User login
Charging for medical records: For whom and at what cost?
Do you charge for medical records?
You probably do, and so do I, at times.
Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.
That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.
How much you can charge is a more complex issue, with each state setting its own rules. A recent article published in JAMA Internal Medicine noted that a patient in Georgia could pay up to $111.68 for a 100-page record. Hitting someone up for that amount, who’s already having health problems and may be relocating or trying to find a new doctor, seems like making an already difficult situation worse.
But we’re in the digital age now. So how much does it cost to send records? Most files (.doc, .pdf, .jpg, and so on) are interchangeable between Mac and Windows.
Things get iffy here. I mean, it’s easy to send a .pdf file by email, but that’s not particularly secure. And I hate having to sign up and create passwords for the many allegedly safer file-sharing services out there.
Burning records on a CD or DVD certainly saves postage, though takes about the same amount of computer time as printing them up. Not only that, but this seems to be a format that’s on its way out. The last three computers I’ve bought didn’t even have optical drives. CD/DVD’s are starting to resemble VHS tapes in the late 1990s.
Flash drives are the present and immediate future of transferred records. Small, lightweight, and capable of holding a lot. But they still need to be mailed, and are more expensive than paper. They also have security risks that concern me. When a patient hands me one and asks me to plug it in, I never do. There could be a virus or spyware that can compromise the security and privacy of my office, and cost a fortune to reverse the damage.
And so, at the end of that chain of thought, paper still appears to be king. It’s not going to carry ransomware into my office. It can be mailed or faxed, and is easily adaptable to any system (like mine) with a scanner. The paper world may hypothetically no longer exist, but for many things in medicine it still does, and is critical.
Some ultimate solutions, such as a universal database of health care data on all patients or a complete interchangeability between systems, sound great. No one would need to transfer records between doctors and all would have access to their own charts. But at this point in time, while technologically achievable, the privacy concerns and high-stakes security risks make such a thing impossible.
It’s easy to hope that the age of electronic medical records will lead to, as the article states, “easy, inexpensive” reproduction of medical records. But things never seem to be that simple, for some of the reasons I’ve mentioned above.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Do you charge for medical records?
You probably do, and so do I, at times.
Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.
That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.
How much you can charge is a more complex issue, with each state setting its own rules. A recent article published in JAMA Internal Medicine noted that a patient in Georgia could pay up to $111.68 for a 100-page record. Hitting someone up for that amount, who’s already having health problems and may be relocating or trying to find a new doctor, seems like making an already difficult situation worse.
But we’re in the digital age now. So how much does it cost to send records? Most files (.doc, .pdf, .jpg, and so on) are interchangeable between Mac and Windows.
Things get iffy here. I mean, it’s easy to send a .pdf file by email, but that’s not particularly secure. And I hate having to sign up and create passwords for the many allegedly safer file-sharing services out there.
Burning records on a CD or DVD certainly saves postage, though takes about the same amount of computer time as printing them up. Not only that, but this seems to be a format that’s on its way out. The last three computers I’ve bought didn’t even have optical drives. CD/DVD’s are starting to resemble VHS tapes in the late 1990s.
Flash drives are the present and immediate future of transferred records. Small, lightweight, and capable of holding a lot. But they still need to be mailed, and are more expensive than paper. They also have security risks that concern me. When a patient hands me one and asks me to plug it in, I never do. There could be a virus or spyware that can compromise the security and privacy of my office, and cost a fortune to reverse the damage.
And so, at the end of that chain of thought, paper still appears to be king. It’s not going to carry ransomware into my office. It can be mailed or faxed, and is easily adaptable to any system (like mine) with a scanner. The paper world may hypothetically no longer exist, but for many things in medicine it still does, and is critical.
Some ultimate solutions, such as a universal database of health care data on all patients or a complete interchangeability between systems, sound great. No one would need to transfer records between doctors and all would have access to their own charts. But at this point in time, while technologically achievable, the privacy concerns and high-stakes security risks make such a thing impossible.
It’s easy to hope that the age of electronic medical records will lead to, as the article states, “easy, inexpensive” reproduction of medical records. But things never seem to be that simple, for some of the reasons I’ve mentioned above.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Do you charge for medical records?
You probably do, and so do I, at times.
Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.
That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.
How much you can charge is a more complex issue, with each state setting its own rules. A recent article published in JAMA Internal Medicine noted that a patient in Georgia could pay up to $111.68 for a 100-page record. Hitting someone up for that amount, who’s already having health problems and may be relocating or trying to find a new doctor, seems like making an already difficult situation worse.
But we’re in the digital age now. So how much does it cost to send records? Most files (.doc, .pdf, .jpg, and so on) are interchangeable between Mac and Windows.
Things get iffy here. I mean, it’s easy to send a .pdf file by email, but that’s not particularly secure. And I hate having to sign up and create passwords for the many allegedly safer file-sharing services out there.
Burning records on a CD or DVD certainly saves postage, though takes about the same amount of computer time as printing them up. Not only that, but this seems to be a format that’s on its way out. The last three computers I’ve bought didn’t even have optical drives. CD/DVD’s are starting to resemble VHS tapes in the late 1990s.
Flash drives are the present and immediate future of transferred records. Small, lightweight, and capable of holding a lot. But they still need to be mailed, and are more expensive than paper. They also have security risks that concern me. When a patient hands me one and asks me to plug it in, I never do. There could be a virus or spyware that can compromise the security and privacy of my office, and cost a fortune to reverse the damage.
And so, at the end of that chain of thought, paper still appears to be king. It’s not going to carry ransomware into my office. It can be mailed or faxed, and is easily adaptable to any system (like mine) with a scanner. The paper world may hypothetically no longer exist, but for many things in medicine it still does, and is critical.
Some ultimate solutions, such as a universal database of health care data on all patients or a complete interchangeability between systems, sound great. No one would need to transfer records between doctors and all would have access to their own charts. But at this point in time, while technologically achievable, the privacy concerns and high-stakes security risks make such a thing impossible.
It’s easy to hope that the age of electronic medical records will lead to, as the article states, “easy, inexpensive” reproduction of medical records. But things never seem to be that simple, for some of the reasons I’ve mentioned above.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Substantial long-term increase seen in multiple myeloma survival
The 5-year survival rate for multiple myeloma increased eightfold over an approximately 60-year span starting in the early 1950s, said Ali H. Mokdad, PhD, and his associates.
Patients with multiple myeloma had a 5-year relative survival rate of 6% in 1950-1954, compared with 49.8% in 2008-2013, according to data from the Surveillance, Epidemiology, and End Results Program (JAMA 2017;317[4]:388-406).
In 2014, there were about 13,000 deaths resulting from multiple myeloma, with 219,000 years of life lost, which ranked 17th among the 29 selected cancers, noted Dr. Mokdad and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
The 5-year survival rate for multiple myeloma increased eightfold over an approximately 60-year span starting in the early 1950s, said Ali H. Mokdad, PhD, and his associates.
Patients with multiple myeloma had a 5-year relative survival rate of 6% in 1950-1954, compared with 49.8% in 2008-2013, according to data from the Surveillance, Epidemiology, and End Results Program (JAMA 2017;317[4]:388-406).
In 2014, there were about 13,000 deaths resulting from multiple myeloma, with 219,000 years of life lost, which ranked 17th among the 29 selected cancers, noted Dr. Mokdad and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
The 5-year survival rate for multiple myeloma increased eightfold over an approximately 60-year span starting in the early 1950s, said Ali H. Mokdad, PhD, and his associates.
Patients with multiple myeloma had a 5-year relative survival rate of 6% in 1950-1954, compared with 49.8% in 2008-2013, according to data from the Surveillance, Epidemiology, and End Results Program (JAMA 2017;317[4]:388-406).
In 2014, there were about 13,000 deaths resulting from multiple myeloma, with 219,000 years of life lost, which ranked 17th among the 29 selected cancers, noted Dr. Mokdad and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
FROM JAMA
AML leads percent gains in 5-year survival among leukemias
Over the 60-year span from the early 1950s to 2013, the 5-year survival rate for all leukemias increased by 500%, according to data from the Surveillance, Epidemiology, and End Results Program.
For 2008-2013, the 5-year relative survival rate for all leukemias was 60.1%, compared with 10% during 1950-1954, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle (JAMA 2017;317[4]:388-406).
Over the 60-year span from the early 1950s to 2013, the 5-year survival rate for all leukemias increased by 500%, according to data from the Surveillance, Epidemiology, and End Results Program.
