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Cannulas versus needles for soft tissue filler injection
With loss of deep fat pad compartments and bony resorption with normal aging, soft tissue fillers have become a mainstay in minimally invasive aesthetic treatments. Preference of injecting with a needle versus a cannula is often user and training dependent. Blunt-tipped cannulas may provide a lower risk of bruising, as well as potentially devastating complications such as intravascular occlusion that can lead to skin necrosis and blindness. Even for advanced injectors, however, cannula use may portend a learning curve if the clinicians are used to injecting with needles.
A recently published observational study using cadaver heads looked at precision in supraperiosteal placement with a sharp needle compared with a blunt tipped cannula.1 The investigators injected dye material with soft-tissue fillers at different aesthetic facial sites on the supraperiosteum, then observed the placement of dye and filler after dissection. In this study, the placement of product was more precise with the cannulas. The filler was injected on the periosteum with a needle. Some of the filler then migrated along the trajectory of the needle path back toward the epidermis, ending up in multiple tissue layers. So there was more extrusion of the filler in the superficial layers with a needle without a retrograde injection technique. Even with the needle tip on the periosteum and no movement of the needle, the needle technique showed a higher risk of intra-arterial injections. This study is limited by the fact that in vivo circumstances could potentially alter the outcome, as could user injection technique.
Cannulas should be highly considered in any deep tissue compartment, but especially in more advanced injection technique areas, such as the nasal dorsum. Another cadaver study from Thailand showed that the anatomy of the dorsal nasal artery is not consistent.2 It is injection into this artery that can lead to blindness via flow to the ophthalmic artery. The study showed that both the diameter of the artery and the presence of a single or bilateral dorsal nasal artery varied. The dorsal nasal artery travels in the subcutaneous tissue layer of the nasal dorsum on the transverse nasalis muscle and its midline nasal aponeurosis, which connects the muscles on both sides. Bilateral dorsal nasal arteries were present in 34% of the specimens. A single and large dorsal nasal artery was present in 28%.
Needles are still useful in some places where precise small aliquot touch-up of filler placement is needed or where it may be difficult to reach with the cannula without making an additional portal of entry. More viscous fillers such as calcium hydroxylapatite and poly-L-lactic acid can be difficult to inject through a cannula and require a needle for injection. More superficially, small 30- or 32-gauge needles are also required for the injection of certain hyaluronic acid fillers in the superficial dermis for more etched lines.
The risk of arterial wall perforation and emboli with cannulas is lower, but these complications can still occur. The risk increases with a perpendicular angle between the artery and the cannula, thus slow small aliquot injection technique along with knowledge of anatomy is essential.3 While both needles and cannulas are useful in practice and achieve excellent cosmetic results, cannula use in the deeper compartments among practitioners is encouraged to minimize complications.
References
1. Aesthet Surg J. 2016 Dec 16. pii: sjw220.
2. Aesthetic Plast Surg. 2016 Dec 28. doi: 10.1007/s00266-016-0756-0.
3. Aesthetic Plast Surg. 2016 Dec 23. doi: 10.1007/s00266-016-0725-7.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
With loss of deep fat pad compartments and bony resorption with normal aging, soft tissue fillers have become a mainstay in minimally invasive aesthetic treatments. Preference of injecting with a needle versus a cannula is often user and training dependent. Blunt-tipped cannulas may provide a lower risk of bruising, as well as potentially devastating complications such as intravascular occlusion that can lead to skin necrosis and blindness. Even for advanced injectors, however, cannula use may portend a learning curve if the clinicians are used to injecting with needles.
A recently published observational study using cadaver heads looked at precision in supraperiosteal placement with a sharp needle compared with a blunt tipped cannula.1 The investigators injected dye material with soft-tissue fillers at different aesthetic facial sites on the supraperiosteum, then observed the placement of dye and filler after dissection. In this study, the placement of product was more precise with the cannulas. The filler was injected on the periosteum with a needle. Some of the filler then migrated along the trajectory of the needle path back toward the epidermis, ending up in multiple tissue layers. So there was more extrusion of the filler in the superficial layers with a needle without a retrograde injection technique. Even with the needle tip on the periosteum and no movement of the needle, the needle technique showed a higher risk of intra-arterial injections. This study is limited by the fact that in vivo circumstances could potentially alter the outcome, as could user injection technique.
Cannulas should be highly considered in any deep tissue compartment, but especially in more advanced injection technique areas, such as the nasal dorsum. Another cadaver study from Thailand showed that the anatomy of the dorsal nasal artery is not consistent.2 It is injection into this artery that can lead to blindness via flow to the ophthalmic artery. The study showed that both the diameter of the artery and the presence of a single or bilateral dorsal nasal artery varied. The dorsal nasal artery travels in the subcutaneous tissue layer of the nasal dorsum on the transverse nasalis muscle and its midline nasal aponeurosis, which connects the muscles on both sides. Bilateral dorsal nasal arteries were present in 34% of the specimens. A single and large dorsal nasal artery was present in 28%.
Needles are still useful in some places where precise small aliquot touch-up of filler placement is needed or where it may be difficult to reach with the cannula without making an additional portal of entry. More viscous fillers such as calcium hydroxylapatite and poly-L-lactic acid can be difficult to inject through a cannula and require a needle for injection. More superficially, small 30- or 32-gauge needles are also required for the injection of certain hyaluronic acid fillers in the superficial dermis for more etched lines.
The risk of arterial wall perforation and emboli with cannulas is lower, but these complications can still occur. The risk increases with a perpendicular angle between the artery and the cannula, thus slow small aliquot injection technique along with knowledge of anatomy is essential.3 While both needles and cannulas are useful in practice and achieve excellent cosmetic results, cannula use in the deeper compartments among practitioners is encouraged to minimize complications.
References
1. Aesthet Surg J. 2016 Dec 16. pii: sjw220.
2. Aesthetic Plast Surg. 2016 Dec 28. doi: 10.1007/s00266-016-0756-0.
3. Aesthetic Plast Surg. 2016 Dec 23. doi: 10.1007/s00266-016-0725-7.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
With loss of deep fat pad compartments and bony resorption with normal aging, soft tissue fillers have become a mainstay in minimally invasive aesthetic treatments. Preference of injecting with a needle versus a cannula is often user and training dependent. Blunt-tipped cannulas may provide a lower risk of bruising, as well as potentially devastating complications such as intravascular occlusion that can lead to skin necrosis and blindness. Even for advanced injectors, however, cannula use may portend a learning curve if the clinicians are used to injecting with needles.
A recently published observational study using cadaver heads looked at precision in supraperiosteal placement with a sharp needle compared with a blunt tipped cannula.1 The investigators injected dye material with soft-tissue fillers at different aesthetic facial sites on the supraperiosteum, then observed the placement of dye and filler after dissection. In this study, the placement of product was more precise with the cannulas. The filler was injected on the periosteum with a needle. Some of the filler then migrated along the trajectory of the needle path back toward the epidermis, ending up in multiple tissue layers. So there was more extrusion of the filler in the superficial layers with a needle without a retrograde injection technique. Even with the needle tip on the periosteum and no movement of the needle, the needle technique showed a higher risk of intra-arterial injections. This study is limited by the fact that in vivo circumstances could potentially alter the outcome, as could user injection technique.
Cannulas should be highly considered in any deep tissue compartment, but especially in more advanced injection technique areas, such as the nasal dorsum. Another cadaver study from Thailand showed that the anatomy of the dorsal nasal artery is not consistent.2 It is injection into this artery that can lead to blindness via flow to the ophthalmic artery. The study showed that both the diameter of the artery and the presence of a single or bilateral dorsal nasal artery varied. The dorsal nasal artery travels in the subcutaneous tissue layer of the nasal dorsum on the transverse nasalis muscle and its midline nasal aponeurosis, which connects the muscles on both sides. Bilateral dorsal nasal arteries were present in 34% of the specimens. A single and large dorsal nasal artery was present in 28%.
Needles are still useful in some places where precise small aliquot touch-up of filler placement is needed or where it may be difficult to reach with the cannula without making an additional portal of entry. More viscous fillers such as calcium hydroxylapatite and poly-L-lactic acid can be difficult to inject through a cannula and require a needle for injection. More superficially, small 30- or 32-gauge needles are also required for the injection of certain hyaluronic acid fillers in the superficial dermis for more etched lines.
