphabet soup of allied societies, on medical management of vascular disease (SVM), collaboration of vascular surgeons and nurses (SVN), and building and managing a vascular laboratory (SVU).
10:30 a.m. to 12:00 p.m. – Top 10 papers relevant to vascular surgery that were NOT published in the Journal of Vascular Surgery. SDCC, Room 6 A/B.
12:00 p.m. – SVS members, see the passing of the gavel and other business issues, as well as award presentations. SDCC, Room 6 D/E.
1:30 to 3:30 p.m. – Sometimes seeing makes more of an impact than listening. The “How I do it” Video Session will feature 11 video abstracts on a variety of topics. SDCC, Room 6C.
1:30 to 5:00 p.m. – RPVI exam preparation, in collaboration with the Society for Vascular Ultrasound. SDCC, Room 4.
1:30 to 5:15 p.m. – Aortic Summit, with the Society of Thoracic Surgeons. SDCC, Room 3.
3:30 to 4:30 p.m. – Poster Runoff: Championship Round. From 120 posters to just 10, with three winners selected by the audience. SDCC, Room 6C.
Reader inquires about coding for McCall culdoplasty
Reader inquires about coding for McCall culdoplasty
It is difficult to know what CPT code to use for billing when my practice’s physicians do a McCall culdoplasty during a vaginal or laparoscopic hysterectomy. They often do a McCall procedure when a rectocele is present. One provider said it is CPT 57283. But I read an article that said a McCall repairs an “enterocele” and code 58263 would be used if doing one during a vaginal hysterectomy. Do you have a recommendation?
Sonia Pap, CPC, COBGC
Linville/Boone, North Carolina
Melanie Witt responds
Preventing vaginal vault prolapse by supporting the vaginal cuff is an essential part of hysterectomy, whether abdominal or vaginal. The McCall culdoplasty procedure is performed to support the vaginal cuff at the time of a vaginal hysterectomy by attaching the uterosacral and cardinal ligaments to the peritoneal surface with suture material such that, when tied, it draws toward the midline, helping to close off the cul-de-sac. This procedure not only supports the vaginal cuff but also closes off the cul-de-sac, thus preventing the formation of an enterocele.
As such it would be considered integral to the normal vaginal hysterectomy procedure and is not separately billable. However, in some cases where the patient has stage 1 to stage 4 uterovaginal prolapse, adjunct vaginal apex support is necessary. If the patient has this documented prior to the surgery, she will likely need more than the included uterosacral-cardinal ligament attachment to the vaginal membrane. This is where a colpopexy comes into play, and traditionally, sacrospinous fixation has been performed to accomplish this. In recent years, the uterosacral ligaments have been used instead, which is why we now have 2 codes for vaginal approach colpopexy: 57283 (uterosacral) and 57282 (sacrospinous). Both of these procedures will eliminate an existing enterocele and therefore could potentially be billed with a vaginal hysterectomy unless a more comprehensive code exits that describes the total surgery.
If the purpose of the colpopexy is to repair an existing enterocele, you would not itemize, but rather would report a vaginal hysterectomy with enterocele repair code (58263, 58270, 58292, or 58294) for that complete surgery. The codes do not specify the type of enterocele repair performed and so by definition would include “any method” including a colpopexy. You will note that the colpopexy codes 57283 and 57282 are bundled into all vaginal hysterectomy codes, and although you can use a modifier -59 to bypass this edit, you must meet the criteria for doing so. But especially, 57283 and 57282 are permanently bundled with the vaginal hysterectomy codes that include enterocele repair. Since there already exists a code that describes a vaginal hysterectomy with enterocele repair, you cannot report the modifier -59 for a separate colpopexy if the reason for doing it was to repair an enterocele. You could, however, use it if the sole reason was to do an adjunct vaginal vault repair due to documented uterovaginal prolapse.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Reader inquires about coding for McCall culdoplasty
It is difficult to know what CPT code to use for billing when my practice’s physicians do a McCall culdoplasty during a vaginal or laparoscopic hysterectomy. They often do a McCall procedure when a rectocele is present. One provider said it is CPT 57283. But I read an article that said a McCall repairs an “enterocele” and code 58263 would be used if doing one during a vaginal hysterectomy. Do you have a recommendation?
Sonia Pap, CPC, COBGC
Linville/Boone, North Carolina
Melanie Witt responds
Preventing vaginal vault prolapse by supporting the vaginal cuff is an essential part of hysterectomy, whether abdominal or vaginal. The McCall culdoplasty procedure is performed to support the vaginal cuff at the time of a vaginal hysterectomy by attaching the uterosacral and cardinal ligaments to the peritoneal surface with suture material such that, when tied, it draws toward the midline, helping to close off the cul-de-sac. This procedure not only supports the vaginal cuff but also closes off the cul-de-sac, thus preventing the formation of an enterocele.