For 2008-2013, the 5-year relative survival rate for all leukemias was 60.1%, compared with 10% during 1950-1954, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle (JAMA 2017;317[4]:388-406).
Over the 60-year span from the early 1950s to 2013, the 5-year survival rate for all leukemias increased by 500%, according to data from the Surveillance, Epidemiology, and End Results Program.
For 2008-2013, the 5-year relative survival rate for all leukemias was 60.1%, compared with 10% during 1950-1954, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle (JAMA 2017;317[4]:388-406).
Long view shows doubling of survival in non-Hodgkin lymphoma
Five-year survival for patients with non-Hodgkin lymphoma has more than doubled since the early 1950s, according to Ali H. Mokdad, PhD, and his associates.
Data from the Surveillance, Epidemiology, and End Results Program show that the 5-year relative survival rate for non-Hodgkin lymphoma in the United States went from 33% in 1950-1954 to 71.2% in 2008-2013, an increase of 116%, Dr. Mokdad and his associates reported (JAMA 2017;317[4]:388-406).
In 2014, mortality for non-Hodgkin lymphoma was the 7th highest among the 29 cancers included in the study, and more than 487,000 years of life were lost, which put it 6th among the 29 cancers, said Dr. Mokdad and his associates from the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
Five-year survival for patients with non-Hodgkin lymphoma has more than doubled since the early 1950s, according to Ali H. Mokdad, PhD, and his associates.
Data from the Surveillance, Epidemiology, and End Results Program show that the 5-year relative survival rate for non-Hodgkin lymphoma in the United States went from 33% in 1950-1954 to 71.2% in 2008-2013, an increase of 116%, Dr. Mokdad and his associates reported (JAMA 2017;317[4]:388-406).
In 2014, mortality for non-Hodgkin lymphoma was the 7th highest among the 29 cancers included in the study, and more than 487,000 years of life were lost, which put it 6th among the 29 cancers, said Dr. Mokdad and his associates from the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
Five-year survival for patients with non-Hodgkin lymphoma has more than doubled since the early 1950s, according to Ali H. Mokdad, PhD, and his associates.
Data from the Surveillance, Epidemiology, and End Results Program show that the 5-year relative survival rate for non-Hodgkin lymphoma in the United States went from 33% in 1950-1954 to 71.2% in 2008-2013, an increase of 116%, Dr. Mokdad and his associates reported (JAMA 2017;317[4]:388-406).
In 2014, mortality for non-Hodgkin lymphoma was the 7th highest among the 29 cancers included in the study, and more than 487,000 years of life were lost, which put it 6th among the 29 cancers, said Dr. Mokdad and his associates from the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
FROM JAMA
How Do Patients With Epilepsy Use Herbal and Botanical Therapies?
HOUSTON—Many people with epilepsy use herbal and botanical therapies. Some patients use them to help control their seizures, while others use them to treat medication side effects or co-occurring symptoms, such as depression, anxiety, and memory problems.
“Ask your patients about the use of botanicals because they are probably using them,” said Dana Ekstein, MD, PhD, a senior neurologist at Hadassah Medical Center in Jerusalem, in an overview provided at the 70th Annual Meeting of the American Epilepsy Society. “Be ready to advise on the safety of their use.” 
Efficacy and safety data for many of the treatments are limited, but educational resources are available to keep neurologists up to date. In addition, neurologists should ensure that botanicals do not interfere with conventional medication.
Widely Used
According to the 2012 American National Health Interview Survey, about a third of the population uses complementary medicine. Herbal and botanical medicines (ie, nonvitamin, nonmineral natural products) are the most commonly used complementary medicines and are used by about 18% of the population. Among people with epilepsy, studies have found that about half of adults and a third of children use complementary therapies. Patients often do not report the use of complementary medicine to their physicians, Dr. Ekstein said.
Massot-Tarrús and McLachlan examined the use of cannabis by people with epilepsy who were admitted to an epilepsy monitoring unit in Canada. More than half of them had tried marijuana. Many of them—59% of patients with epilepsy and 33% of patients with psychogenic nonepileptic seizures—used cannabis daily.Although botanicals were the mainstay of epilepsy treatment for centuries, modern data on botanicals in epilepsy are limited, Dr. Ekstein said. A 2009 Cochrane review of traditional Chinese medicine for epilepsy included only five unblinded single-center controlled studies. Although the studies reported some benefit, the probability of selection, detection, and performance bias meant that the treatment’s effect could not reliably be evaluated.
Cannabis
A 2014 Cochrane review of cannabinoids for epilepsy considered four randomized controlled trials with a total of 48 patients. Each trial included between nine and 15 patients, and investigators followed patients for between one and 12 months. The studies failed to provide efficacy evidence. In another review that considered all published studies with more than one patient, researchers analyzed eight studies with a total of 105 children and adults. Patients received placebo or cannabis compounds. Of the patients who received cannabis, 61% experienced improvement.
A retrospective trial of medical cannabis oil in Israel published in 2016 included 74 pediatric patients. Fifty-two percent of the patients had a 50% or greater reduction in seizure frequency, and one patient became seizure-free. Sixty percent of patients reported other benefits, such as improved behavior, alertness, language, communication, motor skills, and sleep.
A prospective open-label study by Devinsky et al enrolled 214 patients from 11 centers in the United States. The study included patients with drug-resistant epilepsy with onset in childhood who had at least four seizures per month. Patients received cannabidiol and were followed for three months. Of 137 patients included in the efficacy analysis, 39% had a 50% or greater reduction in seizure frequency.
Mushroom May Treat Depression
A Chinese mushroom called Xylaria nigripes has been studied for the treatment of depression in patients with epilepsy, Dr. Ekstein said. Peng et al conducted a randomized double-blind placebo-controlled trial that included 104 patients with epilepsy and depression. The mushroom significantly improved Hamilton Depression Rating Scale and quality of life scores, compared with placebo.
Although not studied in patients with epilepsy, research has shown that St. John’s wort effectively treats mild to moderate depression; kava treats generalized anxiety; and rosenroot improves attention, fatigue, mild depression, and mental performance, she said.
Safety
Many patients assume that natural products are safe, but there are important safety considerations, Dr. Ekstein said. Some botanicals have been associated with seizures, including ephedra, St. John’s wort, and ginkgo biloba. Cannabinoids, especially tetrahydrocannabinol (THC), may induce memory and executive function impairment and psychiatric symptoms. Cannabinoids also may impair plasticity in the developing brain.
Side effects in cannabis trials have been relatively common. In the retrospective Israeli trial, 46% of patients experienced adverse events (eg, seizure aggravation, somnolence, fatigue, and gastrointestinal disturbances). In the trial by Devinsky et al, 79% of patients experienced adverse events. Although most of the adverse events were mild to moderate and transient, 30% were serious adverse events (eg, status epilepticus, diarrhea, pneumonia, and weight loss).
Interactions between botanicals and antiepileptic drugs also should be taken into account, she said. Some botanicals may decrease or increase bioavailability of antiepileptic drugs. For example, cannabidiol increases concentrations of clobazam.
More clinical trials are needed to establish the efficacy and safety of botanical therapies. Cannabinoids are “on the right path” in terms of receiving further study. “There are almost no planned trials” of other botanicals, however, Dr. Ekstein said. The medical community should prioritize botanicals for further study, and neurologists should offer patients participation in clinical studies when they are available, she said.
Neurologists generally should be better educated regarding the use of botanical therapies. Online resources, such as those provided by the National Center for Complementary and Integrative Health, provide information about botanical therapies. The International League Against Epilepsy recently created the Web-based Epilepsy Naturapedia to provide information about the use of natural products in the treatment of epilepsy, Dr. Ekstein said.
—Jake Remaly
Suggested Reading
Devinsky O, Marsh E, Friedman D, et al. Cannabidiol in patients with treatment-resistant epilepsy: an open-label interventional trial. Lancet Neurol. 2016;15(3):270-278.
Ekstein D, Schachter SC. Natural products in epilepsy-the present situation and perspectives for the future. Pharmaceuticals (Basel). 2010;3(5):1426-1445.
Gloss D, Vickrey B. Cannabinoids for epilepsy. Cochrane Database Syst Rev. 2014;(3):CD009270.
Li Q, Chen X, He L, Zhou D. Traditional Chinese medicine for epilepsy. Cochrane Database Syst Rev. 2009;(3):CD006454.
Massot-Tarrús A, McLachlan RS. Marijuana use in adults admitted to a Canadian epilepsy monitoring unit. Epilepsy Behav. 2016;63:73-78.