The risk of arterial wall perforation and emboli with cannulas is lower, but these complications can still occur. The risk increases with a perpendicular angle between the artery and the cannula, thus slow small aliquot injection technique along with knowledge of anatomy is essential.3 While both needles and cannulas are useful in practice and achieve excellent cosmetic results, cannula use in the deeper compartments among practitioners is encouraged to minimize complications.
References
1. Aesthet Surg J. 2016 Dec 16. pii: sjw220.
2. Aesthetic Plast Surg. 2016 Dec 28. doi: 10.1007/s00266-016-0756-0.
3. Aesthetic Plast Surg. 2016 Dec 23. doi: 10.1007/s00266-016-0725-7.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
Osteopenia risk up in men with sarcopenia and COPD
Men experiencing sarcopenia who also have been diagnosed with chronic obstructive pulmonary disease (COPD) are at a significantly higher risk of developing osteopenia and osteoporosis than are men who do not suffer from COPD, according to a new study published in Chest.
“Muscle depletion has been considered a risk factor for low [bone mineral density (BMD)] in the healthy general population [but] data on the association between sarcopenia and osteopenia/osteoporosis in COPD patients are lacking,” wrote the investigators of the study, coauthored by Moo Suk Park, MD, of Yonsei University in Seoul, South Korea (Chest. 2017 Jan. doi: 10.1016/j.chest.2016.12.006).
“Although previous studies showed that loss of fat-free mass (FFM) was related to BMD loss in COPD patients, it is difficult to know the genuine relationship between skeletal muscle mass and BMD because whole body FFM contains a large proportion of water-retaining organs and nonmuscle soft tissue,” the authors continued.
The investigators examined data from the Korean National Health and Nutritional Examination Survey (KNHANES), looking for men at least 20 years of age with COPD who had both pulmonary function test and the dual-energy x-ray absorptiometry (DXA) performed on them during the years 2008-2011. A total of 864 men were deemed eligible for inclusion, and were scored for sarcopenia and osteopenia/osteoporosis; the former was assessed via the appendicular skeletal mass index (ASMI), with the latter done via T-score.
“Sarcopenia and presarcopenia were defined according to the presence of ASMI values that were less than two standard deviations (SDs) and between 2SDs and 1SD, respectively, below the mean value of a young male reference group aged 20-39 years,” according to the investigators. “Osteoporosis, osteopenia, and normal BMD were identified according to the lowest T-score of the three measured locations and were defined according to the World Health Organization criteria.”
“This study affirms the systemic nature of COPD, as it is not merely a disease that manifests as breathlessness and other respiratory complaints, but affects many aspects of a patient’s functionality and overall health,” explained Eric J. Gartman, MD, of Brown University, Providence, Rhode Island. “In clinical practice, this study reminds us that we need to consider these other issues in a COPD patient’s care, since the outcomes from these problems (e.g. hip fractures) can be devastating.”
A critical limitation of this study, however, is the sample population, according to Dr. Gartman. “It is solely made up of Korean men, thus somewhat limiting the generalizability to a larger population [and] especially to women, given that there are several other considerations surrounding effects on BMD.”
No funding sources were disclosed. The authors reported no conflicts of interest.
*This article was updated on 1/20/17 at 1:30 p.m. It misstated the affiliation for Vera Palo, MD, FCCP.
Men experiencing sarcopenia who also have been diagnosed with chronic obstructive pulmonary disease (COPD) are at a significantly higher risk of developing osteopenia and osteoporosis than are men who do not suffer from COPD, according to a new study published in Chest.
“Muscle depletion has been considered a risk factor for low [bone mineral density (BMD)] in the healthy general population [but] data on the association between sarcopenia and osteopenia/osteoporosis in COPD patients are lacking,” wrote the investigators of the study, coauthored by Moo Suk Park, MD, of Yonsei University in Seoul, South Korea (Chest. 2017 Jan. doi: 10.1016/j.chest.2016.12.006).
“Although previous studies showed that loss of fat-free mass (FFM) was related to BMD loss in COPD patients, it is difficult to know the genuine relationship between skeletal muscle mass and BMD because whole body FFM contains a large proportion of water-retaining organs and nonmuscle soft tissue,” the authors continued.
The investigators examined data from the Korean National Health and Nutritional Examination Survey (KNHANES), looking for men at least 20 years of age with COPD who had both pulmonary function test and the dual-energy x-ray absorptiometry (DXA) performed on them during the years 2008-2011. A total of 864 men were deemed eligible for inclusion, and were scored for sarcopenia and osteopenia/osteoporosis; the former was assessed via the appendicular skeletal mass index (ASMI), with the latter done via T-score.
“Sarcopenia and presarcopenia were defined according to the presence of ASMI values that were less than two standard deviations (SDs) and between 2SDs and 1SD, respectively, below the mean value of a young male reference group aged 20-39 years,” according to the investigators. “Osteoporosis, osteopenia, and normal BMD were identified according to the lowest T-score of the three measured locations and were defined according to the World Health Organization criteria.”
“This study affirms the systemic nature of COPD, as it is not merely a disease that manifests as breathlessness and other respiratory complaints, but affects many aspects of a patient’s functionality and overall health,” explained Eric J. Gartman, MD, of Brown University, Providence, Rhode Island. “In clinical practice, this study reminds us that we need to consider these other issues in a COPD patient’s care, since the outcomes from these problems (e.g. hip fractures) can be devastating.”
A critical limitation of this study, however, is the sample population, according to Dr. Gartman. “It is solely made up of Korean men, thus somewhat limiting the generalizability to a larger population [and] especially to women, given that there are several other considerations surrounding effects on BMD.”
No funding sources were disclosed. The authors reported no conflicts of interest.
*This article was updated on 1/20/17 at 1:30 p.m. It misstated the affiliation for Vera Palo, MD, FCCP.
Men experiencing sarcopenia who also have been diagnosed with chronic obstructive pulmonary disease (COPD) are at a significantly higher risk of developing osteopenia and osteoporosis than are men who do not suffer from COPD, according to a new study published in Chest.
“Muscle depletion has been considered a risk factor for low [bone mineral density (BMD)] in the healthy general population [but] data on the association between sarcopenia and osteopenia/osteoporosis in COPD patients are lacking,” wrote the investigators of the study, coauthored by Moo Suk Park, MD, of Yonsei University in Seoul, South Korea (Chest. 2017 Jan. doi: 10.1016/j.chest.2016.12.006).
“Although previous studies showed that loss of fat-free mass (FFM) was related to BMD loss in COPD patients, it is difficult to know the genuine relationship between skeletal muscle mass and BMD because whole body FFM contains a large proportion of water-retaining organs and nonmuscle soft tissue,” the authors continued.
The investigators examined data from the Korean National Health and Nutritional Examination Survey (KNHANES), looking for men at least 20 years of age with COPD who had both pulmonary function test and the dual-energy x-ray absorptiometry (DXA) performed on them during the years 2008-2011. A total of 864 men were deemed eligible for inclusion, and were scored for sarcopenia and osteopenia/osteoporosis; the former was assessed via the appendicular skeletal mass index (ASMI), with the latter done via T-score.
“Sarcopenia and presarcopenia were defined according to the presence of ASMI values that were less than two standard deviations (SDs) and between 2SDs and 1SD, respectively, below the mean value of a young male reference group aged 20-39 years,” according to the investigators. “Osteoporosis, osteopenia, and normal BMD were identified according to the lowest T-score of the three measured locations and were defined according to the World Health Organization criteria.”
“This study affirms the systemic nature of COPD, as it is not merely a disease that manifests as breathlessness and other respiratory complaints, but affects many aspects of a patient’s functionality and overall health,” explained Eric J. Gartman, MD, of Brown University, Providence, Rhode Island. “In clinical practice, this study reminds us that we need to consider these other issues in a COPD patient’s care, since the outcomes from these problems (e.g. hip fractures) can be devastating.”