As such it would be considered integral to the normal vaginal hysterectomy procedure and is not separately billable. However, in some cases where the patient has stage 1 to stage 4 uterovaginal prolapse, adjunct vaginal apex support is necessary. If the patient has this documented prior to the surgery, she will likely need more than the included uterosacral-cardinal ligament attachment to the vaginal membrane. This is where a colpopexy comes into play, and traditionally, sacrospinous fixation has been performed to accomplish this. In recent years, the uterosacral ligaments have been used instead, which is why we now have 2 codes for vaginal approach colpopexy: 57283 (uterosacral) and 57282 (sacrospinous). Both of these procedures will eliminate an existing enterocele and therefore could potentially be billed with a vaginal hysterectomy unless a more comprehensive code exits that describes the total surgery.
If the purpose of the colpopexy is to repair an existing enterocele, you would not itemize, but rather would report a vaginal hysterectomy with enterocele repair code (58263, 58270, 58292, or 58294) for that complete surgery. The codes do not specify the type of enterocele repair performed and so by definition would include “any method” including a colpopexy. You will note that the colpopexy codes 57283 and 57282 are bundled into all vaginal hysterectomy codes, and although you can use a modifier -59 to bypass this edit, you must meet the criteria for doing so. But especially, 57283 and 57282 are permanently bundled with the vaginal hysterectomy codes that include enterocele repair. Since there already exists a code that describes a vaginal hysterectomy with enterocele repair, you cannot report the modifier -59 for a separate colpopexy if the reason for doing it was to repair an enterocele. You could, however, use it if the sole reason was to do an adjunct vaginal vault repair due to documented uterovaginal prolapse.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Reader inquires about coding for McCall culdoplasty
It is difficult to know what CPT code to use for billing when my practice’s physicians do a McCall culdoplasty during a vaginal or laparoscopic hysterectomy. They often do a McCall procedure when a rectocele is present. One provider said it is CPT 57283. But I read an article that said a McCall repairs an “enterocele” and code 58263 would be used if doing one during a vaginal hysterectomy. Do you have a recommendation?
Sonia Pap, CPC, COBGC
Linville/Boone, North Carolina
Melanie Witt responds
Preventing vaginal vault prolapse by supporting the vaginal cuff is an essential part of hysterectomy, whether abdominal or vaginal. The McCall culdoplasty procedure is performed to support the vaginal cuff at the time of a vaginal hysterectomy by attaching the uterosacral and cardinal ligaments to the peritoneal surface with suture material such that, when tied, it draws toward the midline, helping to close off the cul-de-sac. This procedure not only supports the vaginal cuff but also closes off the cul-de-sac, thus preventing the formation of an enterocele.
As such it would be considered integral to the normal vaginal hysterectomy procedure and is not separately billable. However, in some cases where the patient has stage 1 to stage 4 uterovaginal prolapse, adjunct vaginal apex support is necessary. If the patient has this documented prior to the surgery, she will likely need more than the included uterosacral-cardinal ligament attachment to the vaginal membrane. This is where a colpopexy comes into play, and traditionally, sacrospinous fixation has been performed to accomplish this. In recent years, the uterosacral ligaments have been used instead, which is why we now have 2 codes for vaginal approach colpopexy: 57283 (uterosacral) and 57282 (sacrospinous). Both of these procedures will eliminate an existing enterocele and therefore could potentially be billed with a vaginal hysterectomy unless a more comprehensive code exits that describes the total surgery.
If the purpose of the colpopexy is to repair an existing enterocele, you would not itemize, but rather would report a vaginal hysterectomy with enterocele repair code (58263, 58270, 58292, or 58294) for that complete surgery. The codes do not specify the type of enterocele repair performed and so by definition would include “any method” including a colpopexy. You will note that the colpopexy codes 57283 and 57282 are bundled into all vaginal hysterectomy codes, and although you can use a modifier -59 to bypass this edit, you must meet the criteria for doing so. But especially, 57283 and 57282 are permanently bundled with the vaginal hysterectomy codes that include enterocele repair. Since there already exists a code that describes a vaginal hysterectomy with enterocele repair, you cannot report the modifier -59 for a separate colpopexy if the reason for doing it was to repair an enterocele. You could, however, use it if the sole reason was to do an adjunct vaginal vault repair due to documented uterovaginal prolapse.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Refutes concept of overdiagnosis of breast cancer
“MORE THAN ONE-THIRD OF TUMORS FOUND ON BREAST CANCER SCREENING REPRESENT OVERDIAGNOSIS”
ANDREW M. KAUNITZ, MD (MARCH 2017)
Refutes concept of overdiagnosis of breast cancer
I read with interest and serious concern the commentary and conclusions of “overdiagnosed” breast cancer. Let us revisit a few time-honored principles. Are we throwing away the valued concept of the early diagnosis of node-negative breast cancer? Is it still true that 5-year and long-term survivals are markedly better for stage I and II disease as opposed to stage III and IV disease? Is it still true that treatments designed for cure are substantially less involved, more successful, and more likely to conserve the breast and require less chemotherapy in early stage disease? Is it still true that the majority of women diagnosed with breast cancer are in the lowest risk category, ie, no family history and negative for the BRCA gene? If so, then who can explain the statement that “an invasive breast cancer detected by any means is overdiagnosis”? Would this imply that screening and the biopsy required to make the diagnosis was time poorly spent, the breast cancer should not be treated, and/or we should simply wait for a lump to be found by the patient deep in a large breast most likely at that point representing advanced disease?