Peng WF, Wang X, Hong Z, et al. The anti-depression effect of Xylaria nigripes in patients with epilepsy: A multicenter randomized double-blind study. Seizure. 2015;29:26-33.
Szaflarski JP, Bebin EM. Cannabis, cannabidiol, and epilepsy--from receptors to clinical response. Epilepsy Behav. 2014;41:277-282.
Tzadok M, Uliel-Siboni S, Linder I, et al. CBD-enriched medical cannabis for intractable pediatric epilepsy: the current Israeli experience. Seizure. 2016;35:41-44.
HOUSTON—Many people with epilepsy use herbal and botanical therapies. Some patients use them to help control their seizures, while others use them to treat medication side effects or co-occurring symptoms, such as depression, anxiety, and memory problems.
“Ask your patients about the use of botanicals because they are probably using them,” said Dana Ekstein, MD, PhD, a senior neurologist at Hadassah Medical Center in Jerusalem, in an overview provided at the 70th Annual Meeting of the American Epilepsy Society. “Be ready to advise on the safety of their use.”
Efficacy and safety data for many of the treatments are limited, but educational resources are available to keep neurologists up to date. In addition, neurologists should ensure that botanicals do not interfere with conventional medication.
Widely Used
According to the 2012 American National Health Interview Survey, about a third of the population uses complementary medicine. Herbal and botanical medicines (ie, nonvitamin, nonmineral natural products) are the most commonly used complementary medicines and are used by about 18% of the population. Among people with epilepsy, studies have found that about half of adults and a third of children use complementary therapies. Patients often do not report the use of complementary medicine to their physicians, Dr. Ekstein said.
Massot-Tarrús and McLachlan examined the use of cannabis by people with epilepsy who were admitted to an epilepsy monitoring unit in Canada. More than half of them had tried marijuana. Many of them—59% of patients with epilepsy and 33% of patients with psychogenic nonepileptic seizures—used cannabis daily.Although botanicals were the mainstay of epilepsy treatment for centuries, modern data on botanicals in epilepsy are limited, Dr. Ekstein said. A 2009 Cochrane review of traditional Chinese medicine for epilepsy included only five unblinded single-center controlled studies. Although the studies reported some benefit, the probability of selection, detection, and performance bias meant that the treatment’s effect could not reliably be evaluated.
Cannabis
A 2014 Cochrane review of cannabinoids for epilepsy considered four randomized controlled trials with a total of 48 patients. Each trial included between nine and 15 patients, and investigators followed patients for between one and 12 months. The studies failed to provide efficacy evidence. In another review that considered all published studies with more than one patient, researchers analyzed eight studies with a total of 105 children and adults. Patients received placebo or cannabis compounds. Of the patients who received cannabis, 61% experienced improvement.
A retrospective trial of medical cannabis oil in Israel published in 2016 included 74 pediatric patients. Fifty-two percent of the patients had a 50% or greater reduction in seizure frequency, and one patient became seizure-free. Sixty percent of patients reported other benefits, such as improved behavior, alertness, language, communication, motor skills, and sleep.
A prospective open-label study by Devinsky et al enrolled 214 patients from 11 centers in the United States. The study included patients with drug-resistant epilepsy with onset in childhood who had at least four seizures per month. Patients received cannabidiol and were followed for three months. Of 137 patients included in the efficacy analysis, 39% had a 50% or greater reduction in seizure frequency.
Mushroom May Treat Depression
A Chinese mushroom called Xylaria nigripes has been studied for the treatment of depression in patients with epilepsy, Dr. Ekstein said. Peng et al conducted a randomized double-blind placebo-controlled trial that included 104 patients with epilepsy and depression. The mushroom significantly improved Hamilton Depression Rating Scale and quality of life scores, compared with placebo.
Although not studied in patients with epilepsy, research has shown that St. John’s wort effectively treats mild to moderate depression; kava treats generalized anxiety; and rosenroot improves attention, fatigue, mild depression, and mental performance, she said.
Safety
Many patients assume that natural products are safe, but there are important safety considerations, Dr. Ekstein said. Some botanicals have been associated with seizures, including ephedra, St. John’s wort, and ginkgo biloba. Cannabinoids, especially tetrahydrocannabinol (THC), may induce memory and executive function impairment and psychiatric symptoms. Cannabinoids also may impair plasticity in the developing brain.
Side effects in cannabis trials have been relatively common. In the retrospective Israeli trial, 46% of patients experienced adverse events (eg, seizure aggravation, somnolence, fatigue, and gastrointestinal disturbances). In the trial by Devinsky et al, 79% of patients experienced adverse events. Although most of the adverse events were mild to moderate and transient, 30% were serious adverse events (eg, status epilepticus, diarrhea, pneumonia, and weight loss).
Interactions between botanicals and antiepileptic drugs also should be taken into account, she said. Some botanicals may decrease or increase bioavailability of antiepileptic drugs. For example, cannabidiol increases concentrations of clobazam.
More clinical trials are needed to establish the efficacy and safety of botanical therapies. Cannabinoids are “on the right path” in terms of receiving further study. “There are almost no planned trials” of other botanicals, however, Dr. Ekstein said. The medical community should prioritize botanicals for further study, and neurologists should offer patients participation in clinical studies when they are available, she said.
Neurologists generally should be better educated regarding the use of botanical therapies. Online resources, such as those provided by the National Center for Complementary and Integrative Health, provide information about botanical therapies. The International League Against Epilepsy recently created the Web-based Epilepsy Naturapedia to provide information about the use of natural products in the treatment of epilepsy, Dr. Ekstein said.
—Jake Remaly
Suggested Reading
Devinsky O, Marsh E, Friedman D, et al. Cannabidiol in patients with treatment-resistant epilepsy: an open-label interventional trial. Lancet Neurol. 2016;15(3):270-278.
Ekstein D, Schachter SC. Natural products in epilepsy-the present situation and perspectives for the future. Pharmaceuticals (Basel). 2010;3(5):1426-1445.
Gloss D, Vickrey B. Cannabinoids for epilepsy. Cochrane Database Syst Rev. 2014;(3):CD009270.
Li Q, Chen X, He L, Zhou D. Traditional Chinese medicine for epilepsy. Cochrane Database Syst Rev. 2009;(3):CD006454.
Massot-Tarrús A, McLachlan RS. Marijuana use in adults admitted to a Canadian epilepsy monitoring unit. Epilepsy Behav. 2016;63:73-78.
Peng WF, Wang X, Hong Z, et al. The anti-depression effect of Xylaria nigripes in patients with epilepsy: A multicenter randomized double-blind study. Seizure. 2015;29:26-33.
Szaflarski JP, Bebin EM. Cannabis, cannabidiol, and epilepsy--from receptors to clinical response. Epilepsy Behav. 2014;41:277-282.
Tzadok M, Uliel-Siboni S, Linder I, et al. CBD-enriched medical cannabis for intractable pediatric epilepsy: the current Israeli experience. Seizure. 2016;35:41-44.
HOUSTON—Many people with epilepsy use herbal and botanical therapies. Some patients use them to help control their seizures, while others use them to treat medication side effects or co-occurring symptoms, such as depression, anxiety, and memory problems.
“Ask your patients about the use of botanicals because they are probably using them,” said Dana Ekstein, MD, PhD, a senior neurologist at Hadassah Medical Center in Jerusalem, in an overview provided at the 70th Annual Meeting of the American Epilepsy Society. “Be ready to advise on the safety of their use.”
Efficacy and safety data for many of the treatments are limited, but educational resources are available to keep neurologists up to date. In addition, neurologists should ensure that botanicals do not interfere with conventional medication.
Widely Used
According to the 2012 American National Health Interview Survey, about a third of the population uses complementary medicine. Herbal and botanical medicines (ie, nonvitamin, nonmineral natural products) are the most commonly used complementary medicines and are used by about 18% of the population. Among people with epilepsy, studies have found that about half of adults and a third of children use complementary therapies. Patients often do not report the use of complementary medicine to their physicians, Dr. Ekstein said.
Massot-Tarrús and McLachlan examined the use of cannabis by people with epilepsy who were admitted to an epilepsy monitoring unit in Canada. More than half of them had tried marijuana. Many of them—59% of patients with epilepsy and 33% of patients with psychogenic nonepileptic seizures—used cannabis daily.Although botanicals were the mainstay of epilepsy treatment for centuries, modern data on botanicals in epilepsy are limited, Dr. Ekstein said. A 2009 Cochrane review of traditional Chinese medicine for epilepsy included only five unblinded single-center controlled studies. Although the studies reported some benefit, the probability of selection, detection, and performance bias meant that the treatment’s effect could not reliably be evaluated.