A critical limitation of this study, however, is the sample population, according to Dr. Gartman. “It is solely made up of Korean men, thus somewhat limiting the generalizability to a larger population [and] especially to women, given that there are several other considerations surrounding effects on BMD.”
No funding sources were disclosed. The authors reported no conflicts of interest.
*This article was updated on 1/20/17 at 1:30 p.m. It misstated the affiliation for Vera Palo, MD, FCCP.
FROM CHEST
Key clinical point:
Major finding: Sarcopenia in men with COPD carried a significantly higher risk of bone mineral density loss: OR = 2.31 (95% CI 1.53–3.46) (P less than .001).
Data source: Retrospective cross-sectional study of data on 777 men with COPD during 2008-2011.
Disclosures: No funding sources were disclosed. The authors reported no conflicts of interest.
United States about to top 40,000 Zika cases
The number of pregnant women with laboratory evidence of Zika infection jumped up a bit at the end of 2016, and the United States approached 40,000 Zika cases among all Americans at the beginning of the new year, according to reports from the Centers for Disease Control and Prevention.
There were 187 additional pregnant women with Zika virus infection reported in the 2 weeks ending Dec. 27, compared with the 136 new reports of infected women in each of the two previous comparable periods (Dec. 1-13 and Nov. 18-30). Most of the 187 new cases were reported in the U.S. territories, while 46 were reported in the 50 states and the District of Columbia. There have been delays in reporting, the CDC noted, so these cannot be considered real-time estimates.
For the 2 weeks ending Dec. 27, there were reports of two more infants born with Zika-related birth defects, bringing the total to 36 for the states/D.C. The CDC is no longer reporting adverse pregnancy outcomes for the territories because Puerto Rico is not using the same inclusion criteria. The number of pregnancy losses remains at five in the states/D.C., where it has been since August. Aggregated data from the U.S. Zika Pregnancy Registry show that there have been 875 completed pregnancies with or without birth defects, the CDC said.
Zika-related birth defects reported by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
The number of pregnant women with laboratory evidence of Zika infection jumped up a bit at the end of 2016, and the United States approached 40,000 Zika cases among all Americans at the beginning of the new year, according to reports from the Centers for Disease Control and Prevention.
There were 187 additional pregnant women with Zika virus infection reported in the 2 weeks ending Dec. 27, compared with the 136 new reports of infected women in each of the two previous comparable periods (Dec. 1-13 and Nov. 18-30). Most of the 187 new cases were reported in the U.S. territories, while 46 were reported in the 50 states and the District of Columbia. There have been delays in reporting, the CDC noted, so these cannot be considered real-time estimates.
For the 2 weeks ending Dec. 27, there were reports of two more infants born with Zika-related birth defects, bringing the total to 36 for the states/D.C. The CDC is no longer reporting adverse pregnancy outcomes for the territories because Puerto Rico is not using the same inclusion criteria. The number of pregnancy losses remains at five in the states/D.C., where it has been since August. Aggregated data from the U.S. Zika Pregnancy Registry show that there have been 875 completed pregnancies with or without birth defects, the CDC said.
Zika-related birth defects reported by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
The number of pregnant women with laboratory evidence of Zika infection jumped up a bit at the end of 2016, and the United States approached 40,000 Zika cases among all Americans at the beginning of the new year, according to reports from the Centers for Disease Control and Prevention.
There were 187 additional pregnant women with Zika virus infection reported in the 2 weeks ending Dec. 27, compared with the 136 new reports of infected women in each of the two previous comparable periods (Dec. 1-13 and Nov. 18-30). Most of the 187 new cases were reported in the U.S. territories, while 46 were reported in the 50 states and the District of Columbia. There have been delays in reporting, the CDC noted, so these cannot be considered real-time estimates.
For the 2 weeks ending Dec. 27, there were reports of two more infants born with Zika-related birth defects, bringing the total to 36 for the states/D.C. The CDC is no longer reporting adverse pregnancy outcomes for the territories because Puerto Rico is not using the same inclusion criteria. The number of pregnancy losses remains at five in the states/D.C., where it has been since August. Aggregated data from the U.S. Zika Pregnancy Registry show that there have been 875 completed pregnancies with or without birth defects, the CDC said.
Zika-related birth defects reported by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
Inpatient antibiotic use has not declined
Clinical question: How has inpatient antibiotic use changed in the United States in recent years?
Study design: Retrospective analysis.
Setting: Adult and pediatric data from 300 acute-care hospitals, 2006-2012.
Synopsis: Weighted extrapolation of data from a database was used to estimate national antibiotic use. Overall, 55.1% of discharged patients received antibiotics. The rate of antibiotic use was 755/1,000 patient-days over the study period. The small increase in antibiotic use over the years (5.6 days of therapy/1,000 patient-days increase; 95% CI, –18.9 to 30.1; P = .65) was not statistically significant. There was a significant decrease in the use of aminoglycosides, first- and second-generation cephalosporins, fluoroquinolones, sulfonamide, metronidazole, and penicillins. The use of third- and fourth-generation cephalosporins, macrolides, glycopeptides, beta-lactam/beta-lactamase inhibitor, carbapenems, and tetracyclines has increased significantly.
Limitations of the study include underrepresentation of pediatric hospitals and certain geographic regions.
Bottom line: Antibiotic-use rates have not changed during 2006-2012. However, broad-spectrum antibiotic use has increased significantly.
Citation: Baggs J, Fridkin SK, Pollack LA, Srinivasan A, Jernigan JA. Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012. JAMA Intern Med. 2016;176(11):1639-1648.
Dr. Menon is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: How has inpatient antibiotic use changed in the United States in recent years?
Study design: Retrospective analysis.
Setting: Adult and pediatric data from 300 acute-care hospitals, 2006-2012.
Synopsis: Weighted extrapolation of data from a database was used to estimate national antibiotic use. Overall, 55.1% of discharged patients received antibiotics. The rate of antibiotic use was 755/1,000 patient-days over the study period. The small increase in antibiotic use over the years (5.6 days of therapy/1,000 patient-days increase; 95% CI, –18.9 to 30.1; P = .65) was not statistically significant. There was a significant decrease in the use of aminoglycosides, first- and second-generation cephalosporins, fluoroquinolones, sulfonamide, metronidazole, and penicillins. The use of third- and fourth-generation cephalosporins, macrolides, glycopeptides, beta-lactam/beta-lactamase inhibitor, carbapenems, and tetracyclines has increased significantly.
Limitations of the study include underrepresentation of pediatric hospitals and certain geographic regions.
Bottom line: Antibiotic-use rates have not changed during 2006-2012. However, broad-spectrum antibiotic use has increased significantly.
Citation: Baggs J, Fridkin SK, Pollack LA, Srinivasan A, Jernigan JA. Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012. JAMA Intern Med. 2016;176(11):1639-1648.
Dr. Menon is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: How has inpatient antibiotic use changed in the United States in recent years?
Study design: Retrospective analysis.
Setting: Adult and pediatric data from 300 acute-care hospitals, 2006-2012.
Synopsis: Weighted extrapolation of data from a database was used to estimate national antibiotic use. Overall, 55.1% of discharged patients received antibiotics. The rate of antibiotic use was 755/1,000 patient-days over the study period. The small increase in antibiotic use over the years (5.6 days of therapy/1,000 patient-days increase; 95% CI, –18.9 to 30.1; P = .65) was not statistically significant. There was a significant decrease in the use of aminoglycosides, first- and second-generation cephalosporins, fluoroquinolones, sulfonamide, metronidazole, and penicillins. The use of third- and fourth-generation cephalosporins, macrolides, glycopeptides, beta-lactam/beta-lactamase inhibitor, carbapenems, and tetracyclines has increased significantly.
Limitations of the study include underrepresentation of pediatric hospitals and certain geographic regions.
Bottom line: Antibiotic-use rates have not changed during 2006-2012. However, broad-spectrum antibiotic use has increased significantly.
Citation: Baggs J, Fridkin SK, Pollack LA, Srinivasan A, Jernigan JA. Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012. JAMA Intern Med. 2016;176(11):1639-1648.
Dr. Menon is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Enthesitis seen in 35% of PsA patients
About one-third of people with psoriatic arthritis have clinical enthesitis, according to results from a prospective cohort study of more than 800 patients.