The last paragraph notes the current US Preventive Services Task Force (USPSTF) guidance: wait until 50 years of age to start biennial screening. If so, what do we say to women in their 40s who, through screening with mammography and/or ultrasound, were diagnosed with early node-negative invasive breast cancer? That all of that was unnecessary and would not have led to symptoms? Would extreme morbidity from advanced or recurrent disease and the horrors of treatment just to extend a few months of life qualify as a symptom to these investigators? Lax protocols are not for me, my colleagues, or patients that I know. One of the most common reasons for a lawsuit to be brought against a primary care or ObGyn provider is failure to diagnose breast cancer!
John T. Armstrong, MD
Napa, California
Dr. Kaunitz responds
I thank Dr. Armstrong for his interest in my commentary on screening mammography and overdiagnosis. As I indicated in my commentary, I continue to recommend screening mammography for my patients, encouraging average-risk women to begin biennial screens at age 50 (consistent with USPSTF guidance), when the likelihood that tumors found with mammograms representing overdiagnosis is lower. I also indicated that I recognize that some patients prefer to begin screening at a younger age and to be screened more frequently. Dr. Armstrong’s letter refers to the “horrors of treatment” of breast cancer. From my perspective, the most “horrible” treatment is that which is administered to a woman diagnosed with a tumor destined to not cause clinical problems during her lifetime (overdiagnosis). You also refer to a statement, “an invasive breast cancer detected by any means is overdiagnosis.” That statement does not appear in my commentary.
My commentary’s point is that overdiagnosis is common among tumors diagnosed by screening mammography, and likely explains why, in contrast with cervical cancer screening, screening mammography has failed to reduce the incidence of breast cancers presenting as advanced (metastatic) disease. Although this represents a confusing and disquieting reality for our patients, and for us their clinicians, I agree with Dr. Otis Brawley, Chief Medical and Scientific Officer of the American Cancer Society, that we must acknowledge to our patients that overdiagnosis is common, the benefits of screening have been overstated, and that some patients considered as “cured” from breast cancer have in fact been harmed by unneeded treatment.1
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Brawley OW. Accepting the existence of breast cancer overdiagnosis [published online ahead of print January 10, 2017]. Ann Intern Med. doi:10.7326/M16-2850.
“MORE THAN ONE-THIRD OF TUMORS FOUND ON BREAST CANCER SCREENING REPRESENT OVERDIAGNOSIS”
ANDREW M. KAUNITZ, MD (MARCH 2017)
Refutes concept of overdiagnosis of breast cancer
I read with interest and serious concern the commentary and conclusions of “overdiagnosed” breast cancer. Let us revisit a few time-honored principles. Are we throwing away the valued concept of the early diagnosis of node-negative breast cancer? Is it still true that 5-year and long-term survivals are markedly better for stage I and II disease as opposed to stage III and IV disease? Is it still true that treatments designed for cure are substantially less involved, more successful, and more likely to conserve the breast and require less chemotherapy in early stage disease? Is it still true that the majority of women diagnosed with breast cancer are in the lowest risk category, ie, no family history and negative for the BRCA gene? If so, then who can explain the statement that “an invasive breast cancer detected by any means is overdiagnosis”? Would this imply that screening and the biopsy required to make the diagnosis was time poorly spent, the breast cancer should not be treated, and/or we should simply wait for a lump to be found by the patient deep in a large breast most likely at that point representing advanced disease?
The last paragraph notes the current US Preventive Services Task Force (USPSTF) guidance: wait until 50 years of age to start biennial screening. If so, what do we say to women in their 40s who, through screening with mammography and/or ultrasound, were diagnosed with early node-negative invasive breast cancer? That all of that was unnecessary and would not have led to symptoms? Would extreme morbidity from advanced or recurrent disease and the horrors of treatment just to extend a few months of life qualify as a symptom to these investigators? Lax protocols are not for me, my colleagues, or patients that I know. One of the most common reasons for a lawsuit to be brought against a primary care or ObGyn provider is failure to diagnose breast cancer!
John T. Armstrong, MD
Napa, California
Dr. Kaunitz responds
I thank Dr. Armstrong for his interest in my commentary on screening mammography and overdiagnosis. As I indicated in my commentary, I continue to recommend screening mammography for my patients, encouraging average-risk women to begin biennial screens at age 50 (consistent with USPSTF guidance), when the likelihood that tumors found with mammograms representing overdiagnosis is lower. I also indicated that I recognize that some patients prefer to begin screening at a younger age and to be screened more frequently. Dr. Armstrong’s letter refers to the “horrors of treatment” of breast cancer. From my perspective, the most “horrible” treatment is that which is administered to a woman diagnosed with a tumor destined to not cause clinical problems during her lifetime (overdiagnosis). You also refer to a statement, “an invasive breast cancer detected by any means is overdiagnosis.” That statement does not appear in my commentary.