Cannabis
A 2014 Cochrane review of cannabinoids for epilepsy considered four randomized controlled trials with a total of 48 patients. Each trial included between nine and 15 patients, and investigators followed patients for between one and 12 months. The studies failed to provide efficacy evidence. In another review that considered all published studies with more than one patient, researchers analyzed eight studies with a total of 105 children and adults. Patients received placebo or cannabis compounds. Of the patients who received cannabis, 61% experienced improvement.
A retrospective trial of medical cannabis oil in Israel published in 2016 included 74 pediatric patients. Fifty-two percent of the patients had a 50% or greater reduction in seizure frequency, and one patient became seizure-free. Sixty percent of patients reported other benefits, such as improved behavior, alertness, language, communication, motor skills, and sleep.
A prospective open-label study by Devinsky et al enrolled 214 patients from 11 centers in the United States. The study included patients with drug-resistant epilepsy with onset in childhood who had at least four seizures per month. Patients received cannabidiol and were followed for three months. Of 137 patients included in the efficacy analysis, 39% had a 50% or greater reduction in seizure frequency.
Mushroom May Treat Depression
A Chinese mushroom called Xylaria nigripes has been studied for the treatment of depression in patients with epilepsy, Dr. Ekstein said. Peng et al conducted a randomized double-blind placebo-controlled trial that included 104 patients with epilepsy and depression. The mushroom significantly improved Hamilton Depression Rating Scale and quality of life scores, compared with placebo.
Although not studied in patients with epilepsy, research has shown that St. John’s wort effectively treats mild to moderate depression; kava treats generalized anxiety; and rosenroot improves attention, fatigue, mild depression, and mental performance, she said.
Safety
Many patients assume that natural products are safe, but there are important safety considerations, Dr. Ekstein said. Some botanicals have been associated with seizures, including ephedra, St. John’s wort, and ginkgo biloba. Cannabinoids, especially tetrahydrocannabinol (THC), may induce memory and executive function impairment and psychiatric symptoms. Cannabinoids also may impair plasticity in the developing brain.
Side effects in cannabis trials have been relatively common. In the retrospective Israeli trial, 46% of patients experienced adverse events (eg, seizure aggravation, somnolence, fatigue, and gastrointestinal disturbances). In the trial by Devinsky et al, 79% of patients experienced adverse events. Although most of the adverse events were mild to moderate and transient, 30% were serious adverse events (eg, status epilepticus, diarrhea, pneumonia, and weight loss).
Interactions between botanicals and antiepileptic drugs also should be taken into account, she said. Some botanicals may decrease or increase bioavailability of antiepileptic drugs. For example, cannabidiol increases concentrations of clobazam.
More clinical trials are needed to establish the efficacy and safety of botanical therapies. Cannabinoids are “on the right path” in terms of receiving further study. “There are almost no planned trials” of other botanicals, however, Dr. Ekstein said. The medical community should prioritize botanicals for further study, and neurologists should offer patients participation in clinical studies when they are available, she said.
Neurologists generally should be better educated regarding the use of botanical therapies. Online resources, such as those provided by the National Center for Complementary and Integrative Health, provide information about botanical therapies. The International League Against Epilepsy recently created the Web-based Epilepsy Naturapedia to provide information about the use of natural products in the treatment of epilepsy, Dr. Ekstein said.
—Jake Remaly
Suggested Reading
Devinsky O, Marsh E, Friedman D, et al. Cannabidiol in patients with treatment-resistant epilepsy: an open-label interventional trial. Lancet Neurol. 2016;15(3):270-278.
Ekstein D, Schachter SC. Natural products in epilepsy-the present situation and perspectives for the future. Pharmaceuticals (Basel). 2010;3(5):1426-1445.
Gloss D, Vickrey B. Cannabinoids for epilepsy. Cochrane Database Syst Rev. 2014;(3):CD009270.
Li Q, Chen X, He L, Zhou D. Traditional Chinese medicine for epilepsy. Cochrane Database Syst Rev. 2009;(3):CD006454.
Massot-Tarrús A, McLachlan RS. Marijuana use in adults admitted to a Canadian epilepsy monitoring unit. Epilepsy Behav. 2016;63:73-78.
Peng WF, Wang X, Hong Z, et al. The anti-depression effect of Xylaria nigripes in patients with epilepsy: A multicenter randomized double-blind study. Seizure. 2015;29:26-33.
Szaflarski JP, Bebin EM. Cannabis, cannabidiol, and epilepsy--from receptors to clinical response. Epilepsy Behav. 2014;41:277-282.
Tzadok M, Uliel-Siboni S, Linder I, et al. CBD-enriched medical cannabis for intractable pediatric epilepsy: the current Israeli experience. Seizure. 2016;35:41-44.
Hodgkin lymphoma survival has nearly tripled since the 1950s
Five-year relative survival for Hodgkin lymphoma increased 189% over the approximately 60 years from the early 1950s to 2013, according to investigators looking at data from the Surveillance, Epidemiology, and End Results Program.
During 1950-1954, the 5-year relative survival rate for Hodgkin lymphoma was 30%, compared with 86.6% in 2008-2013, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
In 2014, mortality for Hodgkin lymphoma was 0.4 per 100,000 population, which put it 27th among the 29 included cancers, with about 36,000 years of life lost, which was 26th of the 29 cancers, Dr. Mokdad and his associates said. This part of their study used deidentified death records from the National Center for Health Statistics and population counts from the Census Bureau, the NCHS, and the Human Mortality Database.
Five-year relative survival for Hodgkin lymphoma increased 189% over the approximately 60 years from the early 1950s to 2013, according to investigators looking at data from the Surveillance, Epidemiology, and End Results Program.
During 1950-1954, the 5-year relative survival rate for Hodgkin lymphoma was 30%, compared with 86.6% in 2008-2013, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
In 2014, mortality for Hodgkin lymphoma was 0.4 per 100,000 population, which put it 27th among the 29 included cancers, with about 36,000 years of life lost, which was 26th of the 29 cancers, Dr. Mokdad and his associates said. This part of their study used deidentified death records from the National Center for Health Statistics and population counts from the Census Bureau, the NCHS, and the Human Mortality Database.
Five-year relative survival for Hodgkin lymphoma increased 189% over the approximately 60 years from the early 1950s to 2013, according to investigators looking at data from the Surveillance, Epidemiology, and End Results Program.
During 1950-1954, the 5-year relative survival rate for Hodgkin lymphoma was 30%, compared with 86.6% in 2008-2013, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle.
In 2014, mortality for Hodgkin lymphoma was 0.4 per 100,000 population, which put it 27th among the 29 included cancers, with about 36,000 years of life lost, which was 26th of the 29 cancers, Dr. Mokdad and his associates said. This part of their study used deidentified death records from the National Center for Health Statistics and population counts from the Census Bureau, the NCHS, and the Human Mortality Database.
FROM JAMA
Sterile fecal filtrate effectively treated recurrent CDI
Sterile fecal filtrate transplantation (FFT) effectively treated five cases of symptomatic chronic-relapsing Clostridium difficile infection, investigators reported.
The procedure restored normal bowel habits and eliminated symptoms through the end of the study – that is, for at least 6 months – in all patients, Stephan J. Ott, MD, and his associates wrote (Gastroenterology. 2019. doi: 10.1053/j.gastro.2016.11.010).
Proteome analyses did not identify proteins likely to explain this efficacy, but 16S rRNA gene sequencing did demonstrate diverse bacterial DNA signatures in the filtrates, and tests of virus-like particles yielded “a complex signature of macrophages,” Dr. Ott and his associates reported. Additional tests suggested that recipients’ microbiomes continued to change weeks after FFT. “This open-label series strongly suggests that FFT should be evaluated in a controlled setting in comparison with standard fecal microbiota transplantation,” the researchers concluded.
Fecal microbiota transplantation (FMT) effectively treats recurrent Clostridium difficile infection (CDI), but even “the most rigorous and costly donor screening procedures, or defined panels of bacteria, cannot exclude the risk of transferring unknown pathogens or undetectable functional characteristics within the living microorganisms to the recipient, including bacterial or viral risk factors for metabolic diseases, cancer, atopy, or autoimmunity,” the investigators wrote.