Enthesitis, or soreness and inflammation at sites where soft tissue attaches to bone, is considered to be common in psoriatic arthritis (PsA), but its true prevalence has been difficult to define in this population, according to a group of researchers led by Ari Polachek, MD, of the University of Toronto.
Previous studies attempting to quantify enthesitis prevalence in PsA populations have found it to be as low as 8% to more than 50% of patients affected, Dr. Polachek and his colleagues noted, but such disparities can likely be attributed to the use of different enthesitis measures. To define enthesitis in the current study, the investigators used the SPondyloArthritis Research Consortium Canada (SPARCC) enthesitis index, which they called “valid and reliable, particularly for patients with PsA.”
Dr. Polachek and his colleagues detected enthesitis in 281 (35%) of 803 patents who had been recruited during 2008-2014 at a single clinic dedicated to PsA. The enthesitis diagnoses were established for at least one site on an initial visit (n = 128) or during a mean 3 years’ follow-up (n = 192).
The investigators reported that the annual incidence of enthesitis in this population was 0.9% (Arthritis Care Res. 2016 Dec 20. doi: 10.1002/acr.23174). About half of the patients in the cohort had only one site affected, and one-third had two sites affected. The most common of these sites were the Achilles tendon, plantar fascia, and the lateral epicondyle, Dr. Polachek and colleagues reported. They also found several factors associated with enthesitis: higher inflamed joint count (odds ratio, 1.06; P = .0002), less clinical damage (OR, 0.9; P = .04), more pain (OR, 1.15; P = .01), and presence of tenosynovitis (OR, 5.3; P less than .0001) or dactylitis (OR, 2.5; P = .02).
Significant risk factors for enthesitis included higher body mass index (hazard ratio, 1.04; P = .02), more actively inflamed joints (HR, 1.04; P = .0004), and younger age (HR, 0.98; P = .02). Among the patients in the cohort, 57% were male, the mean age was 50.8 years, and mean PsA disease duration was 12.3 years. Median time to resolution of enthesitis was 7.5 months, with 70% of patients improving without changes to their treatment.
The University of Toronto PsA research program receives funding from Krembil Foundation. Dr. Polachek disclosed grant funding from Janssen Canada. No other authors reported conflicts of interest.
About one-third of people with psoriatic arthritis have clinical enthesitis, according to results from a prospective cohort study of more than 800 patients.
Enthesitis, or soreness and inflammation at sites where soft tissue attaches to bone, is considered to be common in psoriatic arthritis (PsA), but its true prevalence has been difficult to define in this population, according to a group of researchers led by Ari Polachek, MD, of the University of Toronto.
Previous studies attempting to quantify enthesitis prevalence in PsA populations have found it to be as low as 8% to more than 50% of patients affected, Dr. Polachek and his colleagues noted, but such disparities can likely be attributed to the use of different enthesitis measures. To define enthesitis in the current study, the investigators used the SPondyloArthritis Research Consortium Canada (SPARCC) enthesitis index, which they called “valid and reliable, particularly for patients with PsA.”
Dr. Polachek and his colleagues detected enthesitis in 281 (35%) of 803 patents who had been recruited during 2008-2014 at a single clinic dedicated to PsA. The enthesitis diagnoses were established for at least one site on an initial visit (n = 128) or during a mean 3 years’ follow-up (n = 192).
The investigators reported that the annual incidence of enthesitis in this population was 0.9% (Arthritis Care Res. 2016 Dec 20. doi: 10.1002/acr.23174). About half of the patients in the cohort had only one site affected, and one-third had two sites affected. The most common of these sites were the Achilles tendon, plantar fascia, and the lateral epicondyle, Dr. Polachek and colleagues reported. They also found several factors associated with enthesitis: higher inflamed joint count (odds ratio, 1.06; P = .0002), less clinical damage (OR, 0.9; P = .04), more pain (OR, 1.15; P = .01), and presence of tenosynovitis (OR, 5.3; P less than .0001) or dactylitis (OR, 2.5; P = .02).
Significant risk factors for enthesitis included higher body mass index (hazard ratio, 1.04; P = .02), more actively inflamed joints (HR, 1.04; P = .0004), and younger age (HR, 0.98; P = .02). Among the patients in the cohort, 57% were male, the mean age was 50.8 years, and mean PsA disease duration was 12.3 years. Median time to resolution of enthesitis was 7.5 months, with 70% of patients improving without changes to their treatment.
The University of Toronto PsA research program receives funding from Krembil Foundation. Dr. Polachek disclosed grant funding from Janssen Canada. No other authors reported conflicts of interest.
About one-third of people with psoriatic arthritis have clinical enthesitis, according to results from a prospective cohort study of more than 800 patients.
Enthesitis, or soreness and inflammation at sites where soft tissue attaches to bone, is considered to be common in psoriatic arthritis (PsA), but its true prevalence has been difficult to define in this population, according to a group of researchers led by Ari Polachek, MD, of the University of Toronto.
Previous studies attempting to quantify enthesitis prevalence in PsA populations have found it to be as low as 8% to more than 50% of patients affected, Dr. Polachek and his colleagues noted, but such disparities can likely be attributed to the use of different enthesitis measures. To define enthesitis in the current study, the investigators used the SPondyloArthritis Research Consortium Canada (SPARCC) enthesitis index, which they called “valid and reliable, particularly for patients with PsA.”
Dr. Polachek and his colleagues detected enthesitis in 281 (35%) of 803 patents who had been recruited during 2008-2014 at a single clinic dedicated to PsA. The enthesitis diagnoses were established for at least one site on an initial visit (n = 128) or during a mean 3 years’ follow-up (n = 192).
The investigators reported that the annual incidence of enthesitis in this population was 0.9% (Arthritis Care Res. 2016 Dec 20. doi: 10.1002/acr.23174). About half of the patients in the cohort had only one site affected, and one-third had two sites affected. The most common of these sites were the Achilles tendon, plantar fascia, and the lateral epicondyle, Dr. Polachek and colleagues reported. They also found several factors associated with enthesitis: higher inflamed joint count (odds ratio, 1.06; P = .0002), less clinical damage (OR, 0.9; P = .04), more pain (OR, 1.15; P = .01), and presence of tenosynovitis (OR, 5.3; P less than .0001) or dactylitis (OR, 2.5; P = .02).
Significant risk factors for enthesitis included higher body mass index (hazard ratio, 1.04; P = .02), more actively inflamed joints (HR, 1.04; P = .0004), and younger age (HR, 0.98; P = .02). Among the patients in the cohort, 57% were male, the mean age was 50.8 years, and mean PsA disease duration was 12.3 years. Median time to resolution of enthesitis was 7.5 months, with 70% of patients improving without changes to their treatment.
The University of Toronto PsA research program receives funding from Krembil Foundation. Dr. Polachek disclosed grant funding from Janssen Canada. No other authors reported conflicts of interest.
FROM ARTHRITIS CARE & RESEARCH
Key clinical point:
Major finding: Prevalence of enthesitis was 35% in a cohort of PsA patients; significant risk factors included high BMI, higher disease activity, and younger age.
Data source: About 800 PsA patients treated at a university clinic during 2008-2014; mean follow-up was 3.3 years.
Disclosures: The Krembil Foundation indirectly supported the study, whose lead author disclosed receipt of a grant from a pharmaceutical manufacturer.
CTCs help predict breast cancer outcomes in neoadjuvant setting
SAN ANTONIO – Circulating tumor cells are a useful prognostic biomarker in early breast cancer patients treated with neoadjuvant chemotherapy, according to findings from an international meta-analysis of individual patient data.
The cells (CTCs), which can be measured using a Food and Drug Administration–approved assay, are known to seed distant metastases and to be prognostic before and during therapy for patients with metastatic breast cancer, and prognostic before adjuvant therapy for patients with nonmetastatic breast cancer.
However, findings in the neoadjuvant setting have been variable, Francois-Clement Bidard, MD, of Institut Curie, Paris, reported at the San Antonio Breast Cancer Symposium.