My commentary’s point is that overdiagnosis is common among tumors diagnosed by screening mammography, and likely explains why, in contrast with cervical cancer screening, screening mammography has failed to reduce the incidence of breast cancers presenting as advanced (metastatic) disease. Although this represents a confusing and disquieting reality for our patients, and for us their clinicians, I agree with Dr. Otis Brawley, Chief Medical and Scientific Officer of the American Cancer Society, that we must acknowledge to our patients that overdiagnosis is common, the benefits of screening have been overstated, and that some patients considered as “cured” from breast cancer have in fact been harmed by unneeded treatment.1
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“MORE THAN ONE-THIRD OF TUMORS FOUND ON BREAST CANCER SCREENING REPRESENT OVERDIAGNOSIS”
ANDREW M. KAUNITZ, MD (MARCH 2017)
Refutes concept of overdiagnosis of breast cancer
I read with interest and serious concern the commentary and conclusions of “overdiagnosed” breast cancer. Let us revisit a few time-honored principles. Are we throwing away the valued concept of the early diagnosis of node-negative breast cancer? Is it still true that 5-year and long-term survivals are markedly better for stage I and II disease as opposed to stage III and IV disease? Is it still true that treatments designed for cure are substantially less involved, more successful, and more likely to conserve the breast and require less chemotherapy in early stage disease? Is it still true that the majority of women diagnosed with breast cancer are in the lowest risk category, ie, no family history and negative for the BRCA gene? If so, then who can explain the statement that “an invasive breast cancer detected by any means is overdiagnosis”? Would this imply that screening and the biopsy required to make the diagnosis was time poorly spent, the breast cancer should not be treated, and/or we should simply wait for a lump to be found by the patient deep in a large breast most likely at that point representing advanced disease?
The last paragraph notes the current US Preventive Services Task Force (USPSTF) guidance: wait until 50 years of age to start biennial screening. If so, what do we say to women in their 40s who, through screening with mammography and/or ultrasound, were diagnosed with early node-negative invasive breast cancer? That all of that was unnecessary and would not have led to symptoms? Would extreme morbidity from advanced or recurrent disease and the horrors of treatment just to extend a few months of life qualify as a symptom to these investigators? Lax protocols are not for me, my colleagues, or patients that I know. One of the most common reasons for a lawsuit to be brought against a primary care or ObGyn provider is failure to diagnose breast cancer!
John T. Armstrong, MD
Napa, California
Dr. Kaunitz responds
I thank Dr. Armstrong for his interest in my commentary on screening mammography and overdiagnosis. As I indicated in my commentary, I continue to recommend screening mammography for my patients, encouraging average-risk women to begin biennial screens at age 50 (consistent with USPSTF guidance), when the likelihood that tumors found with mammograms representing overdiagnosis is lower. I also indicated that I recognize that some patients prefer to begin screening at a younger age and to be screened more frequently. Dr. Armstrong’s letter refers to the “horrors of treatment” of breast cancer. From my perspective, the most “horrible” treatment is that which is administered to a woman diagnosed with a tumor destined to not cause clinical problems during her lifetime (overdiagnosis). You also refer to a statement, “an invasive breast cancer detected by any means is overdiagnosis.” That statement does not appear in my commentary.
My commentary’s point is that overdiagnosis is common among tumors diagnosed by screening mammography, and likely explains why, in contrast with cervical cancer screening, screening mammography has failed to reduce the incidence of breast cancers presenting as advanced (metastatic) disease. Although this represents a confusing and disquieting reality for our patients, and for us their clinicians, I agree with Dr. Otis Brawley, Chief Medical and Scientific Officer of the American Cancer Society, that we must acknowledge to our patients that overdiagnosis is common, the benefits of screening have been overstated, and that some patients considered as “cured” from breast cancer have in fact been harmed by unneeded treatment.1
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Brawley OW. Accepting the existence of breast cancer overdiagnosis [published online ahead of print January 10, 2017]. Ann Intern Med. doi:10.7326/M16-2850.
- Brawley OW. Accepting the existence of breast cancer overdiagnosis [published online ahead of print January 10, 2017]. Ann Intern Med. doi:10.7326/M16-2850.
Highlights from new guidelines, and a chance to weigh in
Though the Society for Vascular Surgery has long published clinical practice guidelines, its 2017 annual meeting marks the first seminar dedicated to guidelines in progress, allowing for more interaction, debate, and feedback across the vascular community before these guidelines become final.
At Friday afternoon’s update on SVS clinical practice guidelines, speakers will present on four that are in advanced development, including new global vascular guidelines.
All too often, Dr. Forbes said, the guideline process can seem opaque, or top-town or cumbersome in soliciting and incorporating feedback – problems that this kind of interactive seminar can help rectify. “We don’t want to be Moses with the tablet from the mountain, handing them down and asking everybody to follow them without question,” he said.
Keith D. Calligaro, MD, who practices in Philadelphia, starts the seminar off with highlights from new guidelines on hospital privileges across practice settings, an update of SVS guidelines from 2008. The new guidelines “describe specific procedure-related training requirements that would then lead to privileges in a hospital setting. This is especially relevant in some of the practice environments in the U.S.,” Dr. Forbes said.