Therefore, they performed sterile FFT in five patients who were positive on at least two of three tests: enzyme-linked immunosorbent assay for C. difficile–specific glutamate dehydrogenase; C. difficile toxin enzyme-linked immunosorbent assay; and culture of toxin-producing C. difficile. Patients chose their own stool donors, who were then screened based on published guidelines (Clin Gastroenterol Hepatol. 2011;9[12]:1044-49). Next, “slurries” were prepared from donor stool and filtered with a custom-built air pressure filtration system, yielding a “light brown, clear liquid with a subjectively less unpleasant and intensive odor” than conventional FMT stool preparations. Bacterial cultures of these filtrates yielded no growth, whereas donor stool cultures showed profuse growth of aerobic and anaerobic bacterial colonies, Dr. Ott and his associates said.
Patients became symptom-free 2-4 days after undergoing FFT. Notably, one patient had previously undergone FMT, which led to acute fever and diarrhea and recurrence of baseline symptoms after 3 months. This patient did not develop fever or diarrhea after FFT, was symptom-free after 3 days, and remained symptom-free until the study ended 2 years later, the researchers said. All other patients also remained symptom-free through the end of the study, that is, for 6 months to more than 2 years.
Analyses of 16S rRNA revealed substantial longitudinal shifts after FFT that often were present by week 1 and remained stable until week 6, the investigators said. Further tests confirmed marked shifts in bacterial phylotypes and in their relative abundance over time. Repeated virus analyses of one patient also showed that the phageome shifted over time to resemble that of the donor.
Patients were between 49 and 75 years old, three were female and two were male, and all had received more than one antibiotic before their first episode of CDI. Antibiotics for CDI had included metronidazole, vancomycin, and rifaximin. Comorbidities included pseudomembranous colitis, renal failure, HIV infection, epilepsy, and chronic heart failure, and medical histories included recurrent diverticulitis with sigmoid resection, gastric carcinoma, and colon cancer.
“It is important to keep in mind that, in contrast to conventional FMT, transferring sterile FFT filtrates cannot be expected to establish a microbiota similar to that of the donor in the receiving patient,” Dr. Ott and his associates noted. Instead, bacterial DNA in the filtrate might trigger the re-establishment of the recipient microbiome, they said. Bacterial cell wall fragments or bacteriophages also might play a role, they added.
The German Excellence Cluster and CONARIS Research Institute AG supported the work. Dr. Ott reported having lectured for Allergosan. Two coinvestigators reported employment with CONARIS. A third coinvestigator reported shareholder relationships with CONARIS, Allergosan, Danone, and Nestle and lectureship compensation from Allergosan. The other eight coinvestigators had no relevant conflicts of interest.
The remarkable efficacy of fecal microbial transplant in recurrent C. difficile infection provides a compelling example of ecologic microbiome-based therapy. Its mechanism is widely considered to be the restoration of select microbial species that suppress C. difficile colonization and virulence in healthy individuals. Identification of such suppressive microbiota is still at an early stage, with empirical studies revealing effective synthetic microbial consortia, and evidence of some modes of action, such as bile salt metabolism (Nature 2015;517:205-8; PLoS Pathog. 2012;8:e1002995).
Clouding this elegant concept is the provocative new study of Dr. Ott and his colleagues. Prompted by long-term safety concerns, they evaluated the efficacy of a donor fecal microfiltrate lacking viable intact organisms. Indeed, in five patients, long-term eradication of C. difficile was achieved with a single dose. This observation indicates that the initial action of fecal transplant may not require restoration of viable organisms into the antibiotic-damaged ecosystem.
What mechanisms might account for the therapeutic action of organism-free fecal microfiltrate? First, this material is laden with a complex, potentially distinct mix of microbial products and particulates (Cell. 2016;165[5]:1106-19) from donor origin or ex vivo processing. These biologicals may induce immune processes to promote control of C. difficile directly or via changes in other commensals of the patient's microbiome. Second, the microfiltrate retains abundant and diverse bacteria-targeting viruses of the fecal stream. Perhaps certain viruses, deficient in patients, target C. difficile and/or beneficially reshape microbial composition (Cell Mol Gastroenterol Hepatol. 2015;1[1]:28-40). So, C. difficile challenges us once more into the breach with new insights ahead for the principles and practice of ecologic microbiome therapy.
Jonathan Braun, MD, PhD, is professor and chair of pathology and laboratory medicine at the University of California, Los Angeles. He has no conflicts of interest.
The remarkable efficacy of fecal microbial transplant in recurrent C. difficile infection provides a compelling example of ecologic microbiome-based therapy. Its mechanism is widely considered to be the restoration of select microbial species that suppress C. difficile colonization and virulence in healthy individuals. Identification of such suppressive microbiota is still at an early stage, with empirical studies revealing effective synthetic microbial consortia, and evidence of some modes of action, such as bile salt metabolism (Nature 2015;517:205-8; PLoS Pathog. 2012;8:e1002995).
Clouding this elegant concept is the provocative new study of Dr. Ott and his colleagues. Prompted by long-term safety concerns, they evaluated the efficacy of a donor fecal microfiltrate lacking viable intact organisms. Indeed, in five patients, long-term eradication of C. difficile was achieved with a single dose. This observation indicates that the initial action of fecal transplant may not require restoration of viable organisms into the antibiotic-damaged ecosystem.
What mechanisms might account for the therapeutic action of organism-free fecal microfiltrate? First, this material is laden with a complex, potentially distinct mix of microbial products and particulates (Cell. 2016;165[5]:1106-19) from donor origin or ex vivo processing. These biologicals may induce immune processes to promote control of C. difficile directly or via changes in other commensals of the patient's microbiome. Second, the microfiltrate retains abundant and diverse bacteria-targeting viruses of the fecal stream. Perhaps certain viruses, deficient in patients, target C. difficile and/or beneficially reshape microbial composition (Cell Mol Gastroenterol Hepatol. 2015;1[1]:28-40). So, C. difficile challenges us once more into the breach with new insights ahead for the principles and practice of ecologic microbiome therapy.
Jonathan Braun, MD, PhD, is professor and chair of pathology and laboratory medicine at the University of California, Los Angeles. He has no conflicts of interest.
The remarkable efficacy of fecal microbial transplant in recurrent C. difficile infection provides a compelling example of ecologic microbiome-based therapy. Its mechanism is widely considered to be the restoration of select microbial species that suppress C. difficile colonization and virulence in healthy individuals. Identification of such suppressive microbiota is still at an early stage, with empirical studies revealing effective synthetic microbial consortia, and evidence of some modes of action, such as bile salt metabolism (Nature 2015;517:205-8; PLoS Pathog. 2012;8:e1002995).
Clouding this elegant concept is the provocative new study of Dr. Ott and his colleagues. Prompted by long-term safety concerns, they evaluated the efficacy of a donor fecal microfiltrate lacking viable intact organisms. Indeed, in five patients, long-term eradication of C. difficile was achieved with a single dose. This observation indicates that the initial action of fecal transplant may not require restoration of viable organisms into the antibiotic-damaged ecosystem.
What mechanisms might account for the therapeutic action of organism-free fecal microfiltrate? First, this material is laden with a complex, potentially distinct mix of microbial products and particulates (Cell. 2016;165[5]:1106-19) from donor origin or ex vivo processing. These biologicals may induce immune processes to promote control of C. difficile directly or via changes in other commensals of the patient's microbiome. Second, the microfiltrate retains abundant and diverse bacteria-targeting viruses of the fecal stream. Perhaps certain viruses, deficient in patients, target C. difficile and/or beneficially reshape microbial composition (Cell Mol Gastroenterol Hepatol. 2015;1[1]:28-40). So, C. difficile challenges us once more into the breach with new insights ahead for the principles and practice of ecologic microbiome therapy.
Jonathan Braun, MD, PhD, is professor and chair of pathology and laboratory medicine at the University of California, Los Angeles. He has no conflicts of interest.
Sterile fecal filtrate transplantation (FFT) effectively treated five cases of symptomatic chronic-relapsing Clostridium difficile infection, investigators reported.
The procedure restored normal bowel habits and eliminated symptoms through the end of the study – that is, for at least 6 months – in all patients, Stephan J. Ott, MD, and his associates wrote (Gastroenterology. 2019. doi: 10.1053/j.gastro.2016.11.010).
Proteome analyses did not identify proteins likely to explain this efficacy, but 16S rRNA gene sequencing did demonstrate diverse bacterial DNA signatures in the filtrates, and tests of virus-like particles yielded “a complex signature of macrophages,” Dr. Ott and his associates reported. Additional tests suggested that recipients’ microbiomes continued to change weeks after FFT. “This open-label series strongly suggests that FFT should be evaluated in a controlled setting in comparison with standard fecal microbiota transplantation,” the researchers concluded.