In the study (the international meta-analysis of circulating tumor cell detection in early breast cancer patients treated by neoadjuvant chemotherapy, or IMENEO), CTCs were useful, independent of pathologic complete response, for predicting overall survival and distant disease-free survival in the neoadjuvant setting. Further, IMENEO showed for the first time that CTCs also predict locoregional relapse-free survival,
Based on the analysis of data from 2,156 patients from 21 studies and 16 centers in 10 countries, the CTC positivity rates using thresholds of one or more, two or more, and five or more, respectively, were 25%, 13%, and 6% in 1,574 patients tested at baseline, 17%, 6%, and 3% in 290 tested after neoadjuvant chemotherapy, 15%, 5%, and 1% in 1,200 tested before surgery, and 11%, 4%, and 1% in 285 tested after surgery, Dr. Bidard said.
Prior to neoadjuvant chemotherapy, at least one CTC was found in 19%, 22%, 24%, 29% and 41% of cT1, T2, T3, T4a-c, and T4d breast cancers, respectively, and this was marginally associated with hormone receptor negativity, he said, noting that later CTC detection rates were not associated with any patient baseline characteristics.
Nearly one in four patients (24%) achieved pathologic complete response, but this was not associated at any time point with CTC count.
For the primary study endpoint of overall survival, a significant association was found with the presence of at least two CTCs at baseline (hazard ratio, 2.6 for two CTCs; 3.84 for three to four CTCs; and 6.25 for five or more CTCs). Similar associations were found for distant disease-free survival (hazard ratios, 2.4, 3.4, and 5.0, respectively) and for locoregional relapse-free interval with two CTCs and five or more CTCs (hazard ratios, 2.4 and 4.2, respectively).
Similar results were found using later time points, such as after the start of neoadjuvant chemotherapy or before surgery, he said.
On multivariate analysis, baseline CTC detection using any of the thresholds remained an independent predictor of overall and distant disease-free survival and locoregional relapse-free interval when considered together with pathologic complete response, cT, cN, and tumor subtype, suggesting that CTC measurement adds value to comprehensive prognostic models.
That is, they complement rather than duplicate usual prognostic factors and pathologic complete response rates to better predict outcomes in patients with early breast cancer in the neoadjuvant setting, Dr. Bidard said.
This study was supported by a research grant from Janssen Diagnostics. Dr. Bidard reported having no disclosures.
SAN ANTONIO – Circulating tumor cells are a useful prognostic biomarker in early breast cancer patients treated with neoadjuvant chemotherapy, according to findings from an international meta-analysis of individual patient data.
The cells (CTCs), which can be measured using a Food and Drug Administration–approved assay, are known to seed distant metastases and to be prognostic before and during therapy for patients with metastatic breast cancer, and prognostic before adjuvant therapy for patients with nonmetastatic breast cancer.
However, findings in the neoadjuvant setting have been variable, Francois-Clement Bidard, MD, of Institut Curie, Paris, reported at the San Antonio Breast Cancer Symposium.
In the study (the international meta-analysis of circulating tumor cell detection in early breast cancer patients treated by neoadjuvant chemotherapy, or IMENEO), CTCs were useful, independent of pathologic complete response, for predicting overall survival and distant disease-free survival in the neoadjuvant setting. Further, IMENEO showed for the first time that CTCs also predict locoregional relapse-free survival,
Based on the analysis of data from 2,156 patients from 21 studies and 16 centers in 10 countries, the CTC positivity rates using thresholds of one or more, two or more, and five or more, respectively, were 25%, 13%, and 6% in 1,574 patients tested at baseline, 17%, 6%, and 3% in 290 tested after neoadjuvant chemotherapy, 15%, 5%, and 1% in 1,200 tested before surgery, and 11%, 4%, and 1% in 285 tested after surgery, Dr. Bidard said.
Prior to neoadjuvant chemotherapy, at least one CTC was found in 19%, 22%, 24%, 29% and 41% of cT1, T2, T3, T4a-c, and T4d breast cancers, respectively, and this was marginally associated with hormone receptor negativity, he said, noting that later CTC detection rates were not associated with any patient baseline characteristics.
Nearly one in four patients (24%) achieved pathologic complete response, but this was not associated at any time point with CTC count.
For the primary study endpoint of overall survival, a significant association was found with the presence of at least two CTCs at baseline (hazard ratio, 2.6 for two CTCs; 3.84 for three to four CTCs; and 6.25 for five or more CTCs). Similar associations were found for distant disease-free survival (hazard ratios, 2.4, 3.4, and 5.0, respectively) and for locoregional relapse-free interval with two CTCs and five or more CTCs (hazard ratios, 2.4 and 4.2, respectively).
Similar results were found using later time points, such as after the start of neoadjuvant chemotherapy or before surgery, he said.
On multivariate analysis, baseline CTC detection using any of the thresholds remained an independent predictor of overall and distant disease-free survival and locoregional relapse-free interval when considered together with pathologic complete response, cT, cN, and tumor subtype, suggesting that CTC measurement adds value to comprehensive prognostic models.
That is, they complement rather than duplicate usual prognostic factors and pathologic complete response rates to better predict outcomes in patients with early breast cancer in the neoadjuvant setting, Dr. Bidard said.
This study was supported by a research grant from Janssen Diagnostics. Dr. Bidard reported having no disclosures.
SAN ANTONIO – Circulating tumor cells are a useful prognostic biomarker in early breast cancer patients treated with neoadjuvant chemotherapy, according to findings from an international meta-analysis of individual patient data.
The cells (CTCs), which can be measured using a Food and Drug Administration–approved assay, are known to seed distant metastases and to be prognostic before and during therapy for patients with metastatic breast cancer, and prognostic before adjuvant therapy for patients with nonmetastatic breast cancer.
However, findings in the neoadjuvant setting have been variable, Francois-Clement Bidard, MD, of Institut Curie, Paris, reported at the San Antonio Breast Cancer Symposium.
In the study (the international meta-analysis of circulating tumor cell detection in early breast cancer patients treated by neoadjuvant chemotherapy, or IMENEO), CTCs were useful, independent of pathologic complete response, for predicting overall survival and distant disease-free survival in the neoadjuvant setting. Further, IMENEO showed for the first time that CTCs also predict locoregional relapse-free survival,
Based on the analysis of data from 2,156 patients from 21 studies and 16 centers in 10 countries, the CTC positivity rates using thresholds of one or more, two or more, and five or more, respectively, were 25%, 13%, and 6% in 1,574 patients tested at baseline, 17%, 6%, and 3% in 290 tested after neoadjuvant chemotherapy, 15%, 5%, and 1% in 1,200 tested before surgery, and 11%, 4%, and 1% in 285 tested after surgery, Dr. Bidard said.
Prior to neoadjuvant chemotherapy, at least one CTC was found in 19%, 22%, 24%, 29% and 41% of cT1, T2, T3, T4a-c, and T4d breast cancers, respectively, and this was marginally associated with hormone receptor negativity, he said, noting that later CTC detection rates were not associated with any patient baseline characteristics.
Nearly one in four patients (24%) achieved pathologic complete response, but this was not associated at any time point with CTC count.
For the primary study endpoint of overall survival, a significant association was found with the presence of at least two CTCs at baseline (hazard ratio, 2.6 for two CTCs; 3.84 for three to four CTCs; and 6.25 for five or more CTCs). Similar associations were found for distant disease-free survival (hazard ratios, 2.4, 3.4, and 5.0, respectively) and for locoregional relapse-free interval with two CTCs and five or more CTCs (hazard ratios, 2.4 and 4.2, respectively).
Similar results were found using later time points, such as after the start of neoadjuvant chemotherapy or before surgery, he said.
On multivariate analysis, baseline CTC detection using any of the thresholds remained an independent predictor of overall and distant disease-free survival and locoregional relapse-free interval when considered together with pathologic complete response, cT, cN, and tumor subtype, suggesting that CTC measurement adds value to comprehensive prognostic models.
That is, they complement rather than duplicate usual prognostic factors and pathologic complete response rates to better predict outcomes in patients with early breast cancer in the neoadjuvant setting, Dr. Bidard said.
This study was supported by a research grant from Janssen Diagnostics. Dr. Bidard reported having no disclosures.