R. Eugene Zierler, MD, of the University of Washington in Seattle, will present broad-reaching new advice on the follow-up of patients after vascular procedures. These guidelines cover patients who’ve undergone a wide variety of procedures, “all the way from carotid to abdominal aortic aneurysm repairs to venous surgery – and offers specific, evidence-based recommendations for how patients should be followed up, how often they should undergo imaging, bloodwork, and other follow-up modalities,” Dr. Forbes said.
And Elliot Chaikof, MD, of Beth Israel Deaconess Medical Center in Boston, will discuss new guidelines on the care of patients with abdominal aortic aneurysms that incorporates “what we know today about the different therapeutic options: from medical management to endovascular and open repair to different treatment strategies for men and women – all this based on advances from the last couple years,” Dr. Forbes said.
Finally, in separate talks, two presenters will describe different elements of a new global vascular guideline developed jointly by the SVS, the European Society for Vascular Surgery, and the World Federation of Vascular Societies.
Andrew W. Bradbury, MD, of the University of Birmingham in the U.K. and Michael S. Conte of the University of California San Francisco will speak on some issues the guidelines are tackling, all with an aim to reflect a more inclusive, worldwide picture of vascular practice.
“This is the first time we’re going to hear what these recommendations are,” Dr. Forbes said. One highlight is likely to be a new global classification system for peripheral arterial disease. “This is a new and novel concept in vascular disease, and that is similar to the classification systems used for cancer,” Dr. Forbes said.
Dr. Forbes said that he hopes that a seminar focused on guidelines in progress will become a regular feature of the annual meeting, and that this year’s seminar will help shape the society’s approach to future guidelines as well.
“Members may know of areas of vascular surgery where there’s a real need for guidelines, or some evidence-based recommendations that we don’t have, and we’d love them to come forward and propose those topics,” he said. “We need practitioners in academic centers and community practitioners alike, to represent the breath of the work being done out there.”
Friday, June 2
3:30 p.m. - 5:00 p.m., SDCC, Room 4
C9: Update on Society for Vascular Surgery Clinical Practice Guidelines
Though the Society for Vascular Surgery has long published clinical practice guidelines, its 2017 annual meeting marks the first seminar dedicated to guidelines in progress, allowing for more interaction, debate, and feedback across the vascular community before these guidelines become final.
At Friday afternoon’s update on SVS clinical practice guidelines, speakers will present on four that are in advanced development, including new global vascular guidelines.
All too often, Dr. Forbes said, the guideline process can seem opaque, or top-town or cumbersome in soliciting and incorporating feedback – problems that this kind of interactive seminar can help rectify. “We don’t want to be Moses with the tablet from the mountain, handing them down and asking everybody to follow them without question,” he said.
Keith D. Calligaro, MD, who practices in Philadelphia, starts the seminar off with highlights from new guidelines on hospital privileges across practice settings, an update of SVS guidelines from 2008. The new guidelines “describe specific procedure-related training requirements that would then lead to privileges in a hospital setting. This is especially relevant in some of the practice environments in the U.S.,” Dr. Forbes said.
R. Eugene Zierler, MD, of the University of Washington in Seattle, will present broad-reaching new advice on the follow-up of patients after vascular procedures. These guidelines cover patients who’ve undergone a wide variety of procedures, “all the way from carotid to abdominal aortic aneurysm repairs to venous surgery – and offers specific, evidence-based recommendations for how patients should be followed up, how often they should undergo imaging, bloodwork, and other follow-up modalities,” Dr. Forbes said.
And Elliot Chaikof, MD, of Beth Israel Deaconess Medical Center in Boston, will discuss new guidelines on the care of patients with abdominal aortic aneurysms that incorporates “what we know today about the different therapeutic options: from medical management to endovascular and open repair to different treatment strategies for men and women – all this based on advances from the last couple years,” Dr. Forbes said.
Finally, in separate talks, two presenters will describe different elements of a new global vascular guideline developed jointly by the SVS, the European Society for Vascular Surgery, and the World Federation of Vascular Societies.
Andrew W. Bradbury, MD, of the University of Birmingham in the U.K. and Michael S. Conte of the University of California San Francisco will speak on some issues the guidelines are tackling, all with an aim to reflect a more inclusive, worldwide picture of vascular practice.
“This is the first time we’re going to hear what these recommendations are,” Dr. Forbes said. One highlight is likely to be a new global classification system for peripheral arterial disease. “This is a new and novel concept in vascular disease, and that is similar to the classification systems used for cancer,” Dr. Forbes said.
Dr. Forbes said that he hopes that a seminar focused on guidelines in progress will become a regular feature of the annual meeting, and that this year’s seminar will help shape the society’s approach to future guidelines as well.
“Members may know of areas of vascular surgery where there’s a real need for guidelines, or some evidence-based recommendations that we don’t have, and we’d love them to come forward and propose those topics,” he said. “We need practitioners in academic centers and community practitioners alike, to represent the breath of the work being done out there.”
Friday, June 2
3:30 p.m. - 5:00 p.m., SDCC, Room 4
C9: Update on Society for Vascular Surgery Clinical Practice Guidelines
Though the Society for Vascular Surgery has long published clinical practice guidelines, its 2017 annual meeting marks the first seminar dedicated to guidelines in progress, allowing for more interaction, debate, and feedback across the vascular community before these guidelines become final.