Fecal microbiota transplantation (FMT) effectively treats recurrent Clostridium difficile infection (CDI), but even “the most rigorous and costly donor screening procedures, or defined panels of bacteria, cannot exclude the risk of transferring unknown pathogens or undetectable functional characteristics within the living microorganisms to the recipient, including bacterial or viral risk factors for metabolic diseases, cancer, atopy, or autoimmunity,” the investigators wrote.
Therefore, they performed sterile FFT in five patients who were positive on at least two of three tests: enzyme-linked immunosorbent assay for C. difficile–specific glutamate dehydrogenase; C. difficile toxin enzyme-linked immunosorbent assay; and culture of toxin-producing C. difficile. Patients chose their own stool donors, who were then screened based on published guidelines (Clin Gastroenterol Hepatol. 2011;9[12]:1044-49). Next, “slurries” were prepared from donor stool and filtered with a custom-built air pressure filtration system, yielding a “light brown, clear liquid with a subjectively less unpleasant and intensive odor” than conventional FMT stool preparations. Bacterial cultures of these filtrates yielded no growth, whereas donor stool cultures showed profuse growth of aerobic and anaerobic bacterial colonies, Dr. Ott and his associates said.
Patients became symptom-free 2-4 days after undergoing FFT. Notably, one patient had previously undergone FMT, which led to acute fever and diarrhea and recurrence of baseline symptoms after 3 months. This patient did not develop fever or diarrhea after FFT, was symptom-free after 3 days, and remained symptom-free until the study ended 2 years later, the researchers said. All other patients also remained symptom-free through the end of the study, that is, for 6 months to more than 2 years.
Analyses of 16S rRNA revealed substantial longitudinal shifts after FFT that often were present by week 1 and remained stable until week 6, the investigators said. Further tests confirmed marked shifts in bacterial phylotypes and in their relative abundance over time. Repeated virus analyses of one patient also showed that the phageome shifted over time to resemble that of the donor.
Patients were between 49 and 75 years old, three were female and two were male, and all had received more than one antibiotic before their first episode of CDI. Antibiotics for CDI had included metronidazole, vancomycin, and rifaximin. Comorbidities included pseudomembranous colitis, renal failure, HIV infection, epilepsy, and chronic heart failure, and medical histories included recurrent diverticulitis with sigmoid resection, gastric carcinoma, and colon cancer.
“It is important to keep in mind that, in contrast to conventional FMT, transferring sterile FFT filtrates cannot be expected to establish a microbiota similar to that of the donor in the receiving patient,” Dr. Ott and his associates noted. Instead, bacterial DNA in the filtrate might trigger the re-establishment of the recipient microbiome, they said. Bacterial cell wall fragments or bacteriophages also might play a role, they added.
The German Excellence Cluster and CONARIS Research Institute AG supported the work. Dr. Ott reported having lectured for Allergosan. Two coinvestigators reported employment with CONARIS. A third coinvestigator reported shareholder relationships with CONARIS, Allergosan, Danone, and Nestle and lectureship compensation from Allergosan. The other eight coinvestigators had no relevant conflicts of interest.
Sterile fecal filtrate transplantation (FFT) effectively treated five cases of symptomatic chronic-relapsing Clostridium difficile infection, investigators reported.
The procedure restored normal bowel habits and eliminated symptoms through the end of the study – that is, for at least 6 months – in all patients, Stephan J. Ott, MD, and his associates wrote (Gastroenterology. 2019. doi: 10.1053/j.gastro.2016.11.010).
Proteome analyses did not identify proteins likely to explain this efficacy, but 16S rRNA gene sequencing did demonstrate diverse bacterial DNA signatures in the filtrates, and tests of virus-like particles yielded “a complex signature of macrophages,” Dr. Ott and his associates reported. Additional tests suggested that recipients’ microbiomes continued to change weeks after FFT. “This open-label series strongly suggests that FFT should be evaluated in a controlled setting in comparison with standard fecal microbiota transplantation,” the researchers concluded.
Fecal microbiota transplantation (FMT) effectively treats recurrent Clostridium difficile infection (CDI), but even “the most rigorous and costly donor screening procedures, or defined panels of bacteria, cannot exclude the risk of transferring unknown pathogens or undetectable functional characteristics within the living microorganisms to the recipient, including bacterial or viral risk factors for metabolic diseases, cancer, atopy, or autoimmunity,” the investigators wrote.
Therefore, they performed sterile FFT in five patients who were positive on at least two of three tests: enzyme-linked immunosorbent assay for C. difficile–specific glutamate dehydrogenase; C. difficile toxin enzyme-linked immunosorbent assay; and culture of toxin-producing C. difficile. Patients chose their own stool donors, who were then screened based on published guidelines (Clin Gastroenterol Hepatol. 2011;9[12]:1044-49). Next, “slurries” were prepared from donor stool and filtered with a custom-built air pressure filtration system, yielding a “light brown, clear liquid with a subjectively less unpleasant and intensive odor” than conventional FMT stool preparations. Bacterial cultures of these filtrates yielded no growth, whereas donor stool cultures showed profuse growth of aerobic and anaerobic bacterial colonies, Dr. Ott and his associates said.
Patients became symptom-free 2-4 days after undergoing FFT. Notably, one patient had previously undergone FMT, which led to acute fever and diarrhea and recurrence of baseline symptoms after 3 months. This patient did not develop fever or diarrhea after FFT, was symptom-free after 3 days, and remained symptom-free until the study ended 2 years later, the researchers said. All other patients also remained symptom-free through the end of the study, that is, for 6 months to more than 2 years.
Analyses of 16S rRNA revealed substantial longitudinal shifts after FFT that often were present by week 1 and remained stable until week 6, the investigators said. Further tests confirmed marked shifts in bacterial phylotypes and in their relative abundance over time. Repeated virus analyses of one patient also showed that the phageome shifted over time to resemble that of the donor.
Patients were between 49 and 75 years old, three were female and two were male, and all had received more than one antibiotic before their first episode of CDI. Antibiotics for CDI had included metronidazole, vancomycin, and rifaximin. Comorbidities included pseudomembranous colitis, renal failure, HIV infection, epilepsy, and chronic heart failure, and medical histories included recurrent diverticulitis with sigmoid resection, gastric carcinoma, and colon cancer.
“It is important to keep in mind that, in contrast to conventional FMT, transferring sterile FFT filtrates cannot be expected to establish a microbiota similar to that of the donor in the receiving patient,” Dr. Ott and his associates noted. Instead, bacterial DNA in the filtrate might trigger the re-establishment of the recipient microbiome, they said. Bacterial cell wall fragments or bacteriophages also might play a role, they added.
The German Excellence Cluster and CONARIS Research Institute AG supported the work. Dr. Ott reported having lectured for Allergosan. Two coinvestigators reported employment with CONARIS. A third coinvestigator reported shareholder relationships with CONARIS, Allergosan, Danone, and Nestle and lectureship compensation from Allergosan. The other eight coinvestigators had no relevant conflicts of interest.
FROM GASTROENTEROLOGY
Key clinical point: Sterile fecal filtrate transplantation effectively treated symptomatic chronic-relapsing Clostridium difficile infection.
Major finding: For all patients, transplantation restored normal bowel habits within 2-4 days and eliminated symptoms for at least 6 months.
Data source: A single-center cases series of five patients with recurrent symptomatic CDI.
Disclosures: The German Excellence Cluster and CONARIS Research Institute AG supported the work. Dr. Ott reported having lectured for Allergosan. Two coinvestigators reported employment with CONARIS. A third coinvestigator reported shareholder relationships with CONARIS, Allergosan, Danone, and Nestle and lectureship compensation from Allergosan. The other eight coinvestigators had no relevant conflicts of interest.
How to Ensure a Smooth Transition Into Adult Epilepsy Care
Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications, including valproic acid,and has tried the ketogenic diet. You receive a report that she has focal epilepsy, she is having frequent seizures, and her last MRI was performed at age 2.
Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in the clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist. 
Why does this happen? When patients are simply transferred instead of transitioned between providers when they get too old to be seen by pediatric specialists, the process often does not go smoothly. A true transition of care prepares the patient and the family to understand the underlying disease and everything that goes along with it to be able to successfully seek appropriate care as they move into the adult world.
There is not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a transition tool that is helpful in outlining the steps for a successful transition. In 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care, and they recommend that all offices have a written policy.
Talking about transitioning should start as early as 10 to 12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers, they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.