AT SABCS 2016
Key clinical point:
Major finding: Overall survival was associated with the presence of at least two CTCs at baseline (hazard ratio, 2.6 for two CTCs; 3.84 for three to four CTCs; and 6.25 for five or more CTCs).
Data source: A meta-analysis of data for 2,156 patients.
Disclosures: This study was supported by a research grant from Janssen Diagnostics. Dr. Bidard reported having no disclosures.
Adjuvant chemo prolonged survival after radical nephroureterectomy
Adjuvant chemotherapy prolonged survival after radical nephroureterectomy by nearly a year, compared with observation alone, among patients with locally advanced or positive regional lymph node upper tract urothelial carcinoma, researchers reported.
After a median follow-up period of 49 months, median overall survival was 47 months with adjuvant chemotherapy and 36 months with observation alone (P less than .001), reported Thomas Seisen, MD, of Harvard Medical School, Boston, and his associates.
This analysis included 3,253 patients with pT3/T4 and/or pN+ upper tract urothelial carcinoma from the National Cancer Database. A total of 762 (23%) patients received adjuvant chemotherapy within 90 days after surgery, while 2,491 (77%) patients underwent observation only (J Clin Oncol. 2017 Jan 3. doi: 10.1200/JCO.2016.69.414).
Kaplan Meier analyses yielded 5-year adjusted overall survival rates of 44% and 36%, respectively. Adjuvant chemotherapy conferred a significant overall survival benefit in a Cox proportional hazards regression analysis (hazard ratio, 0.77; 95% confidence interval, 0.68 to 0.88), and the effect held up in tests designed to minimize selection bias – including propensity score adjustment (HR, 0.82; 0.73 to 0.93), stratification (HR, 0.84; 0.74 to 0.95), and matching (HR, 0.84; 0.75 to 0.95).
The effect persisted across subgroups stratified by age, gender, comorbidity burden, pathologic stage, and surgical margin status, and there was no significant variability in treatment effects, the researchers said. The findings are subject to “the usual biases related to the observational study design,” but pending level 1 evidence, they inform the management of patients with advanced upper tract urothelial carcinoma who undergo radical nephroureterectomy, the researchers concluded.
The work was supported by the Vattikuti Urology Institute, the Conquer Cancer Foundation of the American Society of Clinical Oncology, and the Prostate Cancer Foundation. Dr. Seisen had no relevant financial disclosures.
Adjuvant chemotherapy prolonged survival after radical nephroureterectomy by nearly a year, compared with observation alone, among patients with locally advanced or positive regional lymph node upper tract urothelial carcinoma, researchers reported.
After a median follow-up period of 49 months, median overall survival was 47 months with adjuvant chemotherapy and 36 months with observation alone (P less than .001), reported Thomas Seisen, MD, of Harvard Medical School, Boston, and his associates.
This analysis included 3,253 patients with pT3/T4 and/or pN+ upper tract urothelial carcinoma from the National Cancer Database. A total of 762 (23%) patients received adjuvant chemotherapy within 90 days after surgery, while 2,491 (77%) patients underwent observation only (J Clin Oncol. 2017 Jan 3. doi: 10.1200/JCO.2016.69.414).
Kaplan Meier analyses yielded 5-year adjusted overall survival rates of 44% and 36%, respectively. Adjuvant chemotherapy conferred a significant overall survival benefit in a Cox proportional hazards regression analysis (hazard ratio, 0.77; 95% confidence interval, 0.68 to 0.88), and the effect held up in tests designed to minimize selection bias – including propensity score adjustment (HR, 0.82; 0.73 to 0.93), stratification (HR, 0.84; 0.74 to 0.95), and matching (HR, 0.84; 0.75 to 0.95).
The effect persisted across subgroups stratified by age, gender, comorbidity burden, pathologic stage, and surgical margin status, and there was no significant variability in treatment effects, the researchers said. The findings are subject to “the usual biases related to the observational study design,” but pending level 1 evidence, they inform the management of patients with advanced upper tract urothelial carcinoma who undergo radical nephroureterectomy, the researchers concluded.
The work was supported by the Vattikuti Urology Institute, the Conquer Cancer Foundation of the American Society of Clinical Oncology, and the Prostate Cancer Foundation. Dr. Seisen had no relevant financial disclosures.
Adjuvant chemotherapy prolonged survival after radical nephroureterectomy by nearly a year, compared with observation alone, among patients with locally advanced or positive regional lymph node upper tract urothelial carcinoma, researchers reported.
After a median follow-up period of 49 months, median overall survival was 47 months with adjuvant chemotherapy and 36 months with observation alone (P less than .001), reported Thomas Seisen, MD, of Harvard Medical School, Boston, and his associates.
This analysis included 3,253 patients with pT3/T4 and/or pN+ upper tract urothelial carcinoma from the National Cancer Database. A total of 762 (23%) patients received adjuvant chemotherapy within 90 days after surgery, while 2,491 (77%) patients underwent observation only (J Clin Oncol. 2017 Jan 3. doi: 10.1200/JCO.2016.69.414).
Kaplan Meier analyses yielded 5-year adjusted overall survival rates of 44% and 36%, respectively. Adjuvant chemotherapy conferred a significant overall survival benefit in a Cox proportional hazards regression analysis (hazard ratio, 0.77; 95% confidence interval, 0.68 to 0.88), and the effect held up in tests designed to minimize selection bias – including propensity score adjustment (HR, 0.82; 0.73 to 0.93), stratification (HR, 0.84; 0.74 to 0.95), and matching (HR, 0.84; 0.75 to 0.95).
The effect persisted across subgroups stratified by age, gender, comorbidity burden, pathologic stage, and surgical margin status, and there was no significant variability in treatment effects, the researchers said. The findings are subject to “the usual biases related to the observational study design,” but pending level 1 evidence, they inform the management of patients with advanced upper tract urothelial carcinoma who undergo radical nephroureterectomy, the researchers concluded.
The work was supported by the Vattikuti Urology Institute, the Conquer Cancer Foundation of the American Society of Clinical Oncology, and the Prostate Cancer Foundation. Dr. Seisen had no relevant financial disclosures.
Key clinical point: Adjuvant chemotherapy prolonged survival after radical nephroureterectomy by nearly a year, compared with observation alone, among patients with locally advanced or positive regional lymph node upper tract urothelial carcinoma.
Major finding: After a median follow-up period of 49 months, median overall survival was 47 months with adjuvant chemotherapy and 36 months with observation alone (P less than .001).
Data source: An analysis of 3,253 patients with pT3/T4 and/or pN+ upper tract urothelial carcinoma from the National Cancer Database.
Disclosures: The work was supported by the Vattikuti Urology Institute, the Conquer Cancer Foundation of the American Society of Clinical Oncology, and the Prostate Cancer Foundation. Dr. Seisen had no relevant financial disclosures.
Alexa
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
‘Weekend warrior’ exercise pattern sufficient to cut mortality
The “weekend warrior” exercise pattern – having one or two rather than five to seven leisure-time activity sessions per week – may be sufficient to reduce all-cause, cardiovascular disease, and cancer mortality risks, according to a report published online Jan. 9 in JAMA Internal Medicine.
The World Health Organization and U.S. Department of Health & Human Services recommend that adults perform at least 150 minutes per week of moderate-intensity aerobic activity, at least 75 minutes per week of vigorous-intensity aerobic activity, or equivalent combinations, spread out over the week.
They performed a pooled analysis of data in eight household surveillance studies across England and Scotland, focusing on the self-reported physical activity patterns of 63,591 adults older than 40 years from 1994 through 2012. The mean age of the survey respondents was 58.6 years. A total of 62.8% were classified as inactive, 22.4% as insufficiently active (performing less than 150 minutes per week of moderate-intensity activity), 3.7% as weekend warriors, and 11.1% as regularly active.
There were 8,802 deaths because of all causes, including 2,780 deaths due to cardiovascular disease (CVD) and 2,526 deaths due to cancer, during 561,159 person-years of follow-up.
Compared with inactive participants, the hazard ratio (HR) for all-cause mortality was 0.69 for insufficiently active participants (a 31% reduction), 0.70 for weekend warriors (a 30% reduction), and 0.65 for regularly active participants (a 35% reduction).