At Friday afternoon’s update on SVS clinical practice guidelines, speakers will present on four that are in advanced development, including new global vascular guidelines.
All too often, Dr. Forbes said, the guideline process can seem opaque, or top-town or cumbersome in soliciting and incorporating feedback – problems that this kind of interactive seminar can help rectify. “We don’t want to be Moses with the tablet from the mountain, handing them down and asking everybody to follow them without question,” he said.
Keith D. Calligaro, MD, who practices in Philadelphia, starts the seminar off with highlights from new guidelines on hospital privileges across practice settings, an update of SVS guidelines from 2008. The new guidelines “describe specific procedure-related training requirements that would then lead to privileges in a hospital setting. This is especially relevant in some of the practice environments in the U.S.,” Dr. Forbes said.
R. Eugene Zierler, MD, of the University of Washington in Seattle, will present broad-reaching new advice on the follow-up of patients after vascular procedures. These guidelines cover patients who’ve undergone a wide variety of procedures, “all the way from carotid to abdominal aortic aneurysm repairs to venous surgery – and offers specific, evidence-based recommendations for how patients should be followed up, how often they should undergo imaging, bloodwork, and other follow-up modalities,” Dr. Forbes said.
And Elliot Chaikof, MD, of Beth Israel Deaconess Medical Center in Boston, will discuss new guidelines on the care of patients with abdominal aortic aneurysms that incorporates “what we know today about the different therapeutic options: from medical management to endovascular and open repair to different treatment strategies for men and women – all this based on advances from the last couple years,” Dr. Forbes said.
Finally, in separate talks, two presenters will describe different elements of a new global vascular guideline developed jointly by the SVS, the European Society for Vascular Surgery, and the World Federation of Vascular Societies.
Andrew W. Bradbury, MD, of the University of Birmingham in the U.K. and Michael S. Conte of the University of California San Francisco will speak on some issues the guidelines are tackling, all with an aim to reflect a more inclusive, worldwide picture of vascular practice.
“This is the first time we’re going to hear what these recommendations are,” Dr. Forbes said. One highlight is likely to be a new global classification system for peripheral arterial disease. “This is a new and novel concept in vascular disease, and that is similar to the classification systems used for cancer,” Dr. Forbes said.
Dr. Forbes said that he hopes that a seminar focused on guidelines in progress will become a regular feature of the annual meeting, and that this year’s seminar will help shape the society’s approach to future guidelines as well.
“Members may know of areas of vascular surgery where there’s a real need for guidelines, or some evidence-based recommendations that we don’t have, and we’d love them to come forward and propose those topics,” he said. “We need practitioners in academic centers and community practitioners alike, to represent the breath of the work being done out there.”
Friday, June 2
3:30 p.m. - 5:00 p.m., SDCC, Room 4
C9: Update on Society for Vascular Surgery Clinical Practice Guidelines
How to get published in JVS and EJVES: Editors disclose secrets of success
Over the past year, the Journal of Vascular Surgery and its two affiliated journals have undergone a number of important changes.
Editorial boards have been revamped, disadvantageous limits on the number of contributing authors and on references have been scrapped, and editors’ videos accompany every new issue. New short abstracts, take-home messages, and extended tables of contents allow even the most time-crunched clinicians to get up to speed.
Even the look of the journals has changed – with a red color scheme for JVS, a blue one for JVS-VL, the venous and lymphatic disorders journal, and a mixed red and blue one for the open-access publication dedicated to cases and techniques.
On Saturday morning, Dr. Gloviczki, the editor in chief of JVS, and senior editor Peter F. Lawrence helm a seminar that describes not only what they’ve been doing since taking over the journals’ leadership in July 2016, but how more SVS members can take part by producing quality papers or reviewing for the journals.
Dr. Gloviczki and Dr. Lawrence have also invited Dr. Philip Kolh if the University of Liege in Liege, Belgium, to co-lead the seminar. Dr. Kolh, who is editor in chief of the European Journal of Vascular and Endovascular Surgery, will advise on what the EJVES is looking for in its reviews and submissions.
“We believe it is important for JVS and EJVES to work together, to develop joint guidelines, to avoid repetition and redundancy, and double-publish papers that are important for both readerships,” Dr. Gloviczki said.
Dr. Gloviczki will start the seminar off by discussing the sweeping changes aimed at raising the quality of all three JVS journals and, he hopes, will also affect their impact factor, currently at 3.45 for JVS.
In addition to increasing the scrutiny of the peer review and the number of statistical reviews performed by master statisticians, the editors are looking for systematic reviews, meta-analyses, practice guidelines, and reporting standards – and will publish paper types not previously accepted, such as study protocols.
The journal will retain many initiatives of the previous editors, including the international debates, and will continue recruiting international authors and reviewers. Having the best reviewers, Dr. Gloviczki noted, “is an important parallel to having top-quality studies.”
Dr. Lawrence, of the University of California Los Angeles, will discuss what makes a clinical research paper successful. “We want papers that are highly cited – and the highly cited papers are prospective studies, whether randomized controlled trials or single-arm cohort studies,” Dr. Gloviczki said. “We also favor large retrospective reviews of prospectively collected national or international registries.”