When the pediatric epilepsy patient reaches young adulthood (18 years or older), the adult model of care should be implemented, even if they are still being seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this plan. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition. 
An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to ensure a smooth transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists).
The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And hopefully, next time, the patient scenario seen above will go more smoothly!
Suggested Reading
Brown LW, Camfield P, Capers M, et al. The neurologist’s role in supporting transition to adult health care. Neurology. 2016;87(8):835-840.
Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications, including valproic acid,and has tried the ketogenic diet. You receive a report that she has focal epilepsy, she is having frequent seizures, and her last MRI was performed at age 2.
Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in the clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist.
Why does this happen? When patients are simply transferred instead of transitioned between providers when they get too old to be seen by pediatric specialists, the process often does not go smoothly. A true transition of care prepares the patient and the family to understand the underlying disease and everything that goes along with it to be able to successfully seek appropriate care as they move into the adult world.
There is not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a transition tool that is helpful in outlining the steps for a successful transition. In 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care, and they recommend that all offices have a written policy.
Talking about transitioning should start as early as 10 to 12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers, they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.
When the pediatric epilepsy patient reaches young adulthood (18 years or older), the adult model of care should be implemented, even if they are still being seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this plan. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition.
An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to ensure a smooth transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists).
The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And hopefully, next time, the patient scenario seen above will go more smoothly!
Suggested Reading
Brown LW, Camfield P, Capers M, et al. The neurologist’s role in supporting transition to adult health care. Neurology. 2016;87(8):835-840.
Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications, including valproic acid,and has tried the ketogenic diet. You receive a report that she has focal epilepsy, she is having frequent seizures, and her last MRI was performed at age 2.
Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in the clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist.
Why does this happen? When patients are simply transferred instead of transitioned between providers when they get too old to be seen by pediatric specialists, the process often does not go smoothly. A true transition of care prepares the patient and the family to understand the underlying disease and everything that goes along with it to be able to successfully seek appropriate care as they move into the adult world.
There is not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a transition tool that is helpful in outlining the steps for a successful transition. In 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care, and they recommend that all offices have a written policy.
Talking about transitioning should start as early as 10 to 12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers, they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.
When the pediatric epilepsy patient reaches young adulthood (18 years or older), the adult model of care should be implemented, even if they are still being seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this plan. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition.
An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to ensure a smooth transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists).
The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And hopefully, next time, the patient scenario seen above will go more smoothly!
Suggested Reading
Brown LW, Camfield P, Capers M, et al. The neurologist’s role in supporting transition to adult health care. Neurology. 2016;87(8):835-840.
Lung cancer screening a challenge to implement
A comprehensive lung cancer screening program carried out at Veterans Health Administration hospitals was taxing to implement and revealed a large number of patients with results requiring follow-up, though only 1.5% had cancers.
Investigators at eight VHA hospitals, led by Linda S. Kinsinger, MD, of the VHA’s National Center for Health Promotion and Disease Prevention in Durham, N.C., looked at records from about 93,000 primary care patients and identified 4,246 eligible for screening, based on age, medical history, and smoking history (JAMA Intern Med. 2017 Jan 30. doi: 10.1001/jamainternmed.2016.9022).
Approximately 58% of the eligible patients consented, and 2,106 underwent screening with low-dose computed tomography (LDCT). The mean age of patients was 65 years, and 96% of patients were male.
Nearly 60% of patients screened (1,257) had nodules, 1,184 patients (56.2%) required tracking, and 31 patients (1.5%) had lung cancer.
The pilot study was developed in response to a 2013 recommendation from the U.S. Preventive Services Task Force favoring annual screening with LDCT in current or former heavy smokers between 55 and 80 years old.
The recommendation sparked concerns about the practicability of implementing large-scale lung cancer screening, which Dr. Kinsinger and her colleagues’ study seemed to underscore. For example, “creating electronic tools to capture the necessary clinical data in real time … proved to be difficult, even with the VHA’s highly regarded electronic medical record,” the investigators wrote. A key measure used in the screening program – cigarette pack-years – was “not fully captured” in the system’s EMR.
The investigators also noted that if the eligibility criteria used in the pilot program were applied to the VHA nationwide, about 900,000 patients would be eligible for LDCT screening, and that fewer than 60% of patients in this study had consented. That meant that “accurately identifying these patients and discussing with them the benefits and harms of [screening] will take significant effort for primary care teams,” the researchers noted.
In addition, the required follow-up “may stress the capacity” of radiology and pulmonology services, the study authors cautioned.
Finally, “primary care will need to be involved in deciding which incidental findings need further evaluation,” they wrote. “These clinical efforts will require coordination and communication among clinical services and between patients and staff, and dedicated coordinators will need to be hired.”
The investigators noted that their findings might not be generalizable to non-VHA health care systems. The experience of the VHA, “owing to its central organizational structure, may represent a best-case scenario,” they wrote.
The Veterans Health Administration funded the study. Two of its coauthors reported commercial conflicts of interest; one of those disclosed a grant application to the Bristol-Myers Squibb Foundation related to lung cancer screening.
A comprehensive lung cancer screening program carried out at Veterans Health Administration hospitals was taxing to implement and revealed a large number of patients with results requiring follow-up, though only 1.5% had cancers.
Investigators at eight VHA hospitals, led by Linda S. Kinsinger, MD, of the VHA’s National Center for Health Promotion and Disease Prevention in Durham, N.C., looked at records from about 93,000 primary care patients and identified 4,246 eligible for screening, based on age, medical history, and smoking history (JAMA Intern Med. 2017 Jan 30. doi: 10.1001/jamainternmed.2016.9022).
Approximately 58% of the eligible patients consented, and 2,106 underwent screening with low-dose computed tomography (LDCT). The mean age of patients was 65 years, and 96% of patients were male.
Nearly 60% of patients screened (1,257) had nodules, 1,184 patients (56.2%) required tracking, and 31 patients (1.5%) had lung cancer.
The pilot study was developed in response to a 2013 recommendation from the U.S. Preventive Services Task Force favoring annual screening with LDCT in current or former heavy smokers between 55 and 80 years old.
The recommendation sparked concerns about the practicability of implementing large-scale lung cancer screening, which Dr. Kinsinger and her colleagues’ study seemed to underscore. For example, “creating electronic tools to capture the necessary clinical data in real time … proved to be difficult, even with the VHA’s highly regarded electronic medical record,” the investigators wrote. A key measure used in the screening program – cigarette pack-years – was “not fully captured” in the system’s EMR.
The investigators also noted that if the eligibility criteria used in the pilot program were applied to the VHA nationwide, about 900,000 patients would be eligible for LDCT screening, and that fewer than 60% of patients in this study had consented. That meant that “accurately identifying these patients and discussing with them the benefits and harms of [screening] will take significant effort for primary care teams,” the researchers noted.
In addition, the required follow-up “may stress the capacity” of radiology and pulmonology services, the study authors cautioned.
Finally, “primary care will need to be involved in deciding which incidental findings need further evaluation,” they wrote. “These clinical efforts will require coordination and communication among clinical services and between patients and staff, and dedicated coordinators will need to be hired.”
The investigators noted that their findings might not be generalizable to non-VHA health care systems. The experience of the VHA, “owing to its central organizational structure, may represent a best-case scenario,” they wrote.
The Veterans Health Administration funded the study. Two of its coauthors reported commercial conflicts of interest; one of those disclosed a grant application to the Bristol-Myers Squibb Foundation related to lung cancer screening.
A comprehensive lung cancer screening program carried out at Veterans Health Administration hospitals was taxing to implement and revealed a large number of patients with results requiring follow-up, though only 1.5% had cancers.
Investigators at eight VHA hospitals, led by Linda S. Kinsinger, MD, of the VHA’s National Center for Health Promotion and Disease Prevention in Durham, N.C., looked at records from about 93,000 primary care patients and identified 4,246 eligible for screening, based on age, medical history, and smoking history (JAMA Intern Med. 2017 Jan 30. doi: 10.1001/jamainternmed.2016.9022).
Approximately 58% of the eligible patients consented, and 2,106 underwent screening with low-dose computed tomography (LDCT). The mean age of patients was 65 years, and 96% of patients were male.
Nearly 60% of patients screened (1,257) had nodules, 1,184 patients (56.2%) required tracking, and 31 patients (1.5%) had lung cancer.
The pilot study was developed in response to a 2013 recommendation from the U.S. Preventive Services Task Force favoring annual screening with LDCT in current or former heavy smokers between 55 and 80 years old.