The findings remained consistent for men and women alike and regardless of the presence or absence of obesity. However, because 95% of the study population was white, it is not known whether the findings apply to other racial or ethnic groups.
The study results suggest that some leisure-time physical activity is better than none, and that even as few as one to two sessions per week offer considerable health benefits to both men and women, even among obese adults, Dr. O’Donovan and his associates said.
The investigators did not elaborate on the finding that an “insufficient” activity level reduced mortality risks to nearly the same degree as a “weekend warrior” activity level.
The study was supported by the National Institute for Health Research; the Leicester Clinical Trials Unit; the Leicester-Loughborough Diet, Lifestyle, and Physical Activity Biomedical Research Unit; and the National Health and Medical Research Council. Dr. O’Donovan and his associates reported having no relevant financial disclosures.
In response to the question of whether exercise can wait for the weekend, the short answer is “perhaps.”
Meeting current guidelines for physical activity in only one or two sessions per week does yield substantial mortality benefit, but exercising more frequently yields even more.
In addition to studying the timing, frequency, and intensity of physical activity, we hope researchers also examine ways to promote its popularity in the general public.
Hannah Arem, PhD, is in the department of epidemiology and biostatistics at the Milken Institute School of Public Health, George Washington University, Washington. Loretta DiPietro, PhD, is in the department of exercise and nutrition sciences at the Milken Institute. Dr. Arem and Dr. DiPietro reported having no relevant financial disclosures. They made these remarks in an invited commentary accompanying Dr. O’Donovan’s report (JAMA Intern Med. 2017 Jan 9 [doi:10.1001/jamainternmend.2016.8050]).
In response to the question of whether exercise can wait for the weekend, the short answer is “perhaps.”
Meeting current guidelines for physical activity in only one or two sessions per week does yield substantial mortality benefit, but exercising more frequently yields even more.
In addition to studying the timing, frequency, and intensity of physical activity, we hope researchers also examine ways to promote its popularity in the general public.
Hannah Arem, PhD, is in the department of epidemiology and biostatistics at the Milken Institute School of Public Health, George Washington University, Washington. Loretta DiPietro, PhD, is in the department of exercise and nutrition sciences at the Milken Institute. Dr. Arem and Dr. DiPietro reported having no relevant financial disclosures. They made these remarks in an invited commentary accompanying Dr. O’Donovan’s report (JAMA Intern Med. 2017 Jan 9 [doi:10.1001/jamainternmend.2016.8050]).
In response to the question of whether exercise can wait for the weekend, the short answer is “perhaps.”
Meeting current guidelines for physical activity in only one or two sessions per week does yield substantial mortality benefit, but exercising more frequently yields even more.
In addition to studying the timing, frequency, and intensity of physical activity, we hope researchers also examine ways to promote its popularity in the general public.
Hannah Arem, PhD, is in the department of epidemiology and biostatistics at the Milken Institute School of Public Health, George Washington University, Washington. Loretta DiPietro, PhD, is in the department of exercise and nutrition sciences at the Milken Institute. Dr. Arem and Dr. DiPietro reported having no relevant financial disclosures. They made these remarks in an invited commentary accompanying Dr. O’Donovan’s report (JAMA Intern Med. 2017 Jan 9 [doi:10.1001/jamainternmend.2016.8050]).
The “weekend warrior” exercise pattern – having one or two rather than five to seven leisure-time activity sessions per week – may be sufficient to reduce all-cause, cardiovascular disease, and cancer mortality risks, according to a report published online Jan. 9 in JAMA Internal Medicine.
The World Health Organization and U.S. Department of Health & Human Services recommend that adults perform at least 150 minutes per week of moderate-intensity aerobic activity, at least 75 minutes per week of vigorous-intensity aerobic activity, or equivalent combinations, spread out over the week.
They performed a pooled analysis of data in eight household surveillance studies across England and Scotland, focusing on the self-reported physical activity patterns of 63,591 adults older than 40 years from 1994 through 2012. The mean age of the survey respondents was 58.6 years. A total of 62.8% were classified as inactive, 22.4% as insufficiently active (performing less than 150 minutes per week of moderate-intensity activity), 3.7% as weekend warriors, and 11.1% as regularly active.
There were 8,802 deaths because of all causes, including 2,780 deaths due to cardiovascular disease (CVD) and 2,526 deaths due to cancer, during 561,159 person-years of follow-up.
Compared with inactive participants, the hazard ratio (HR) for all-cause mortality was 0.69 for insufficiently active participants (a 31% reduction), 0.70 for weekend warriors (a 30% reduction), and 0.65 for regularly active participants (a 35% reduction).
The findings remained consistent for men and women alike and regardless of the presence or absence of obesity. However, because 95% of the study population was white, it is not known whether the findings apply to other racial or ethnic groups.
The study results suggest that some leisure-time physical activity is better than none, and that even as few as one to two sessions per week offer considerable health benefits to both men and women, even among obese adults, Dr. O’Donovan and his associates said.
The investigators did not elaborate on the finding that an “insufficient” activity level reduced mortality risks to nearly the same degree as a “weekend warrior” activity level.
The study was supported by the National Institute for Health Research; the Leicester Clinical Trials Unit; the Leicester-Loughborough Diet, Lifestyle, and Physical Activity Biomedical Research Unit; and the National Health and Medical Research Council. Dr. O’Donovan and his associates reported having no relevant financial disclosures.
The “weekend warrior” exercise pattern – having one or two rather than five to seven leisure-time activity sessions per week – may be sufficient to reduce all-cause, cardiovascular disease, and cancer mortality risks, according to a report published online Jan. 9 in JAMA Internal Medicine.
The World Health Organization and U.S. Department of Health & Human Services recommend that adults perform at least 150 minutes per week of moderate-intensity aerobic activity, at least 75 minutes per week of vigorous-intensity aerobic activity, or equivalent combinations, spread out over the week.
They performed a pooled analysis of data in eight household surveillance studies across England and Scotland, focusing on the self-reported physical activity patterns of 63,591 adults older than 40 years from 1994 through 2012. The mean age of the survey respondents was 58.6 years. A total of 62.8% were classified as inactive, 22.4% as insufficiently active (performing less than 150 minutes per week of moderate-intensity activity), 3.7% as weekend warriors, and 11.1% as regularly active.
There were 8,802 deaths because of all causes, including 2,780 deaths due to cardiovascular disease (CVD) and 2,526 deaths due to cancer, during 561,159 person-years of follow-up.
Compared with inactive participants, the hazard ratio (HR) for all-cause mortality was 0.69 for insufficiently active participants (a 31% reduction), 0.70 for weekend warriors (a 30% reduction), and 0.65 for regularly active participants (a 35% reduction).
The findings remained consistent for men and women alike and regardless of the presence or absence of obesity. However, because 95% of the study population was white, it is not known whether the findings apply to other racial or ethnic groups.
The study results suggest that some leisure-time physical activity is better than none, and that even as few as one to two sessions per week offer considerable health benefits to both men and women, even among obese adults, Dr. O’Donovan and his associates said.
The investigators did not elaborate on the finding that an “insufficient” activity level reduced mortality risks to nearly the same degree as a “weekend warrior” activity level.
The study was supported by the National Institute for Health Research; the Leicester Clinical Trials Unit; the Leicester-Loughborough Diet, Lifestyle, and Physical Activity Biomedical Research Unit; and the National Health and Medical Research Council. Dr. O’Donovan and his associates reported having no relevant financial disclosures.
FROM JAMA INTERNAL MEDICINE
Key clinical point: The “weekend warrior” exercise pattern – having one or two rather than five to seven leisure-time activity sessions per week – may be sufficient to reduce mortality risks.
Major finding: Compared with inactive participants, the hazard ratio for all-cause mortality was 0.69 for insufficiently active participants (a 31% reduction), 0.70 for weekend warriors (a 30% reduction), and 0.65 for regularly active participants (a 35% reduction).
Data source: A pooled analysis of eight household surveillance studies in England and Scotland during 1994-2012, involving 63,591 adults older than 40 years.