Peter Henke, MD, of the University of Michigan in Ann Arbor, Mich., will talk about what the JVS editors and reviewers want in basic science papers – which Dr. Gloviczki called an important and sometimes overlooked counterpart to the clinical studies. “We believe that our profession must be in charge of basic research, that whoever owns basic research in our field owns the disease,” he said.
“To understand vascular disease you have to start at the basics of anatomy, pathophysiology, etiology, prevention, presentation and finally treatment,” he said, noting that vascular surgeons at many academic centers are conducting experimental studies and other basic research, efforts often supported by SVS grants.
Last year the JVS editors re-named the journal’s basic science section and called it “From Bench to Bedside” to try and capture the importance of preclinical vascular studies. “It’s a relatively small section of our journal but it’s important,” Dr. Gloviczki said. “And now we are really pushing to get commentaries that emphasize the potential clinical application of the basic science research.”
Richard L. Amdur, MD, of George Washington University in Washington, DC, will talk about what the JVS journal editors want to see in terms of statistics, while Marc L. Schermerhorn, MD, of Beth Israel Deaconess Medical Center in Boston and Martin Bjorck, MD, PhD, of Uppsala University, Uppsala, Sweden, will both discuss mining the large vascular registries from the United States and Europe for studies attractive to JVS or EJVES.
“There are so many papers where real-world experience is given to us by analyzing these registries,” Dr. Gloviczki said. Studies from the SVS Vascular Quality Initiatives database, the American College of Surgeons’ National Surgical Quality Improvement Program, the National Inpatient Sample, the Swedish Vascular registry, VADUNET and the International Consortium of Vascular Registries, “have changed the way we practice vascular surgery, and we publish multiple papers from these in every issue.”
Saturday, June 3
6:30 a.m. - 8:00 a.m.
Breakfast Session B9: How to Write a Paper and Have it Accepted in the JVS or EJVES
Over the past year, the Journal of Vascular Surgery and its two affiliated journals have undergone a number of important changes.
Editorial boards have been revamped, disadvantageous limits on the number of contributing authors and on references have been scrapped, and editors’ videos accompany every new issue. New short abstracts, take-home messages, and extended tables of contents allow even the most time-crunched clinicians to get up to speed.
Even the look of the journals has changed – with a red color scheme for JVS, a blue one for JVS-VL, the venous and lymphatic disorders journal, and a mixed red and blue one for the open-access publication dedicated to cases and techniques.
On Saturday morning, Dr. Gloviczki, the editor in chief of JVS, and senior editor Peter F. Lawrence helm a seminar that describes not only what they’ve been doing since taking over the journals’ leadership in July 2016, but how more SVS members can take part by producing quality papers or reviewing for the journals.
Dr. Gloviczki and Dr. Lawrence have also invited Dr. Philip Kolh if the University of Liege in Liege, Belgium, to co-lead the seminar. Dr. Kolh, who is editor in chief of the European Journal of Vascular and Endovascular Surgery, will advise on what the EJVES is looking for in its reviews and submissions.
“We believe it is important for JVS and EJVES to work together, to develop joint guidelines, to avoid repetition and redundancy, and double-publish papers that are important for both readerships,” Dr. Gloviczki said.
Dr. Gloviczki will start the seminar off by discussing the sweeping changes aimed at raising the quality of all three JVS journals and, he hopes, will also affect their impact factor, currently at 3.45 for JVS.
In addition to increasing the scrutiny of the peer review and the number of statistical reviews performed by master statisticians, the editors are looking for systematic reviews, meta-analyses, practice guidelines, and reporting standards – and will publish paper types not previously accepted, such as study protocols.
The journal will retain many initiatives of the previous editors, including the international debates, and will continue recruiting international authors and reviewers. Having the best reviewers, Dr. Gloviczki noted, “is an important parallel to having top-quality studies.”
Dr. Lawrence, of the University of California Los Angeles, will discuss what makes a clinical research paper successful. “We want papers that are highly cited – and the highly cited papers are prospective studies, whether randomized controlled trials or single-arm cohort studies,” Dr. Gloviczki said. “We also favor large retrospective reviews of prospectively collected national or international registries.”
Peter Henke, MD, of the University of Michigan in Ann Arbor, Mich., will talk about what the JVS editors and reviewers want in basic science papers – which Dr. Gloviczki called an important and sometimes overlooked counterpart to the clinical studies. “We believe that our profession must be in charge of basic research, that whoever owns basic research in our field owns the disease,” he said.
“To understand vascular disease you have to start at the basics of anatomy, pathophysiology, etiology, prevention, presentation and finally treatment,” he said, noting that vascular surgeons at many academic centers are conducting experimental studies and other basic research, efforts often supported by SVS grants.
Last year the JVS editors re-named the journal’s basic science section and called it “From Bench to Bedside” to try and capture the importance of preclinical vascular studies. “It’s a relatively small section of our journal but it’s important,” Dr. Gloviczki said. “And now we are really pushing to get commentaries that emphasize the potential clinical application of the basic science research.”