The recommendation sparked concerns about the practicability of implementing large-scale lung cancer screening, which Dr. Kinsinger and her colleagues’ study seemed to underscore. For example, “creating electronic tools to capture the necessary clinical data in real time … proved to be difficult, even with the VHA’s highly regarded electronic medical record,” the investigators wrote. A key measure used in the screening program – cigarette pack-years – was “not fully captured” in the system’s EMR.
The investigators also noted that if the eligibility criteria used in the pilot program were applied to the VHA nationwide, about 900,000 patients would be eligible for LDCT screening, and that fewer than 60% of patients in this study had consented. That meant that “accurately identifying these patients and discussing with them the benefits and harms of [screening] will take significant effort for primary care teams,” the researchers noted.
In addition, the required follow-up “may stress the capacity” of radiology and pulmonology services, the study authors cautioned.
Finally, “primary care will need to be involved in deciding which incidental findings need further evaluation,” they wrote. “These clinical efforts will require coordination and communication among clinical services and between patients and staff, and dedicated coordinators will need to be hired.”
The investigators noted that their findings might not be generalizable to non-VHA health care systems. The experience of the VHA, “owing to its central organizational structure, may represent a best-case scenario,” they wrote.
The Veterans Health Administration funded the study. Two of its coauthors reported commercial conflicts of interest; one of those disclosed a grant application to the Bristol-Myers Squibb Foundation related to lung cancer screening.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Comprehensive lung cancer screening is complex to implement in hospital primary care settings and may trigger resource-intensive follow-up.
Major finding: Of more than 2,000 patients screened, nearly 60% were positive for nodules, though only 1.5% had cancer.
Data source: A pilot study in 4,246 eligible primary care patients at eight Veterans Health Administration hospitals; 2,106 were screened using low-dose computed tomography.
Disclosures: The Veterans Health Administration funded the study. Two of its coauthors reported commercial conflicts of interest; one of those disclosed a grant application to the Bristol-Myers Squibb Foundation related to lung cancer screening.
Hypertension risk soars in offspring of early-HT parents
NEW ORLEANS – Young adults whose parents develop hypertension before age 55 years are themselves at sharply increased risk of developing the disease, according to a new report from the Framingham (Mass.) Heart Study.
“Our results demonstrate that early-onset but not late-onset hypertension in parents is a strong risk factor for incident hypertension. It may be important for physicians to distinguish between early- and late-onset hypertension as a familial trait when assessing an individual’s risk for hypertension,” Teemu J. Niiranen, MD, said at the American Heart Association scientific sessions.
He reported on 1,635 participants in the Offspring cohort of the Framingham Heart Study who were normotensive when they enrolled in the prospective study beginning in 1972. At that time, they averaged 32 years of age. They were followed for a mean of 26 years. Like their parents who enrolled in the Original cohort of the landmark study beginning in 1948, they underwent meticulous blood pressure measurement roughly every 2 years.
Dr. Niiranen and his coinvestigators divided the Offspring cohort into four groups based upon parental hypertension status. There were 107 offspring with normotensive parents, 480 with one or both parents having developed late-onset hypertension after age 55 years, 721 offspring who had one parent with onset of hypertension before age 55 years, and 327 with both parents having early-onset hypertension.
The incidence rate of hypertension in the Offspring cohort climbed in concert with parental early hypertension status. So did the multivariate-adjusted relative risk of the disease, compared with children of normotensive parents.
Moreover, the earlier in life the parents developed hypertension, the earlier their offspring did, too.
Session moderator David J. Maron, MD, of Stanford (Calif.) University, commented, “Everybody’s thinking ‘genetics’ as we look at your findings. But do you have any way to tease out nature versus nurture in understanding the association?”
Dr. Niiranen replied that in a separate study of three generations of Framingham participants, the investigators incorporated two lifestyle factors in their analysis: level of exercise and sodium intake.
“Those didn’t have much effect on the results, so it seems like genetics is driving most of the outcome,” he said.
Dr. Niiranen reported having no financial conflicts of interest regarding his study, sponsored by the National Heart, Lung, and Blood Institute.
NEW ORLEANS – Young adults whose parents develop hypertension before age 55 years are themselves at sharply increased risk of developing the disease, according to a new report from the Framingham (Mass.) Heart Study.
“Our results demonstrate that early-onset but not late-onset hypertension in parents is a strong risk factor for incident hypertension. It may be important for physicians to distinguish between early- and late-onset hypertension as a familial trait when assessing an individual’s risk for hypertension,” Teemu J. Niiranen, MD, said at the American Heart Association scientific sessions.
He reported on 1,635 participants in the Offspring cohort of the Framingham Heart Study who were normotensive when they enrolled in the prospective study beginning in 1972. At that time, they averaged 32 years of age. They were followed for a mean of 26 years. Like their parents who enrolled in the Original cohort of the landmark study beginning in 1948, they underwent meticulous blood pressure measurement roughly every 2 years.
Dr. Niiranen and his coinvestigators divided the Offspring cohort into four groups based upon parental hypertension status. There were 107 offspring with normotensive parents, 480 with one or both parents having developed late-onset hypertension after age 55 years, 721 offspring who had one parent with onset of hypertension before age 55 years, and 327 with both parents having early-onset hypertension.
The incidence rate of hypertension in the Offspring cohort climbed in concert with parental early hypertension status. So did the multivariate-adjusted relative risk of the disease, compared with children of normotensive parents.
Moreover, the earlier in life the parents developed hypertension, the earlier their offspring did, too.
Session moderator David J. Maron, MD, of Stanford (Calif.) University, commented, “Everybody’s thinking ‘genetics’ as we look at your findings. But do you have any way to tease out nature versus nurture in understanding the association?”
Dr. Niiranen replied that in a separate study of three generations of Framingham participants, the investigators incorporated two lifestyle factors in their analysis: level of exercise and sodium intake.
“Those didn’t have much effect on the results, so it seems like genetics is driving most of the outcome,” he said.
Dr. Niiranen reported having no financial conflicts of interest regarding his study, sponsored by the National Heart, Lung, and Blood Institute.
NEW ORLEANS – Young adults whose parents develop hypertension before age 55 years are themselves at sharply increased risk of developing the disease, according to a new report from the Framingham (Mass.) Heart Study.
“Our results demonstrate that early-onset but not late-onset hypertension in parents is a strong risk factor for incident hypertension. It may be important for physicians to distinguish between early- and late-onset hypertension as a familial trait when assessing an individual’s risk for hypertension,” Teemu J. Niiranen, MD, said at the American Heart Association scientific sessions.
He reported on 1,635 participants in the Offspring cohort of the Framingham Heart Study who were normotensive when they enrolled in the prospective study beginning in 1972. At that time, they averaged 32 years of age. They were followed for a mean of 26 years. Like their parents who enrolled in the Original cohort of the landmark study beginning in 1948, they underwent meticulous blood pressure measurement roughly every 2 years.
Dr. Niiranen and his coinvestigators divided the Offspring cohort into four groups based upon parental hypertension status. There were 107 offspring with normotensive parents, 480 with one or both parents having developed late-onset hypertension after age 55 years, 721 offspring who had one parent with onset of hypertension before age 55 years, and 327 with both parents having early-onset hypertension.
The incidence rate of hypertension in the Offspring cohort climbed in concert with parental early hypertension status. So did the multivariate-adjusted relative risk of the disease, compared with children of normotensive parents.
Moreover, the earlier in life the parents developed hypertension, the earlier their offspring did, too.
Session moderator David J. Maron, MD, of Stanford (Calif.) University, commented, “Everybody’s thinking ‘genetics’ as we look at your findings. But do you have any way to tease out nature versus nurture in understanding the association?”
Dr. Niiranen replied that in a separate study of three generations of Framingham participants, the investigators incorporated two lifestyle factors in their analysis: level of exercise and sodium intake.
“Those didn’t have much effect on the results, so it seems like genetics is driving most of the outcome,” he said.
Dr. Niiranen reported having no financial conflicts of interest regarding his study, sponsored by the National Heart, Lung, and Blood Institute.
Key clinical point:
Major finding: Young adults with two parents who developed hypertension before age 55 years are at 3.5-fold greater risk of subsequently developing hypertension than if both parents were normotensive.
Data source: This was an analysis of the incidence of hypertension during a mean prospective follow-up of 26 years in 1,635 members of the Offspring cohort of the Framingham Heart Study who enrolled as young adults.
Disclosures: The presenter reported having no financial conflicts of interest regarding this study sponsored by the National Heart, Lung, and Blood Institute.