Disclosures: The study was supported by the National Institute for Health Research; the Leicester Clinical Trials Unit; the Leicester-Loughborough Diet, Lifestyle, and Physical Activity Biomedical Research Unit; and the National Health and Medical Research Council. Dr. O’Donovan and his associates reported having no relevant financial disclosures.
Study highlights need to address vitamin D deficiency in epilepsy patients
HOUSTON – Neurologists and other clinicians ordered vitamin D levels, dual-energy x-ray absorptiometry (DXA) scans, and vitamin D supplementation for epilepsy patients in order to diagnose and prevent vitamin D deficiency and osteopenia, results from a single-center study showed.
Vitamin D deficiency and osteopenia are well described in the literature for patients on enzyme-inducing antiepileptic drugs (EIADs), but no guidelines currently exist for when to order tests or supplementation for patients on EIADs or non–enzyme inducing antiepileptic drugs (NEIADs). “Further studies with larger sample sizes will be helpful in order to establish guidelines for neurologists and other physicians,” Sher Afgan, MD, said in an interview at the annual meeting of the American Epilepsy Society.
Dr. Afgan, a research assistant at Drexel, went on to report that neurologists ordered vitamin D levels in 22% of patients; another 12% had already been ordered by another physician. Neurologists were more likely to order vitamin D levels for patients on EIADs, compared with those on NEIADs (32% vs. 10.4%; P less than .001), and vitamin D levels were more likely to be ordered by either neurologists or other physicians for patients on EIADs, compared with those on NEIADs (41% vs. 26%; P = .02). Neurologists ordered DXA scans in 22% of patients, and more often for those on EIADs, compared with those on NEIADs (33% vs. 10.4%; P less than .001). Similarly, DXA scans were more likely to be ordered by either neurologists or other physicians for patients on EIADs, compared with those on NEIADs (35.3% vs. 18.2%; P = .006). Supplementation was ordered in 23% of patients and was more likely to be ordered by neurologists for patients on EIADs, compared with those on NEIADs (36% vs. 8%; P less than .001).
The researchers also found that neurologists were more likely to order vitamin D levels, DXA scans, and supplements for men on EIADs, compared with women on EIADs (odds ratio, 2.178, P = .03; OR, 2.31, P = .02; OR, 1.87, P = .09, respectively). Generalized epilepsy did not significantly account for increases in ordering vitamin D for EIADs. Median total vitamin D levels were lower in patients on EIADs, compared with those on NEIADs (29 vs. 18 ng/mL; P = .03), but age and body mass index were not different among patients for whom neurologists ordered Vitamin D levels, DXA scans, or supplementation.
Dr. Afgan acknowledged certain limitations of the study, including its retrospective design and small sample size. “Also, type and duration of epilepsy, type and duration of antiepileptic drugs, and comorbidities should be considered in further studies with larger sample sizes,” he said. He reported having no financial disclosures.
HOUSTON – Neurologists and other clinicians ordered vitamin D levels, dual-energy x-ray absorptiometry (DXA) scans, and vitamin D supplementation for epilepsy patients in order to diagnose and prevent vitamin D deficiency and osteopenia, results from a single-center study showed.
Vitamin D deficiency and osteopenia are well described in the literature for patients on enzyme-inducing antiepileptic drugs (EIADs), but no guidelines currently exist for when to order tests or supplementation for patients on EIADs or non–enzyme inducing antiepileptic drugs (NEIADs). “Further studies with larger sample sizes will be helpful in order to establish guidelines for neurologists and other physicians,” Sher Afgan, MD, said in an interview at the annual meeting of the American Epilepsy Society.
Dr. Afgan, a research assistant at Drexel, went on to report that neurologists ordered vitamin D levels in 22% of patients; another 12% had already been ordered by another physician. Neurologists were more likely to order vitamin D levels for patients on EIADs, compared with those on NEIADs (32% vs. 10.4%; P less than .001), and vitamin D levels were more likely to be ordered by either neurologists or other physicians for patients on EIADs, compared with those on NEIADs (41% vs. 26%; P = .02). Neurologists ordered DXA scans in 22% of patients, and more often for those on EIADs, compared with those on NEIADs (33% vs. 10.4%; P less than .001). Similarly, DXA scans were more likely to be ordered by either neurologists or other physicians for patients on EIADs, compared with those on NEIADs (35.3% vs. 18.2%; P = .006). Supplementation was ordered in 23% of patients and was more likely to be ordered by neurologists for patients on EIADs, compared with those on NEIADs (36% vs. 8%; P less than .001).
The researchers also found that neurologists were more likely to order vitamin D levels, DXA scans, and supplements for men on EIADs, compared with women on EIADs (odds ratio, 2.178, P = .03; OR, 2.31, P = .02; OR, 1.87, P = .09, respectively). Generalized epilepsy did not significantly account for increases in ordering vitamin D for EIADs. Median total vitamin D levels were lower in patients on EIADs, compared with those on NEIADs (29 vs. 18 ng/mL; P = .03), but age and body mass index were not different among patients for whom neurologists ordered Vitamin D levels, DXA scans, or supplementation.
Dr. Afgan acknowledged certain limitations of the study, including its retrospective design and small sample size. “Also, type and duration of epilepsy, type and duration of antiepileptic drugs, and comorbidities should be considered in further studies with larger sample sizes,” he said. He reported having no financial disclosures.
HOUSTON – Neurologists and other clinicians ordered vitamin D levels, dual-energy x-ray absorptiometry (DXA) scans, and vitamin D supplementation for epilepsy patients in order to diagnose and prevent vitamin D deficiency and osteopenia, results from a single-center study showed.
Vitamin D deficiency and osteopenia are well described in the literature for patients on enzyme-inducing antiepileptic drugs (EIADs), but no guidelines currently exist for when to order tests or supplementation for patients on EIADs or non–enzyme inducing antiepileptic drugs (NEIADs). “Further studies with larger sample sizes will be helpful in order to establish guidelines for neurologists and other physicians,” Sher Afgan, MD, said in an interview at the annual meeting of the American Epilepsy Society.
Dr. Afgan, a research assistant at Drexel, went on to report that neurologists ordered vitamin D levels in 22% of patients; another 12% had already been ordered by another physician. Neurologists were more likely to order vitamin D levels for patients on EIADs, compared with those on NEIADs (32% vs. 10.4%; P less than .001), and vitamin D levels were more likely to be ordered by either neurologists or other physicians for patients on EIADs, compared with those on NEIADs (41% vs. 26%; P = .02). Neurologists ordered DXA scans in 22% of patients, and more often for those on EIADs, compared with those on NEIADs (33% vs. 10.4%; P less than .001). Similarly, DXA scans were more likely to be ordered by either neurologists or other physicians for patients on EIADs, compared with those on NEIADs (35.3% vs. 18.2%; P = .006). Supplementation was ordered in 23% of patients and was more likely to be ordered by neurologists for patients on EIADs, compared with those on NEIADs (36% vs. 8%; P less than .001).
The researchers also found that neurologists were more likely to order vitamin D levels, DXA scans, and supplements for men on EIADs, compared with women on EIADs (odds ratio, 2.178, P = .03; OR, 2.31, P = .02; OR, 1.87, P = .09, respectively). Generalized epilepsy did not significantly account for increases in ordering vitamin D for EIADs. Median total vitamin D levels were lower in patients on EIADs, compared with those on NEIADs (29 vs. 18 ng/mL; P = .03), but age and body mass index were not different among patients for whom neurologists ordered Vitamin D levels, DXA scans, or supplementation.
Dr. Afgan acknowledged certain limitations of the study, including its retrospective design and small sample size. “Also, type and duration of epilepsy, type and duration of antiepileptic drugs, and comorbidities should be considered in further studies with larger sample sizes,” he said. He reported having no financial disclosures.
AT AES 2016
Key clinical point:
Major finding: Neurologists ordered vitamin D levels in 22% of patients; another 12% were already ordered by another physician.
Data source: A retrospective review of 190 patients who had a diagnosis of epilepsy or seizures, were currently on antiepileptic medications, and whose most recent neurology visit occurred between 2009 and 2015.
Disclosures: Dr. Afgan reported having no financial disclosures.