Richard L. Amdur, MD, of George Washington University in Washington, DC, will talk about what the JVS journal editors want to see in terms of statistics, while Marc L. Schermerhorn, MD, of Beth Israel Deaconess Medical Center in Boston and Martin Bjorck, MD, PhD, of Uppsala University, Uppsala, Sweden, will both discuss mining the large vascular registries from the United States and Europe for studies attractive to JVS or EJVES.
“There are so many papers where real-world experience is given to us by analyzing these registries,” Dr. Gloviczki said. Studies from the SVS Vascular Quality Initiatives database, the American College of Surgeons’ National Surgical Quality Improvement Program, the National Inpatient Sample, the Swedish Vascular registry, VADUNET and the International Consortium of Vascular Registries, “have changed the way we practice vascular surgery, and we publish multiple papers from these in every issue.”
Saturday, June 3
6:30 a.m. - 8:00 a.m.
Breakfast Session B9: How to Write a Paper and Have it Accepted in the JVS or EJVES
Over the past year, the Journal of Vascular Surgery and its two affiliated journals have undergone a number of important changes.
Editorial boards have been revamped, disadvantageous limits on the number of contributing authors and on references have been scrapped, and editors’ videos accompany every new issue. New short abstracts, take-home messages, and extended tables of contents allow even the most time-crunched clinicians to get up to speed.
Even the look of the journals has changed – with a red color scheme for JVS, a blue one for JVS-VL, the venous and lymphatic disorders journal, and a mixed red and blue one for the open-access publication dedicated to cases and techniques.
On Saturday morning, Dr. Gloviczki, the editor in chief of JVS, and senior editor Peter F. Lawrence helm a seminar that describes not only what they’ve been doing since taking over the journals’ leadership in July 2016, but how more SVS members can take part by producing quality papers or reviewing for the journals.
Dr. Gloviczki and Dr. Lawrence have also invited Dr. Philip Kolh if the University of Liege in Liege, Belgium, to co-lead the seminar. Dr. Kolh, who is editor in chief of the European Journal of Vascular and Endovascular Surgery, will advise on what the EJVES is looking for in its reviews and submissions.
“We believe it is important for JVS and EJVES to work together, to develop joint guidelines, to avoid repetition and redundancy, and double-publish papers that are important for both readerships,” Dr. Gloviczki said.
Dr. Gloviczki will start the seminar off by discussing the sweeping changes aimed at raising the quality of all three JVS journals and, he hopes, will also affect their impact factor, currently at 3.45 for JVS.
In addition to increasing the scrutiny of the peer review and the number of statistical reviews performed by master statisticians, the editors are looking for systematic reviews, meta-analyses, practice guidelines, and reporting standards – and will publish paper types not previously accepted, such as study protocols.
The journal will retain many initiatives of the previous editors, including the international debates, and will continue recruiting international authors and reviewers. Having the best reviewers, Dr. Gloviczki noted, “is an important parallel to having top-quality studies.”
Dr. Lawrence, of the University of California Los Angeles, will discuss what makes a clinical research paper successful. “We want papers that are highly cited – and the highly cited papers are prospective studies, whether randomized controlled trials or single-arm cohort studies,” Dr. Gloviczki said. “We also favor large retrospective reviews of prospectively collected national or international registries.”
Peter Henke, MD, of the University of Michigan in Ann Arbor, Mich., will talk about what the JVS editors and reviewers want in basic science papers – which Dr. Gloviczki called an important and sometimes overlooked counterpart to the clinical studies. “We believe that our profession must be in charge of basic research, that whoever owns basic research in our field owns the disease,” he said.
“To understand vascular disease you have to start at the basics of anatomy, pathophysiology, etiology, prevention, presentation and finally treatment,” he said, noting that vascular surgeons at many academic centers are conducting experimental studies and other basic research, efforts often supported by SVS grants.
Last year the JVS editors re-named the journal’s basic science section and called it “From Bench to Bedside” to try and capture the importance of preclinical vascular studies. “It’s a relatively small section of our journal but it’s important,” Dr. Gloviczki said. “And now we are really pushing to get commentaries that emphasize the potential clinical application of the basic science research.”
Richard L. Amdur, MD, of George Washington University in Washington, DC, will talk about what the JVS journal editors want to see in terms of statistics, while Marc L. Schermerhorn, MD, of Beth Israel Deaconess Medical Center in Boston and Martin Bjorck, MD, PhD, of Uppsala University, Uppsala, Sweden, will both discuss mining the large vascular registries from the United States and Europe for studies attractive to JVS or EJVES.
“There are so many papers where real-world experience is given to us by analyzing these registries,” Dr. Gloviczki said. Studies from the SVS Vascular Quality Initiatives database, the American College of Surgeons’ National Surgical Quality Improvement Program, the National Inpatient Sample, the Swedish Vascular registry, VADUNET and the International Consortium of Vascular Registries, “have changed the way we practice vascular surgery, and we publish multiple papers from these in every issue.”
Saturday, June 3
6:30 a.m. - 8:00 a.m.
Breakfast Session B9: How to Write a Paper and Have it Accepted in the JVS or EJVES